Endoscopic Diagnosis of an The
Aortoduodenal Fistula Michael S. Baker, MD; John H. Fisher, MD; Leo van der Reis, MD; Burton H. Baker, MD \s=b\ An aortoduodenal fistula is a serious complication of aortic reconstructive surgery. This article describes a case in which the diagnosis of an aortoduodenal fistula was made by upper gastrointestinal endoscopy. The endoscopic finding of a vascular prosthesis within the duodenum allowed immediate surgical intervention and control of the gastrointestinal
hemorrhage. (Arch Surg 111:304, 1976) An aortoduodenal fistula is XI aortic vascular surgery.
complication of Arteriography and upper a
serious
gastrointestinal roentgenograms have heretofore been the sole means of establishing the preoperative diagnosis. This report describes the diagnosis of an aortoduodenal fistula by upper gastrointestinal endoscopy, a technique that may provide rapid and precise diagnosis of upper gastrointes¬ tinal hemorrhage. REPORT OF A CASE
brought to the emergency room in shock; blood pressure was palpable at 70 mm Hg, and she was pale, cool, and diaphoretic. Her hematocrit value was 15.8%, and hemo¬ globin level 5.1 gm/100 ml. Intravenous fluid resuscitation improved the patient's sensorium, and she related that she had had a backache in the A
49-year-old
graft
in duodenal lumen seen
showed an aortofemoral graft that had eroded into the duodenum. The graft was bile-stained in this area, and was slowly leaking blood. An axillofemoral bypass graft and femorofemoral crossover was performed to maintain circulation to the lower extremities. The aortofemoral graft was then removed and the duodenal defect closed. The patient is currently well and has no symptoms of vascular insufficiency in the lower extremities.
COMMENT
woman was
thoracolumbar area for one month. Prior to admission, she had vomited coffee ground material, passed bright red bloody stools, and become obtunded. She also stated that she had type II hyperlipoproteinemia, and had undergone an aortofemoral bypass graft six months previously. Endoscopy on the evening of admission showed multiple punc¬ tate hemorrhagic lesions of the stomach and esophagus. Chest roentgenogram and abdominal plain films showed no abnormali¬ ties. Results of upper gastrointestinal barium studies were unre¬ markable. The patient continued to undergo blood loss, as evidenced by decreasing hematocrit values. Repeat endoscopy showed a tubular structure that had the appearance of a vascular graft protruding into the duodenal lumen and oozing bright red blood (Figure). Exploration of the abdomen was performed that evening, and
Accepted
Arrow indicates aortic vascular
through panendoscope.
for publication Sept 10, 1975. From the Public Health Service Hospital, San Francisco (Dr M. Baker and Dr B. Baker), and Mary's Help Hospital, Daly City, Calif (Drs Fisher and van der Reis). Dr B. Baker is now in private practice. Reprint requests to Public Health Service Hospital, 15th Ave and Lake St, San Francisco, CA 94118 (Dr M. Baker).
The cardinal sign of the development of an aortoduode¬ nal fistula is gastrointestinal hemorrhage, as manifested by hematemesis, hematochezia, or melena.'- This complica¬ tion must be strongly suspected when gastrointestinal hemorrhage occurs in a patient who has had aortic recon¬ structive surgery. The diagnosis of an aortoduodenal fistula was made when endoscopy showed a vascular prosthesis in the duode¬ nal lumen. This diagnosis should also be considered when endoscopy demonstrates (1) arterial bleeding in the second or third part of the duodenum, (2) a pulsatile structure in the wall or lumen, (3) a suture line, or (4) a bile-stained structure in a patient who has had aortic reconstructive surgery.
We strongly urge the early and aggressive use of upper gastrointestinal endoscopy as a diagnostic adjunct in upper gastrointestinal hemorrhage. Drs Hollister Brewster and Arnold of this article.
preparation
Goldshlagger
gave advice in the
References 1. Crisler C, Bahnson HT: Aneurysms of the aorta. Curr Probl Surg, December 1972, pp 1-64. 2. Pinkerton JA: Aortoduodenal fistula. JAMA 225:1196-1199, 1973.
Downloaded From: http://archsurg.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/30/2015
Aortoduodenal Fistula Michael S. Baker, MD; John H. Fisher, MD; Leo van der Reis, MD; Burton H. Baker, MD \s=b\ An aortoduodenal fistula is a serious complication of aortic reconstructive surgery. This article describes a case in which the diagnosis of an aortoduodenal fistula was made by upper gastrointestinal endoscopy. The endoscopic finding of a vascular prosthesis within the duodenum allowed immediate surgical intervention and control of the gastrointestinal
hemorrhage. (Arch Surg 111:304, 1976) An aortoduodenal fistula is XI aortic vascular surgery.
complication of Arteriography and upper a
serious
gastrointestinal roentgenograms have heretofore been the sole means of establishing the preoperative diagnosis. This report describes the diagnosis of an aortoduodenal fistula by upper gastrointestinal endoscopy, a technique that may provide rapid and precise diagnosis of upper gastrointes¬ tinal hemorrhage. REPORT OF A CASE
brought to the emergency room in shock; blood pressure was palpable at 70 mm Hg, and she was pale, cool, and diaphoretic. Her hematocrit value was 15.8%, and hemo¬ globin level 5.1 gm/100 ml. Intravenous fluid resuscitation improved the patient's sensorium, and she related that she had had a backache in the A
49-year-old
graft
in duodenal lumen seen
showed an aortofemoral graft that had eroded into the duodenum. The graft was bile-stained in this area, and was slowly leaking blood. An axillofemoral bypass graft and femorofemoral crossover was performed to maintain circulation to the lower extremities. The aortofemoral graft was then removed and the duodenal defect closed. The patient is currently well and has no symptoms of vascular insufficiency in the lower extremities.
COMMENT
woman was
thoracolumbar area for one month. Prior to admission, she had vomited coffee ground material, passed bright red bloody stools, and become obtunded. She also stated that she had type II hyperlipoproteinemia, and had undergone an aortofemoral bypass graft six months previously. Endoscopy on the evening of admission showed multiple punc¬ tate hemorrhagic lesions of the stomach and esophagus. Chest roentgenogram and abdominal plain films showed no abnormali¬ ties. Results of upper gastrointestinal barium studies were unre¬ markable. The patient continued to undergo blood loss, as evidenced by decreasing hematocrit values. Repeat endoscopy showed a tubular structure that had the appearance of a vascular graft protruding into the duodenal lumen and oozing bright red blood (Figure). Exploration of the abdomen was performed that evening, and
Accepted
Arrow indicates aortic vascular
through panendoscope.
for publication Sept 10, 1975. From the Public Health Service Hospital, San Francisco (Dr M. Baker and Dr B. Baker), and Mary's Help Hospital, Daly City, Calif (Drs Fisher and van der Reis). Dr B. Baker is now in private practice. Reprint requests to Public Health Service Hospital, 15th Ave and Lake St, San Francisco, CA 94118 (Dr M. Baker).
The cardinal sign of the development of an aortoduode¬ nal fistula is gastrointestinal hemorrhage, as manifested by hematemesis, hematochezia, or melena.'- This complica¬ tion must be strongly suspected when gastrointestinal hemorrhage occurs in a patient who has had aortic recon¬ structive surgery. The diagnosis of an aortoduodenal fistula was made when endoscopy showed a vascular prosthesis in the duode¬ nal lumen. This diagnosis should also be considered when endoscopy demonstrates (1) arterial bleeding in the second or third part of the duodenum, (2) a pulsatile structure in the wall or lumen, (3) a suture line, or (4) a bile-stained structure in a patient who has had aortic reconstructive surgery.
We strongly urge the early and aggressive use of upper gastrointestinal endoscopy as a diagnostic adjunct in upper gastrointestinal hemorrhage. Drs Hollister Brewster and Arnold of this article.
preparation
Goldshlagger
gave advice in the
References 1. Crisler C, Bahnson HT: Aneurysms of the aorta. Curr Probl Surg, December 1972, pp 1-64. 2. Pinkerton JA: Aortoduodenal fistula. JAMA 225:1196-1199, 1973.
Downloaded From: http://archsurg.jamanetwork.com/ by a Karolinska Institutet University Library User on 05/30/2015
