Digestive Endoscopy 2015; 27: 627–632
Letters, Techniques and Images
631
2
Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan doi: 10.1111/den.12480
REFERENCES 1 Inoue H, Minami H, Kobayashi Yet al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265–71. 2 Shiwaku H, Inoue H, Beppu R et al. Successful treatment of diffuse esophageal spasm by peroral endoscopic myotomy. Gastrointest. Endosc. 2013; 77: 149–50. 3 Saxena P, Chavez YH, Kord Valeshabad A, Kalloo AN, Khashab MA. An alternative method for mucosal flap closure during peroral endoscopic myotomy using an over-the-scope clipping device. Endoscopy 2013; 45: 579–81. 4 Yang D, Draganov PV. Closing the gap in POEM. Endoscopy 2013; 45: 677. 5 Li H, Linghu E, Wang X. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM). Endoscopy 2012; 44: E215–16.
SUPPORTING INFORMATION DDITIONAL SUPPORTING INFORMATION may be found in the online version of this article at the publisher’s web site. Video S1 Endoloop/clips technique carried out in a purse-string manner (porcine model). First, the distal side of the mucostomy was fixed to the endoloop using a clip. Then, the clips were placed at an equal distance from both the distal and proximal sides of the mucostomy. Finally, the mucostomy was closed in a purse-string manner.
A
Figure 1 Abdominal computed tomography scan with contrast prior to lower gastrointestinal bleeding (axial image). (A) Left common iliac artery aneurysm with contrast medium extravasation, suggesting aneurysmal rupture (arrow). (B) Perianeurysmal hematoma.
diagnostic tools.3 We report a rare case of acute lower gastrointestinal bleeding caused by fistula formation between the sigmoid colon and a perianeurysmal hematoma because of rupture of left common iliac artery aneurysm. A 76-year-old Asian man was referred to St. Luke’s International Hospital because of several episodes of bloody stool 5 days after aortic replacement with vascular prosthesis for rupture of left common iliac artery aneurysm. On admission, preoperative abdominal CT scan revealed
Fistula formation between perianeurysmal hematoma and sigmoid colon: Rare cause of lower gastrointestinal bleeding
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Aortoenteric fistula is a rare but potentially fatal condition, causing acute gastrointestinal bleeding. Typical symptoms include abdominal pain, gastrointestinal bleeding, and a pulsatile abdominal mass; however, these may be clinically occult. The initial harbinger of the disease in a majority of patients is gastrointestinal bleeding followed by massive exsanguination.1,2 Although the diagnosis of aortoenteric fistula can be challenging, abdominal computed tomography (CT) and endoscopic examination are the preferred initial
Figure 2 Gastrointestinal endoscopy images. (A) Large mucosal defect in the sigmoid colon forming a fistula between the sigmoid colon and the perianeurysmal hematoma . (B) Hollow cavity inside the perianeurysmal hematoma. (C) Closure of the fistula.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
632
Letters, Techniques and Images
Digestive Endoscopy 2015; 27: 627–632
perianeurysmal hematoma caused by the aneurysmal rupture, but no signs of bowel perforation or active bleeding were observed (Fig. 1). Colonoscopy revealed a large mucosal defect in the sigmoid colon, with fistula formation in the hollow cavity (Fig. 2A). The endoscope was introduced through the fenestration into this hollow cavity, which was suspected to be the perianeurysmal hematoma observed on CT (Fig. 2B). There was no other bleeding site identified on total colonoscopy. Air leak inside the hematoma was seen on subsequent abdominal CT scan, confirming the penetration of hematoma into the sigmoid colon. The repair strategy of the colonic defect of aortoenteric fistula is still debated, and the type of surgical intervention generally depends on the situation. In the present study, we carried out transverse colostomy to anticipate spontaneous closure of the fistula.4 After confirming complete closure of the fistula (Fig. 2C) after 4 months, the patient successfully underwent stoma closure. Authors disclose no conflicts of interest for this article.
Kazuhiro Kosugi1, Shoko Suzuki2 and Yuto Shimamura1 1 Department of Gastroenterology, St Luke’s International Hospital, and 2 Department of Gastroenterology, Japanese Red Cross Musashino Hospital, Tokyo, Japan doi: 10.1111/den.12484
REFERENCES 1 Antinori CH, Andrew CT, Santaspirt JS et al. The many faces of aortoenteric fistulas. Am. Surg.1996; 62: 344–349. 2 Song Y, Liu Q, Shen H, Jia X, Zhang H, Qiao L. Diagnosis and management of primary aortoenteric fistulas–experience learned from eighteen patients. Surgery 2008; 143: 43–50. 3 Xiromeritis K, Dalainas I, Stamatakos M, Filis K. Aortoenteric fistulae: present-day management. Int. Surg. 2011; 96: 266–273. 4 Bognar G, Sugar I, Sipos P, Ledniczky G, Laczko A, Ondrejka P. Secondary iliac-enteric fistula to the sigmoid colon complicated with entero-grafto-cutaneous fistula. Case Rep. Gastroenterol. 2008; 2: 138–143.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
Letters, Techniques and Images
631
2
Digestive Disease Center, Showa University Koto Toyosu Hospital, Tokyo, Japan doi: 10.1111/den.12480
REFERENCES 1 Inoue H, Minami H, Kobayashi Yet al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265–71. 2 Shiwaku H, Inoue H, Beppu R et al. Successful treatment of diffuse esophageal spasm by peroral endoscopic myotomy. Gastrointest. Endosc. 2013; 77: 149–50. 3 Saxena P, Chavez YH, Kord Valeshabad A, Kalloo AN, Khashab MA. An alternative method for mucosal flap closure during peroral endoscopic myotomy using an over-the-scope clipping device. Endoscopy 2013; 45: 579–81. 4 Yang D, Draganov PV. Closing the gap in POEM. Endoscopy 2013; 45: 677. 5 Li H, Linghu E, Wang X. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM). Endoscopy 2012; 44: E215–16.
SUPPORTING INFORMATION DDITIONAL SUPPORTING INFORMATION may be found in the online version of this article at the publisher’s web site. Video S1 Endoloop/clips technique carried out in a purse-string manner (porcine model). First, the distal side of the mucostomy was fixed to the endoloop using a clip. Then, the clips were placed at an equal distance from both the distal and proximal sides of the mucostomy. Finally, the mucostomy was closed in a purse-string manner.
A
Figure 1 Abdominal computed tomography scan with contrast prior to lower gastrointestinal bleeding (axial image). (A) Left common iliac artery aneurysm with contrast medium extravasation, suggesting aneurysmal rupture (arrow). (B) Perianeurysmal hematoma.
diagnostic tools.3 We report a rare case of acute lower gastrointestinal bleeding caused by fistula formation between the sigmoid colon and a perianeurysmal hematoma because of rupture of left common iliac artery aneurysm. A 76-year-old Asian man was referred to St. Luke’s International Hospital because of several episodes of bloody stool 5 days after aortic replacement with vascular prosthesis for rupture of left common iliac artery aneurysm. On admission, preoperative abdominal CT scan revealed
Fistula formation between perianeurysmal hematoma and sigmoid colon: Rare cause of lower gastrointestinal bleeding
bs_bs_banner
Aortoenteric fistula is a rare but potentially fatal condition, causing acute gastrointestinal bleeding. Typical symptoms include abdominal pain, gastrointestinal bleeding, and a pulsatile abdominal mass; however, these may be clinically occult. The initial harbinger of the disease in a majority of patients is gastrointestinal bleeding followed by massive exsanguination.1,2 Although the diagnosis of aortoenteric fistula can be challenging, abdominal computed tomography (CT) and endoscopic examination are the preferred initial
Figure 2 Gastrointestinal endoscopy images. (A) Large mucosal defect in the sigmoid colon forming a fistula between the sigmoid colon and the perianeurysmal hematoma . (B) Hollow cavity inside the perianeurysmal hematoma. (C) Closure of the fistula.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
632
Letters, Techniques and Images
Digestive Endoscopy 2015; 27: 627–632
perianeurysmal hematoma caused by the aneurysmal rupture, but no signs of bowel perforation or active bleeding were observed (Fig. 1). Colonoscopy revealed a large mucosal defect in the sigmoid colon, with fistula formation in the hollow cavity (Fig. 2A). The endoscope was introduced through the fenestration into this hollow cavity, which was suspected to be the perianeurysmal hematoma observed on CT (Fig. 2B). There was no other bleeding site identified on total colonoscopy. Air leak inside the hematoma was seen on subsequent abdominal CT scan, confirming the penetration of hematoma into the sigmoid colon. The repair strategy of the colonic defect of aortoenteric fistula is still debated, and the type of surgical intervention generally depends on the situation. In the present study, we carried out transverse colostomy to anticipate spontaneous closure of the fistula.4 After confirming complete closure of the fistula (Fig. 2C) after 4 months, the patient successfully underwent stoma closure. Authors disclose no conflicts of interest for this article.
Kazuhiro Kosugi1, Shoko Suzuki2 and Yuto Shimamura1 1 Department of Gastroenterology, St Luke’s International Hospital, and 2 Department of Gastroenterology, Japanese Red Cross Musashino Hospital, Tokyo, Japan doi: 10.1111/den.12484
REFERENCES 1 Antinori CH, Andrew CT, Santaspirt JS et al. The many faces of aortoenteric fistulas. Am. Surg.1996; 62: 344–349. 2 Song Y, Liu Q, Shen H, Jia X, Zhang H, Qiao L. Diagnosis and management of primary aortoenteric fistulas–experience learned from eighteen patients. Surgery 2008; 143: 43–50. 3 Xiromeritis K, Dalainas I, Stamatakos M, Filis K. Aortoenteric fistulae: present-day management. Int. Surg. 2011; 96: 266–273. 4 Bognar G, Sugar I, Sipos P, Ledniczky G, Laczko A, Ondrejka P. Secondary iliac-enteric fistula to the sigmoid colon complicated with entero-grafto-cutaneous fistula. Case Rep. Gastroenterol. 2008; 2: 138–143.
© 2015 The Authors Digestive Endoscopy © 2015 Japan Gastroenterological Endoscopy Society
