Superior mesenteric artery–duodenal fistula secondary to a gunshot wound Cory M. Fielding, MD, Wesam Frandah, MD, Steven Krohmer, MD, and Deborah Flomenhoft, MD
Arterioenteric fistulas are a rare cause of massive gastrointestinal hemorrhage. We present a patient who developed a fistula between a middle colic artery pseudoaneurysm, a proximal branch of the superior mesenteric artery (SMA), and the third part of the duodenum 2 weeks after a self-inflicted gunshot wound to the abdomen. The patient’s presentation, evaluation, treatment, and prognosis are discussed. All prior published cases of SMA-duodenal fistulas are reviewed.
A
neurysms of mesenteric arteries are rare, and most are asymptomatic when detected on cross-sectional imaging. Otherwise, patients may present with gastrointestinal bleeding and abdominal pain if an aneurysm forms a fistula upon rupture. Historically a “herald bleed” often precedes massive exsanguination, thus giving a clinician the opportunity to diagnose an often fatal presentation. Although an arterioenteric fistula is rare, this case highlights the importance of quickly diagnosing and intervening in a highly lethal diagnosis. CASE REPORT A 59-year-old white woman experienced two large episodes of bright red emesis associated with dizziness and near syncope. She was admitted 2 weeks prior for a self-inflected gunshot wound to the anterior abdomen and underwent exploratory laparotomy, which showed perforation in the fourth part of the duodenum and a mesenteric defect around the transverse colon. She underwent successful primary repair. Her hospital course was complicated by atrial fibrillation with rapid ventricular response. On physical examination, her heart rate varied from 130 to 140 beats per minute, with a mean systemic arterial pressure of 60 mm Hg. Bowel sounds were normal, and no localized tenderness was noted. She had a hemoglobin of 5.2 g/dL, platelet count of 176,000/uL, international normalized ratio of 1.3, blood urea nitrogen of 16 mg/dL, and creatinine of 0.55 mg/dL. The patient received four units of packed red blood cells, 2 L of lactated Ringer’s solution, intravenous proton pump inhibitors, and 250 mg of erythromycin prior to endoscopy. Esophagogastroduodenoscopy revealed blood in the stomach and duodenum. After the area was cleaned using a water-jet
30
Figure 1. Pulsating clot in the third part of the duodenum.
pump, a pulsating clot was seen in the third part of the duodenum (Figure 1) attached to the wall with the underlying cavity. No intervention was attempted. Computed tomographic angiography showed attenuation in the diameter of the proximal superior mesenteric artery (SMA) adjacent to an air-fluid collection. There was a blush of contrast adjacent to the third portion of the duodenum and the air-fluid collection (Figure 2). A mesenteric angiogram revealed a pseudoaneurysm of the proximal middle colic artery, a proximal branch of the SMA, with a diseased segment of the middle colic artery proximal to the pseudoaneurysm and contrast extravasation (Figure 3). This area was successfully coiled angiographically without any further gastrointestinal bleeding (Figure 4). Later in the hospitalization, lysis of adhesions was performed during repeat exploratory laparotomy, and a drain was placed into a fluid collection near the duodenal perforation. Due to its location From the Division of Digestive Diseases and Nutrition in the Department of Internal Medicine (Fielding, Frandah, Flomenhoft) and the Department of Radiology (Krohmer), University of Kentucky, Lexington, Kentucky, Corresponding author: Wesam Frandah, MD, Department of Internal Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536-0298 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2016;29(1):30–32
Figure 4. Successful endovascular coiling of the bleeding vessel.
Figure 2. Contrast blush on computed tomographic angiogram in the superior mesenteric artery–duodenum area.
near numerous vascular structures and adhesions, no surgical repair was performed on the duodenum. The patient was discharged home 10 days later in stable condition with a hemoglobin of 9.3 g/dL.
Figure 3. Pseudoaneurysm of the middle colic branch (black arrow) of the superior mesenteric artery (white arrow) on mesenteric angiography. January 2016
DISCUSSION Arterioenteric fistulization is a rare, and often feared, presentation of massive gastrointestinal hemorrhage with a high mortality rate. The two types of fistula are primary (from atherosclerosis, an aortic aneurysm, aortitis, penetrating ulcer, radiation, or trauma) or secondary after surgical vascular reconstruction (1, 2). Often, these fistulas develop in the aorta and erode into the duodenum, causing massive hematemesis due to their anatomic proximity (3). In patients with penetrating trauma to the abdominal aorta, 98% have injured viscera as well (4). Patients with arterioenteric fistulas can present with a “herald bleed,” or small episode of bleeding, before massive hemorrhage leading to exsanguination, as described in the first case report by Sir Astley Cooper in 1825 (3). The diagnosis of this presentation can elude the unsuspecting clinician if a thorough history (including any prior vascular repairs) is not obtained. Prompt evaluation, usually with upper endoscopy, should be performed and vascular imaging obtained if a vascular injury is suspected (5). Endoscopic therapy of an adherent clot in the management of gastrointestinal bleeding is controversial. Randomized controlled trials are inconclusive (6, 7). Consensus guidelines state that endoscopic removal can be considered in the management of an adherent clot after injecting the underlying ulcer, or intensive proton pump therapy can be used alone with a similar outcome (8). In our case, because of the clot location, there was significant concern of major vessel communication; the endoscopist thought clot removal would likely lead to massive bleeding and a significant adverse outcome. Because these fistulas are very uncommon, no evidencebased management guidelines are available. Table 1 summarizes all cases of fistulization of the SMA (or its branches) and the duodenum published in the English medical literature (10–18). Most of these reported cases were treated either angiographically or by surgical intervention. Our patient had higher surgical risk and, therefore, we picked the less morbid approach. Exsanguination was the most common cause of death (in 82% of patients) in a series of 28 autopsies of patients
Superior mesenteric artery–duodenal fistula secondary to a gunshot wound
31
Table 1. Published cases of SMA-duodenal fistulas Intestinal segment
Mechanism of fistula
Initial presentation
Later presentation
Third part of duodenum
Gunshot 5 years prior
Hematemesis and pain
Hematemesis
Survived Resections and saphenous vein graft
N/A
1976
10
Proximal branch Second part of Pancreatic cancer of the SMA duodenum
Hematemesis and melena
Hematemesis
Embolization
Died
Not described
1987
11
Branch of the SMA
Third part of duodenum
Melena
Melena
Vasopressin infusion
Died
Massive pulmo- 1991 nary embolism
12
Branch of the SMA
Second part of Pancreatic cancer duodenum after radiation
Emesis and melena
Emesis
Embolization
Died
Exsanguination
2002
13
SMA
Third part of duodenum
Gunshot 1 month prior
Retroperitoneal hematoma
Hematemesis
Ligation of SMA
Died
Cardiac arrest in OR
2002
14
Pancreaticoduodenal artery
Duodenum
Repaired aneurysm
Unknown
Unknown
Ligation
Survived
N/A
2004
15
SMA
Duodenum
Tuberculosis
Massive hematemesis
Massive hematemesis
Duodenectomy
Died
Exsanguination
2004
16
SMA
Third part of duodenum
Pseudoaneurysm
Abdominal pain
Hematemesis
SMA reconstruction
Survived
N/A
2008
17
Inferior pancreaticoduodenal artery
Duodenum
Ruptured pseudoaneurysm
Indigestion, weight loss, jaundice
Hematemesis
Patient refused surgery
Died
Exsanguination
2009
18
Vessel SMA
Metastatic lung cancer to duodenum
Management
Cause of Outcome death
Year published Ref.
SMA indicates superior mesenteric artery; OR, operating room.
with aortoenteric fistulas (9). The vast majority of cases of arterioenteric fistula involve the aorta, but a small number of cases are fistulas from the SMA (or its branches). Including the case described herein, the mortality rate of SMA-duodenal fistulas is 60%, as calculated by collecting all published cases (Table 1).
9.
10.
11. 1.
2. 3. 4.
5.
6.
7.
8.
32
Budimir I, Nikolić M, Supanc V, Ljubicić N, Krpan T, Zovak M, Sabol M. Secondary arterio-enteric fistula: case report and review of the literature. Acta Clin Croat 2012;51(1):79–82. Bergqvist D, Björck M. Secondary arterioenteric fistulation—a systematic literature analysis. Eur J Vasc Endovasc Surg 2009;37(1):31–42. Barry PA, Molland JG, Falk GL. Primary aortoduodenal fistula. Aust N Z J Surg 1998;68(3):243–244. Lopez-Viego MA, Snyder WH 3rd, Valentine RJ, Clagett GP. Penetrating abdominal aortic trauma: a report of 129 cases. J Vasc Surg 1992;16(3):332–335. Schwab CW, McMahon DJ, Phillips G, Pentecost MJ. Aortic balloon control of a traumatic aortoenteric fistula after damage control laparotomy: a case report. J Trauma 1996;40(6):1021–1023. Bleau BL, Gostout CJ, Sherman KE, Shaw MJ, Harford WV, Keate RF, Bracy WP, Fleischer DE. Recurrent bleeding from peptic ulcer associated with adherent clot: a randomized study comparing endoscopic treatment with medical therapy. Gastrointest Endosc 2002;56(1):1–6. Javid G, Masoodi I, Zargar SA, Khan BA, Yatoo GN, Shah AH, Gulzar GM, Sodhi JS. Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer. Am J Med 2001;111(4):280–284. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, Sinclair P; International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152(2):101–113.
12.
13.
14.
15.
16.
17.
18.
Grande JP, Ackermann DM, Edwards WD. Aortoenteric fistulas. A study of 28 autopsied cases spanning 25 years. Arch Pathol Lab Med 1989;113(11):1271–1275. Maloney RD, Nealon TF Jr, Roberts EA. Massive bleeding from a ruptured superior mesenteric artery aneurysm duodenum. Arch Surg 1976;111(3):286–288. Thorstad BL, Keller FS. Fistula from the superior mesenteric artery to duodenum: a rare cause of death from pancreatic carcinoma. Gastrointest Radiol 1987;12(3):200–202. Steinhart AH, Cohen LB, Hegele R, Saibil FG. Upper gastrointestinal bleeding due to superior mesenteric artery to duodenum fistula: rare complication of metastatic lung carcinoma. Am J Gastroenterol 1991;86(6):771–774. Liu B, Howard JM. Vascular-enteric fistulas associated with radiation therapy in patients with pancreatic adenocarcinoma. HPB (Oxford) 2002;4(2):83–86. Miglietta MA, Tanquilut EM, Madlinger RV, Prial MM, Scalea TM. Superior mesenteric artery-duodenal fistula presenting as a late complication of an abdominal gunshot wound. J Trauma 2002;52(3):554– 555. Sessa C, Tinelli G, Porcu P, Aubert A, Thony F, Magne JL. Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Ann Vasc Surg 2004;18(6):695–703. Rao YG, Pande GK, Sahni P, Chattopadhyay TK. Gastroduodenal tuberculosis management guidelines, based on a large experience and a review of the literature. Can J Surg 2004;47(5):364–368. Zhao J. Massive upper gastrointestinal bleeding due to a ruptured superior mesenteric artery aneurysm duodenum fistula. J Vasc Surg 2008;48(3):735–737. Colak MC, Kocaturk H, Bayram E, Karaca L. Inferior pancreaticoduodenal artery false aneurysm: a rare cause of gastrointestinal bleeding diagnosed by three-dimensional computed tomography. Singapore Med J 2009;50(10):e346–349.
Baylor University Medical Center Proceedings
Volume 29, Number 1
Arterioenteric fistulas are a rare cause of massive gastrointestinal hemorrhage. We present a patient who developed a fistula between a middle colic artery pseudoaneurysm, a proximal branch of the superior mesenteric artery (SMA), and the third part of the duodenum 2 weeks after a self-inflicted gunshot wound to the abdomen. The patient’s presentation, evaluation, treatment, and prognosis are discussed. All prior published cases of SMA-duodenal fistulas are reviewed.
A
neurysms of mesenteric arteries are rare, and most are asymptomatic when detected on cross-sectional imaging. Otherwise, patients may present with gastrointestinal bleeding and abdominal pain if an aneurysm forms a fistula upon rupture. Historically a “herald bleed” often precedes massive exsanguination, thus giving a clinician the opportunity to diagnose an often fatal presentation. Although an arterioenteric fistula is rare, this case highlights the importance of quickly diagnosing and intervening in a highly lethal diagnosis. CASE REPORT A 59-year-old white woman experienced two large episodes of bright red emesis associated with dizziness and near syncope. She was admitted 2 weeks prior for a self-inflected gunshot wound to the anterior abdomen and underwent exploratory laparotomy, which showed perforation in the fourth part of the duodenum and a mesenteric defect around the transverse colon. She underwent successful primary repair. Her hospital course was complicated by atrial fibrillation with rapid ventricular response. On physical examination, her heart rate varied from 130 to 140 beats per minute, with a mean systemic arterial pressure of 60 mm Hg. Bowel sounds were normal, and no localized tenderness was noted. She had a hemoglobin of 5.2 g/dL, platelet count of 176,000/uL, international normalized ratio of 1.3, blood urea nitrogen of 16 mg/dL, and creatinine of 0.55 mg/dL. The patient received four units of packed red blood cells, 2 L of lactated Ringer’s solution, intravenous proton pump inhibitors, and 250 mg of erythromycin prior to endoscopy. Esophagogastroduodenoscopy revealed blood in the stomach and duodenum. After the area was cleaned using a water-jet
30
Figure 1. Pulsating clot in the third part of the duodenum.
pump, a pulsating clot was seen in the third part of the duodenum (Figure 1) attached to the wall with the underlying cavity. No intervention was attempted. Computed tomographic angiography showed attenuation in the diameter of the proximal superior mesenteric artery (SMA) adjacent to an air-fluid collection. There was a blush of contrast adjacent to the third portion of the duodenum and the air-fluid collection (Figure 2). A mesenteric angiogram revealed a pseudoaneurysm of the proximal middle colic artery, a proximal branch of the SMA, with a diseased segment of the middle colic artery proximal to the pseudoaneurysm and contrast extravasation (Figure 3). This area was successfully coiled angiographically without any further gastrointestinal bleeding (Figure 4). Later in the hospitalization, lysis of adhesions was performed during repeat exploratory laparotomy, and a drain was placed into a fluid collection near the duodenal perforation. Due to its location From the Division of Digestive Diseases and Nutrition in the Department of Internal Medicine (Fielding, Frandah, Flomenhoft) and the Department of Radiology (Krohmer), University of Kentucky, Lexington, Kentucky, Corresponding author: Wesam Frandah, MD, Department of Internal Medicine, University of Kentucky, 800 Rose Street, Lexington, KY 40536-0298 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2016;29(1):30–32
Figure 4. Successful endovascular coiling of the bleeding vessel.
Figure 2. Contrast blush on computed tomographic angiogram in the superior mesenteric artery–duodenum area.
near numerous vascular structures and adhesions, no surgical repair was performed on the duodenum. The patient was discharged home 10 days later in stable condition with a hemoglobin of 9.3 g/dL.
Figure 3. Pseudoaneurysm of the middle colic branch (black arrow) of the superior mesenteric artery (white arrow) on mesenteric angiography. January 2016
DISCUSSION Arterioenteric fistulization is a rare, and often feared, presentation of massive gastrointestinal hemorrhage with a high mortality rate. The two types of fistula are primary (from atherosclerosis, an aortic aneurysm, aortitis, penetrating ulcer, radiation, or trauma) or secondary after surgical vascular reconstruction (1, 2). Often, these fistulas develop in the aorta and erode into the duodenum, causing massive hematemesis due to their anatomic proximity (3). In patients with penetrating trauma to the abdominal aorta, 98% have injured viscera as well (4). Patients with arterioenteric fistulas can present with a “herald bleed,” or small episode of bleeding, before massive hemorrhage leading to exsanguination, as described in the first case report by Sir Astley Cooper in 1825 (3). The diagnosis of this presentation can elude the unsuspecting clinician if a thorough history (including any prior vascular repairs) is not obtained. Prompt evaluation, usually with upper endoscopy, should be performed and vascular imaging obtained if a vascular injury is suspected (5). Endoscopic therapy of an adherent clot in the management of gastrointestinal bleeding is controversial. Randomized controlled trials are inconclusive (6, 7). Consensus guidelines state that endoscopic removal can be considered in the management of an adherent clot after injecting the underlying ulcer, or intensive proton pump therapy can be used alone with a similar outcome (8). In our case, because of the clot location, there was significant concern of major vessel communication; the endoscopist thought clot removal would likely lead to massive bleeding and a significant adverse outcome. Because these fistulas are very uncommon, no evidencebased management guidelines are available. Table 1 summarizes all cases of fistulization of the SMA (or its branches) and the duodenum published in the English medical literature (10–18). Most of these reported cases were treated either angiographically or by surgical intervention. Our patient had higher surgical risk and, therefore, we picked the less morbid approach. Exsanguination was the most common cause of death (in 82% of patients) in a series of 28 autopsies of patients
Superior mesenteric artery–duodenal fistula secondary to a gunshot wound
31
Table 1. Published cases of SMA-duodenal fistulas Intestinal segment
Mechanism of fistula
Initial presentation
Later presentation
Third part of duodenum
Gunshot 5 years prior
Hematemesis and pain
Hematemesis
Survived Resections and saphenous vein graft
N/A
1976
10
Proximal branch Second part of Pancreatic cancer of the SMA duodenum
Hematemesis and melena
Hematemesis
Embolization
Died
Not described
1987
11
Branch of the SMA
Third part of duodenum
Melena
Melena
Vasopressin infusion
Died
Massive pulmo- 1991 nary embolism
12
Branch of the SMA
Second part of Pancreatic cancer duodenum after radiation
Emesis and melena
Emesis
Embolization
Died
Exsanguination
2002
13
SMA
Third part of duodenum
Gunshot 1 month prior
Retroperitoneal hematoma
Hematemesis
Ligation of SMA
Died
Cardiac arrest in OR
2002
14
Pancreaticoduodenal artery
Duodenum
Repaired aneurysm
Unknown
Unknown
Ligation
Survived
N/A
2004
15
SMA
Duodenum
Tuberculosis
Massive hematemesis
Massive hematemesis
Duodenectomy
Died
Exsanguination
2004
16
SMA
Third part of duodenum
Pseudoaneurysm
Abdominal pain
Hematemesis
SMA reconstruction
Survived
N/A
2008
17
Inferior pancreaticoduodenal artery
Duodenum
Ruptured pseudoaneurysm
Indigestion, weight loss, jaundice
Hematemesis
Patient refused surgery
Died
Exsanguination
2009
18
Vessel SMA
Metastatic lung cancer to duodenum
Management
Cause of Outcome death
Year published Ref.
SMA indicates superior mesenteric artery; OR, operating room.
with aortoenteric fistulas (9). The vast majority of cases of arterioenteric fistula involve the aorta, but a small number of cases are fistulas from the SMA (or its branches). Including the case described herein, the mortality rate of SMA-duodenal fistulas is 60%, as calculated by collecting all published cases (Table 1).
9.
10.
11. 1.
2. 3. 4.
5.
6.
7.
8.
32
Budimir I, Nikolić M, Supanc V, Ljubicić N, Krpan T, Zovak M, Sabol M. Secondary arterio-enteric fistula: case report and review of the literature. Acta Clin Croat 2012;51(1):79–82. Bergqvist D, Björck M. Secondary arterioenteric fistulation—a systematic literature analysis. Eur J Vasc Endovasc Surg 2009;37(1):31–42. Barry PA, Molland JG, Falk GL. Primary aortoduodenal fistula. Aust N Z J Surg 1998;68(3):243–244. Lopez-Viego MA, Snyder WH 3rd, Valentine RJ, Clagett GP. Penetrating abdominal aortic trauma: a report of 129 cases. J Vasc Surg 1992;16(3):332–335. Schwab CW, McMahon DJ, Phillips G, Pentecost MJ. Aortic balloon control of a traumatic aortoenteric fistula after damage control laparotomy: a case report. J Trauma 1996;40(6):1021–1023. Bleau BL, Gostout CJ, Sherman KE, Shaw MJ, Harford WV, Keate RF, Bracy WP, Fleischer DE. Recurrent bleeding from peptic ulcer associated with adherent clot: a randomized study comparing endoscopic treatment with medical therapy. Gastrointest Endosc 2002;56(1):1–6. Javid G, Masoodi I, Zargar SA, Khan BA, Yatoo GN, Shah AH, Gulzar GM, Sodhi JS. Omeprazole as adjuvant therapy to endoscopic combination injection sclerotherapy for treating bleeding peptic ulcer. Am J Med 2001;111(4):280–284. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, Sinclair P; International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152(2):101–113.
12.
13.
14.
15.
16.
17.
18.
Grande JP, Ackermann DM, Edwards WD. Aortoenteric fistulas. A study of 28 autopsied cases spanning 25 years. Arch Pathol Lab Med 1989;113(11):1271–1275. Maloney RD, Nealon TF Jr, Roberts EA. Massive bleeding from a ruptured superior mesenteric artery aneurysm duodenum. Arch Surg 1976;111(3):286–288. Thorstad BL, Keller FS. Fistula from the superior mesenteric artery to duodenum: a rare cause of death from pancreatic carcinoma. Gastrointest Radiol 1987;12(3):200–202. Steinhart AH, Cohen LB, Hegele R, Saibil FG. Upper gastrointestinal bleeding due to superior mesenteric artery to duodenum fistula: rare complication of metastatic lung carcinoma. Am J Gastroenterol 1991;86(6):771–774. Liu B, Howard JM. Vascular-enteric fistulas associated with radiation therapy in patients with pancreatic adenocarcinoma. HPB (Oxford) 2002;4(2):83–86. Miglietta MA, Tanquilut EM, Madlinger RV, Prial MM, Scalea TM. Superior mesenteric artery-duodenal fistula presenting as a late complication of an abdominal gunshot wound. J Trauma 2002;52(3):554– 555. Sessa C, Tinelli G, Porcu P, Aubert A, Thony F, Magne JL. Treatment of visceral artery aneurysms: description of a retrospective series of 42 aneurysms in 34 patients. Ann Vasc Surg 2004;18(6):695–703. Rao YG, Pande GK, Sahni P, Chattopadhyay TK. Gastroduodenal tuberculosis management guidelines, based on a large experience and a review of the literature. Can J Surg 2004;47(5):364–368. Zhao J. Massive upper gastrointestinal bleeding due to a ruptured superior mesenteric artery aneurysm duodenum fistula. J Vasc Surg 2008;48(3):735–737. Colak MC, Kocaturk H, Bayram E, Karaca L. Inferior pancreaticoduodenal artery false aneurysm: a rare cause of gastrointestinal bleeding diagnosed by three-dimensional computed tomography. Singapore Med J 2009;50(10):e346–349.
Baylor University Medical Center Proceedings
Volume 29, Number 1
