Impending Aortoenteric Hemorrhage

Abstract

Aortoenteric hemorrhage is the result of enteric erosion and necrosis of aortic wall or anastomotic site. Mechanical or bacteriologic causes may occur singly or in combination. The temporal sequence is such that warning symptoms, often including back pain, fever, hemotochezia, and anemia, are present long before exsanguinating hemorrhage occurs. Vigorous diagnostic efforts, including gallium-67 citrate nuclear scan and computerized axial tomography, lead to a correct diagnosis. This allows planned semielective corrective operation before severe hemorrhage begins. The ideal operation consists of extra-anatomic revascularization, excision of the infected prosthesis, bowel repair with decompression, and sump drainage. Appropriate antimicrobial therapy should be continued until healing is complete. With aggressive diagnostic and therapeutic intervention according to this plan, marked improvement in survival and limb preservation can be anticipated in patients having this complication of aortic surgery. In this series, 15 of 18 patiets having operation recovered, though delayed limb loss occurred in two.

New Computed Tomographic Signs of Aortoenteric Fistula

“…7,9,1316 Unfortunately, these tests in our experience often give false-normal results (as in our two reported cases) or have shown paraprosthetic fluid collection or high gallium concentration in the para-aortic region that represents the expected hematoma and reactive edema about a recently placed aortic graft.…”

Anomalous Right Subclavian Artery-Esophageal Fistulae

“…In most cases, esophagoscopy cannot be used to assist in diagnosis of acute hemorrhage because of the extreme volume of hematemesis [ 3 ]. Upper endoscopy has been used in six reported cases and was able to identify the source of bleeding in only three patients [ 11 – 13 ]. This is comparable to the sensitivity of EGD in diagnosing artery-esophageal fistulas of 38% [ 11 ].…”

Sentinel Bleeding as a Sign of Gastroaortic Fistula Formation after Oesophageal Surgery

“…More subtle findings during endoscopy might point in direction of a fistula, such as submucosal hematoma shown as a blue-gray discoloration of the oesophageal wall [ 5 ]. However, the sensitivity of detection of fistulae via endoscopy is a mere 38% [ 14 ]; therefore endoscopy might be of more use to exclude other common causes of upper gastrointestinal bleeding, such as Mallory-Weiss lesions and peptic ulcers [ 1 ]. Arterial contrast studies, such as aortography or even computed tomography scans with arterial contrast, are potentially useful in the detection of fistula, but during the symptom-free interval radiological evidence of the fistula may be absent due to the transient clot formation [ 15 ].…”