Primary Aortoenteric Fistula
Definition: arises de novo between the aorta and bowel Epidemiology: less common than secondary aortoenteric fistula Physiology May Involve Septic Aortitis with Formation of Aneurysm or False Aneurysm Which Erodes into Adjacent Structures Commonly Isolated Organism Include Salmonella and Staphylococcus (J Vasc Surg, 1989) [ MEDLINE] Locations Duodenum (Aortoduodenal Fistula): duodenum accounts >75% of primary aortoenteric fistulas Most are Located in the 3rd-4th Portion of Duodenum, Where the Duodenum is Most Closely Located to the Aorta (Surgery, 1977) [ MEDLINE] Stomach (Aortogastric Fistula) Jejunum (Aortojejunal Fistula) Ileum (Aortoilial Fistula Sigmoid Colon (Aortosigmoid Fistula) Secondary Aortoenteric Fistula
Definition: arises between aorta and bowel following an aortic reconstruction procedure Epidemiology: more common than primary aortoenteric fistula Physiology: unclear, but may involve pulsating motion of the graft against the bowel wall, adhesion of an infected inflamed graft to the bowel, etc Prior Procedures Surgically-Placed Aortic Graft: most common Aortic Stent Graft Bare Metal Aortic Stent Infrarenal Aortic Ligation: importantly without any prosthetic material Locations Duodenum (Aortoduodenal Fistula): accounts for most secondary aortoenteric fistulas Colon: less common site of involvement
Technique *Abdominal/Pelvic CT with Intravenous Contrast: Abdominal/Pelvic CT Angiogram: Findings: either the fistula itself or gas/liquid surrounding the aortic graft Esophagogastroduodenoscopy (EGD) (see
Aortoenteric Fistula with Gastrointestinal Hemorrhage
General Comments Classic Triad: palpable abdominal mass + abdominal pain + gastrointestinal hemorrhage Classic Triad Occurs in Only 6-12% of Cases Abdominal Mass (see Abdominal Mass) Abdominal Pain (see Abdominal Pain) Gastrointestinal Hemorrhage (see Gastrointestinal Hemorrhage) Degree of Hemorrhage Ranges from “Herald Bleed” to Exsanguinating Hemorrhage Gastrointestinal Hemorrhage is the Most Common Presentation of Aortoenteric Fistula Rapid Exsanguination is More Common in Secondary Aortoenteric Fistula Anastomotic Fistulas More Commonly Present with Acute Gastrointestinal Hemorrhage, While Prosthetic Fistulas Often Did Not Present with Gastrointestinal Hemorrhage or Presented with Chronic Gastrointestinal Hemorrhage (Ann Surg, 1985) [ MEDLINE] Aortoenteric Fistula with Other Manifestations
Paraprosthetic-enteric fistula. Surgery. 1977 May;81(5):556-66 [ MEDLINE] Mycotic aortic pseudoaneurysm with aortoenteric fistula caused by Arizona hinshawii. Surgery. 1982 Feb;91(2):173-7 Gastrointestinal tract involvement by prosthetic graft infection. The significance of gastrointestinal hemorrhage. Ann Surg. 1985 Sep;202(3):342-8 [ MEDLINE] Tuberculous aortitis presenting with an aortoduodenal fistula: a case report. Angiology. 1986 Jul;37(7):519-23 Primary aortoduodenal fistula caused by Salmonella aortitis. J Vasc Surg. 1987 Oct;6(4):415-8 [ MEDLINE] A ten-year experience with bacterial aortitis. J Vasc Surg. 1989 Oct;10(4):439-49 [ MEDLINE] Aortoenteric fistula: present-day management. Int Surg. 2011;96:266–273 [ MEDLINE] Diverse presentation of secondary aortoenteric fistulae. Case Rep Med. 2011;2011:406730. Epub Dec 29 [ MEDLINE] Clinical problem-solving. The search is on. N Engl J Med. 2013;368:562–567 [ MEDLINE]
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