An Insidious Gastrointestinal Bleeding from Secondary Aortoduodenal Fistula Leading to Septic Shock

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Abstract

Insidious gastrointestinal bleeding from a secondary aortic fistula poses a significant diagnostic challenge. Failure to recognize it early on can lead to devastating outcomes. We describe a case of insidious gastrointestinal bleeding from a secondary aortic fistula in an elderly woman who presented with recurrent admissions for melanotic stools and eventually developed septic shock. Esophagogastroduodenoscopy did not reveal any obvious source of bleeding. The patient eventually had push endoscopy that revealed infected graft and a secondary aortoduodenal fistula. One should proceed with push enteroscopy in occult bleeding if the patient has a history of abdominal aortic aneurysm repair.

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Most cited references 25

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ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding.

Lauren Gerson, Jeff L Fidler, David R Cave … (2015)

Bleeding from the small intestine remains a relatively uncommon event, accounting for ~5-10% of all patients presenting with gastrointestinal (GI) bleeding. Given advances in small bowel imaging with video capsule endoscopy (VCE), deep enteroscopy, and radiographic imaging, the cause of bleeding in the small bowel can now be identified in most patients. The term small bowel bleeding is therefore proposed as a replacement for the previous classification of obscure GI bleeding (OGIB). We recommend that the term OGIB should be reserved for patients in whom a source of bleeding cannot be identified anywhere in the GI tract. A source of small bowel bleeding should be considered in patients with GI bleeding after performance of a normal upper and lower endoscopic examination. Second-look examinations using upper endoscopy, push enteroscopy, and/or colonoscopy can be performed if indicated before small bowel evaluation. VCE should be considered a first-line procedure for small bowel investigation. Any method of deep enteroscopy can be used when endoscopic evaluation and therapy are required. VCE should be performed before deep enteroscopy if there is no contraindication. Computed tomographic enterography should be performed in patients with suspected obstruction before VCE or after negative VCE examinations. When there is acute overt hemorrhage in the unstable patient, angiography should be performed emergently. In patients with occult hemorrhage or stable patients with active overt bleeding, multiphasic computed tomography should be performed after VCE or CTE to identify the source of bleeding and to guide further management. If a source of bleeding is identified in the small bowel that is associated with significant ongoing anemia and/or active bleeding, the patient should be managed with endoscopic therapy. Conservative management is recommended for patients without a source found after small bowel investigation, whereas repeat diagnostic investigations are recommended for patients with initial negative small bowel evaluations and ongoing overt or occult bleeding.

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Aortoenteric fistula and perigraft infection: evaluation with CT.

Mary L Tierney, R. Löw, R J Sollitto … (1990)

A blinded retrospective study was performed to determine the sensitivity and specificity of computed tomography (CT) in detecting perigraft infection (PGI) and aortoenteric fistula (AEF), rare but devastating complications of aortic reconstructive surgery. Two observers independently reviewed CT scans in 55 cases including AEF (n = 23); PGI (n = 12); and normal, noninfected grafts (n = 20). Each scan was assessed for ectopic gas, focal bowel wall thickening, perigraft fluid, perigraft soft tissue, pseudoaneurysm formation, disruption of the aneurysmal wrap, and increased soft tissue between the graft and surrounding wrap. Comparison of CT findings with operative results revealed that each observer correctly identified as abnormal 33 of 35 cases of PGI either with or without AEF (sensitivity, 94%) and that results were falsely positive in three cases (specificity, 85%). CT findings ranged from large amounts of perigraft soft tissue and ectopic gas to subtle findings of minimal or no abnormalities; thus, strict criteria must be applied to the interpretation of CT scans after aortic surgery. Although CT is not 100% sensitive or specific, the authors conclude that it will continue to be valuable for diagnosing PGI and AEF.

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Aortoenteric fistula. Incidence, presentation recognition, and management.

John D Watson, J Coles, M Goldbach … (1982)

Twenty-two patients developed one or more aortoenteric fistulae following aortic reconstruction with a dacron graft. Endoscopy was performed on 11 of these patients on 17 occasions and a preoperative diagnosis was made in eight patients. Fistulous communication was most common between the aorta and duodenum (60%), and a further 30% penetrated into the jejunum and ileum. The mean period from operation to time of diagnosis was 36 months and the mean length of bleeding was 25 days, allowing ample time for preoperative evaluation. Surgery was performed on 21 of the 22 patients with an overall mortality of 77%. The best surgical results were obtained with graft resection, closure of the aorta, and maintenance of circulation by an axillofemoral graft.

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Author and article information

Contributors

Ahmad Khan:

ORCID: http://orcid.org/0000-0002-7743-7740

Journal

Journal ID (nlm-ta): Case Rep Gastrointest Med

Journal ID (iso-abbrev): Case Rep Gastrointest Med

Journal ID (publisher-id): CRIGM

Title: Case Reports in Gastrointestinal Medicine

Publisher: Hindawi

ISSN (Print): 2090-6528

ISSN (Electronic): 2090-6536

Publication date Collection: 2019

Publication date (Electronic): 13 May 2019

Volume: 2019

Electronic Location Identifier: 6261526

Affiliations

¹West Virginia University-Charleston Division, Charleston, WV, USA

²Nishtar Hospital Multan, Pakistan

³Charleston Area Medical Center, Charleston, West Virginia, USA

Author notes

Academic Editor: Gregory Kouraklis

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Ahmad Khan http://orcid.org/0000-0002-7743-7740

Article

DOI: 10.1155/2019/6261526

PMC ID: 6535879

SO-VID: 8359a98b-2e2f-4532-b3d8-ef1d972aa431

License:

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

An Insidious Gastrointestinal Bleeding from Secondary Aortoduodenal Fistula Leading to Septic Shock

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Karger: Gastroenterology

Most cited references 25

ACG Clinical Guideline: Diagnosis and Management of Small Bowel Bleeding.

Aortoenteric fistula and perigraft infection: evaluation with CT.

Aortoenteric fistula. Incidence, presentation recognition, and management.

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