JOURNAL AVAILABLE AT RADIOLOGYUPDATE.ORG Aortoenteric fjstula: clinical case presentation Viktorija VITKUTĖ 1 , Eglė BAKUČIONYTĖ 2 , Paulina TEKORIUTĖ 1 1 Lithuanian University of Health Sciences, Academy of Medicine, Faculty of Medicine, Kaunas, Lithuania 2 Republic Hospital of Klaipeda, Klaipeda, Lithuania ABSTRACT Aortoenteric fjstula (AEF) is a rare but life-threatening condition characterized by abnormal communication between the aorta and any part of the intestinal tract. It has been suggested that primary AEF arises from an abdominal aortic aneurysm, and secondary is caused by an infection, usually consistent with aortic grafu. We present a case report of secondary AEF presented with severe bleeding from the gastrointestinal (GI) tract followed by aortic grafu infection. Keywords: Aortoenteric fjstula, gastrointestinal bleeding, abdominal aortic aneurysm, aortic grafu INTRODUCTION for the last 24 hours. On the day of admission, his vitals were normal. His past medical histo- Tiere are many reasons for bleeding from the GI ry included primary arterial hypertension and tract, and it is essential not to miss an uncom- heart failure. Six years earlier, the patient was mon cause such as AEF. It is a pathological com- diagnosed with an AAA and undergone treat- munication between the aorta and any part of ment with an aortic grafu. Tie initial examina- an intestinal tract (1). AEF is an uncommon but tion was unremarkable. Tie digital rectal exam- life-threatening condition with an incidence rate ination revealed melena. Initial laboratory tests of 1.6 – 4% (2). Tiis pathology was described for showed haemoglobin level 117 g/l, white blood the fjrst time by Sir Ashley Cooper in 1818 (3). cells (WBC) count 7,5 x 109/l, platelet count 217 AEF is associated with diagnostic challenges - it x 109/l, prothrombin time 33,4 seconds, interna- requires careful attention to a patient’s history tional normalized ratio (INR) 1,14, C – reactive and relies on clinical acumen (4). protein (CRB) 5 mg/l , creatinine 85 μmol/l and Tiere are two difgerent types of AEF – prima- urea 14,91 mmol/l. Electrolytes were normal. ry and secondary, depending on their etiology. In the emergency room, esophagogastroduo- Primary AEFs commonly arise from an abdom- denoscopy (EGDS) was performed immediately inal aortic aneurysm (AAA), and secondary is due to melena. EGDS showed bleeding from the a complication of reconstructive surgery of an lower part of the duodenum. However, there was AAA (2 - 6). no possibility to stop the bleeding during the ex- Tie immediate diagnosis and urgent surgery is amination. the only way to save a patient. Otherwise, the Later the patient became hemodynamically un- mortality of untreated pathology reaches almost stable (blood pressure 70/30 mmHg) 100% (1). . Repeated laboratory investigation showed a he- We report a rare case of a secondary AEF fol- moglobin level decrease 97 g/l, INR 1,28, CRB lowed by abdominal aortic grafu infection, pre- 5 mg/l. In the department of intensive care, two sented with GI bleeding. Our purpose is to raise units of packed red blood cells, and two units of awareness of this catastrophic condition. fresh frozen plasma were transfused. Due to the history of AAA repair, computer to- CASE REPORT mography aortography (CTA) was performed A 72–year-old man presented to our hospital to urgently for a potential life-threatening second- ary AEF. CTA revealed adhesion between the the emergency department with general weak- ness, vomiting of blood, and black tarry stools aortic grafu distal part, near the anastomosis, and 32
RADIOLOGY UPDATE VOL. 3 (6) ISSN 2424-5755 Figure 1. CTA coronal view- contrast media extravasation Figure 2. CTA sagittal view- communication between in the duodenum aorta and duodenum Figure 4. CT with contrast media afuer AEF closing sur- gery - air in the aortic grafu, perigrafu infjltration Figure 3. CTA axial view- contrast media extravasation in the duodenum duodenum. Tiere was enhanced blood in the grafu was resected, and axillobifemoral bypass duodenum, indicating communication between surgery was performed, the AEF was occluded. the aorta and the intestinal tract (Figure – 1, 2, Unfortunately, afuer some days, the patient had 3). CTA undoubtedly helped facilitate the diag- the following complication – sepsis caused by nosis of AEF. E.coli occurred, which was correctly treated, and Tie patient was shifued to another hospital for the patient remained alive. further treatment of the vascular surgery unit. During the surgery, a suppurative aortic grafu and 1 cm defect in the duodenum were found. Tie 33
JOURNAL AVAILABLE AT RADIOLOGYUPDATE.ORG AEF is characterized by the classical triad: ab- DISCUSSION dominal pain, gastrointestinal blood loss, which AEFs are divided into two types - primary and can be acute or chronic, and pulsating abdominal mass (1, 8, 9). However, this triad is only found secondary. According to statistics, the incidence rate of secondary AEF is approximately 2,5 times in 11 – 38,5% patients, which makes diagnosis more common than primary (3, 4, 6). even more challenging (1). Abdominal pain can occur only in 35% of patients, pulsating mass in Primary AEFs commonly arise from an AAA of which 85% are atherosclerotic (3, 5, 6), and 25% patients, and the most frequent gastrointes- tinal bleeding presents in 94% cases, as in our it occurs when an erosive aortic segment opens into the adjacent gastrointestinal lumen (4). case. In addition to severe bleeding, signifjcant Rare known conditions related to primary AEF hemodynamic instability ofuen occurs (10). Oth- er symptoms consistent with this pathology may are tuberculosis, syphilis, infection, cancer, for- eign bodies, and collagen vascular disease (2, 3, be intermittent back pain, fever, sepsis, weight loss, and syncope (1). Our patient presented with 6). Even the case of vertebral osteophyte has also been shown to infmuence the development of an melena, haematemesis, and general weakness. AEF (7). Commonly used diagnostic methods for AEFs are abdominal CT with intravenous contrast, Secondary AEF is a complication of reconstruc- tive surgery of an AAA, involving open repair interventional angiography, and EGDS (3). Tie detection rates for each of these modalities are surgery and endovascular treatment, as well as vascular grafus (2, 4). It is more common in pa- 61%, 26%, and 25%, respectively (6). According tients with a history of open aortic repair com- to Chick JFB et al. in the article 'Aortoenteric fjstulae temporization and treatment: lessons paring with patients afuer endovascular stent placement. An abnormal communication can learned from a multidisciplinary approach to 3 patients’ , CT angiography is the fjrst-line imag- develop between the aorta and any part of the intestinal tract. An estimated 80% of secondary ing modality for the detection of aortoenteric AEFs afgect the duodenum, mostly the third and fjstula and has a reported sensitivity of 94% and specifjcity of 85% (8). fourth parts (the horizontal and ascending duo- denum) and the proximal suture line of the aorta Concerning CTA fjndings, active extravasation of contrast media in the GI tract is reported the (3), just as in our case. Tie involvement of the other gastrointestinal segments are less frequent; most ofuen, any part of intestines are seen in close for instance, aortocolonic fjstulae occur only 5 to contact with an AAA or an aortic grafu, there is ofuen fat infjltration around the aortic grafu, con- 6% of all cases (4). MacDougall L. et al., in the article 'Aorto-enteric sistent with infection. Just afuer secondary AEF closing, CT fjndings such as fmuid, ectopic gas, fjstulas: a cause of gastrointestinal bleeding not to be missed,' says that the pathogenesis of this and per grafu sofu tissue edema can be normal- disease has not yet been fully understood (3), ly seen (Figure 4). However, 3 – 4 weeks later, any ectopic gas is abnormal means perigrafu in- but there are two theories. Tie fjrst theory sug- gests that fjstula formation is caused by repeated fection and possibly fjstulization to a GI tract. In 2 – 3 months afuer surgery, the perigrafu sofu mechanical trauma between the pulsating aor- ta and duodenum, and the second asserts low- tissue thickening, hematoma, or fmuid should be grade infection as the primary event with abscess resolved (3). Tie main goals of treatment are control of bleed- formation and subsequent erosion through the bowel wall. Tie second theory is the most likely ing and revascularization, repair of intestinal defects, and eradication of related infection. In because the majority of grafus show signs of in- fection at the time of bleeding, and approximate- this case, surgical intervention is performed, and ly 85% of cases have blood cultures positive for antibiotics are supplied (1, 3). Tie treatment has been improved for many years. Despite numer- enteric organisms (5). In our case, there was the grafu infection caused by E. coli positive culture, ous surgical techniques, many patients do not survive or may remain weak afuer surgery. which also applies the second theory. 34
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