Arterioenteric Fistula Research Articles

A Rare Cause of Gastrointestinal Bleeding in a Kidney-Pancreas Transplant Recipient – Case Report

Kidney-pancreas transplantation is the preferable therapeutic option for patients with type 1 diabetes mellitus and end-stage kidney disease. We describe the case of a 35-year-old pancreas-kidney transplant recipient with dual-graft failure that presents with massive hematochezia and hemodynamic instability, evolving into hemorrhagic shock. The diagnostic assessment revealed a fistula between a pseudoaneurysm of the right common iliac artery and the adjacent transplanted duodenum segment, a rare but life-threatening cause of gastrointestinal bleeding in these patients. An endoprosthesis was placed into the iliac artery, prophylactic antibiotics were instituted, and a pancreatic transplantectomy was performed in a second procedure. This case highlights that the diagnostic workup of gastrointestinal bleeding in pancreas-kidney transplant recipients must include the possibility of arterio-enteric fistulas, which is more frequent in the presence of pancreatic graft failure, as was the case of our patient. Endovascular exclusion is the advocated treatment. Pancreatic graft transplantectomy could also be a possible approach for patients with a failed pancreas but it is highly controversial due to potential risks.

Interventional Radiology Approaches for Managing Postpancreatic Transplant Complications and Type 1 Diabetes Mellitus

Type 1 diabetes mellitus (T1DM) is a chronic autoimmune disorder characterized by the destruction of insulin-secreting beta cells in the pancreas, resulting in metabolic disturbances and long-term complications. While subcutaneous insulin remains the primary approach for achieving normoglycemia, pancreatic transplantation has emerged as an effective intervention for long-standing T1DM, providing insulin independence and normalized glycosylated hemoglobin levels. However, complications associated with pancreatic transplantation are frequent, necessitating thorough evaluation using diverse imaging modalities. This manuscript presents an overview of vascular complications encountered with pancreatic transplantation, including vascular complications such as arterial and venous graft thrombosis, vessel stenosis, pseudoaneurysm, arterio-enteric fistula, and arteriovenous malformations (AVM). Additionally, the manuscript discusses other associated complications such as pancreatitis, pseudocyst formation, fistulas, pseudo-thrombosis of the iliac vein, post-transplantation lymphoproliferative disorder, and fluid collections. The integration of various imaging modalities plays a crucial role in diagnosing and managing these complications, with interventional radiologists assuming a vital role in employing image-guided procedures. Moreover, the manuscript explores pancreatic islet cell transplantation as a promising cellular-based therapy for T1DM, offering stable long-term glycemic control and decreased reliance on exogenous insulin in a significant proportion of recipients. This minimally invasive procedure involves the image-guided transcatheter infusion of islet cells obtained from deceased donors into the recipient's liver. The importance of interventional radiologists in managing complications related to pancreatic transplantation is underscored, with endovascular or image-guided approaches being utilized to address the diverse spectrum of encountered complications. Furthermore, the potential of islet cell transplantation as a minimally invasive alternative to traditional pancreatic transplantation is emphasized, as it offers the prospect of alleviating many associated complications.

Colorectal Malignancy Complicated by Arterioenteric Fistula.

Arterioenteric fistulas (AEF) are rare and devastating complications of colorectal/pelvic malignancies. These fistulas can be seen following neoadjuvant or adjuvant therapy but are exceptionally rare de novo. The reported incidence of AEF is less than 1% and iliac artery-enteric fistulas make up less than .1% of all AEF. Here we present a patient in hemorrhagic shock secondary to an advanced colorectal malignancy without adjuvant therapies with local invasion of the right external iliac artery. Following initial resuscitation and hemorrhage control with coil embolization, definitive control with ligation and excision of the involved artery, end colostomy, and ureteral stent placement was achieved. It is important to consider malignancy as the source of lower gastrointestinal bleeds, especially in elderly patients without current colonoscopy studies. The management of this unfortunate diagnosis often involves a multidisciplinary approach with early and frequent goals of care discussions.

Endovascular treatment of massive hemorrhage from a radiation-induced iliac artery-enteric fistula: A case report and review of the literature

Arterioenteric fistula is a rare cause of massive gastrointestinal tract hemorrhage. It is defined as an abnormal communication between an artery and a bowel loop. Radiation-induced iliac artery-enteric fistula (IEF) is an extremely rare subtype with only a few cases reported in the literature. Here, we present a case of successful endovascular treatment of massive hemorrhage due to radiation-induced IEF.

Nonvariceal Upper Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding that is proximal to the ligament of Treitz is considered upper GI bleeding (UGIB). UGIB can be further divided into variceal and nonvariceal, differentiated by etiology, presentation, management, and mortality. This review of nonvariceal UGIB addresses the epidemiology, diagnosis, treatment (including endoscopic therapy), prognosis, and differential diagnosis. Recommendations presented are evidence based and consistent with consensus statements and society guidelines. Figures show stigmata of recent hemorrhage, endoscopic therapy, peptic ulcer disease, Mallory-Weiss syndrome, angiodysplasia, Dieulafoy lesion, and arterioenteric fistula. Tables list the manifestation of GI bleeding and the presumed source of the bleeding, clues in the symptom and presentation of the patient that may suggest the diagnosis, medical history and physical examination findings that can suggest a specific diagnosis, a comparison of different prognostic scoring systems, differential diagnosis of UGIB, various etiologies of peptic ulcer disease, and treatment regimens for Helicobacter pylori. This review contains 7 highly rendered figures, 10 tables, and 85 references

Nonvariceal Upper Gastrointestinal Bleeding

Gastrointestinal (GI) bleeding that is proximal to the ligament of Treitz is considered upper GI bleeding (UGIB). UGIB can be further divided into variceal and nonvariceal, differentiated by etiology, presentation, management, and mortality. This review of nonvariceal UGIB addresses the epidemiology, diagnosis, treatment (including endoscopic therapy), prognosis, and differential diagnosis. Recommendations presented are evidence based and consistent with consensus statements and society guidelines. Figures show stigmata of recent hemorrhage, endoscopic therapy, peptic ulcer disease, Mallory-Weiss syndrome, angiodysplasia, Dieulafoy lesion, and arterioenteric fistula. Tables list the manifestation of GI bleeding and the presumed source of the bleeding, clues in the symptom and presentation of the patient that may suggest the diagnosis, medical history and physical examination findings that can suggest a specific diagnosis, a comparison of different prognostic scoring systems, differential diagnosis of UGIB, various etiologies of peptic ulcer disease, and treatment regimens for Helicobacter pylori. This review contains 7 highly rendered figures, 10 tables, and 85 references

Successful Surgical Management of an External Iliac Arterio-enteric Fistula after Surgery for Uterine Cancer

Successful Surgical Management of an External Iliac Arterio-enteric Fistula after Surgery for Uterine Cancer

Lower gastrointestinal bleeding due to iliac artery-cecal fistulax: A late presentation of blunt injury abdomen

We report a case of an arterio-enteric fistula between an Right iliac artery and otherwise healthy cecum, presenting with torrential lower gastrointestinal bleed in an 14-year-old patient. Whilst fistulization to the aorta and common iliac arteries has been reported, to our knowledge no previous cases of post traumatic fistulization between an right iliac artery and normal cecum has been reported. Successful open exploration primary repair of iliac artery rent with ileostomy and colostomy was done. Later stoma reversal was done successfully.

Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

Superior Mesenteric Artery-Duodenal Fistula Secondary to a Gunshot Wound

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.

Allograft Pancreatectomy: Indications and Outcomes

This study evaluated the indications, surgical techniques, and outcomes of allograft pancreatectomy based on a single center experience. Between 2003 and 2013, 47 patients developed pancreas allograft failure, excluding mortality with a functioning pancreas allograft. Early graft loss (within 14 days) occurred in 16, and late graft loss in 31. All patients with early graft loss eventually required allograft pancreatectomy. Nineteen of 31 patients (61%) with late graft loss underwent allograft pancreatectomy. The main indication for early allograft pancreatectomy included vascular thrombosis with or without severe pancreatitis, whereas one recipient required urgent allograft pancreatectomy for gastrointestinal hemorrhage secondary to an arterioenteric fistula. In cases of late allograft pancreatectomy, graft failure with clinical symptoms such as abdominal discomfort, pain, and nausea were the main indications (13/19 [68%]), simultaneous retransplantation without clinical symptoms in 3 (16%), and vascular catastrophes including pseudoaneurysm and enteric arterial fistula in 3 (16%). Postoperative morbidity included one case each of pulmonary embolism leading to mortality, formation of pseudoaneurysm requiring placement of covered stent, and postoperative bleeding requiring relaparotomy eventually leading to femoro-femoral bypass surgery 2 years after allograftectomy. Allograft pancreatectomy can be performed safely, does not preclude subsequent retransplantation, and may be lifesaving in certain instances.

Arterio-enteric fistula between iliac artery and cecum as an endograft complication

Endovascular treatment of aneurysms and pseudoaneurysms is more frequently employed in emergent situations since it is less invasive and has lower morbidity. Although it has excellent immediate results in regard to patency and sealing of the aneurysm, long term follow up is advised due to the risk of endoleak or graft migration. Arterio-enteric fistulas are less commonly encountered complications following endovascular procedures mostly between aorta and duodenum. Here, we present a late arterio-enteric fistula in the cecum following an endovascular repair of a pseudoaneurysm in iliac position accompanied with arterio-ureteral fistula. The patient was successfully treated by surgical approach.

Bleeding Arterioenteric Fistula between a Right Internal Iliac Artery Aneurysm After an Exclusion Operation and Sigmoid Colon Treated by Collateral Embolization: A Case Report

Bleeding Arterioenteric Fistula between a Right Internal Iliac Artery Aneurysm After an Exclusion Operation and Sigmoid Colon Treated by Collateral Embolization: A Case Report

Meckel’s Diverticulum Masquerading as an Arterio-Enteric Fistula in an Adult Patient With Simultaneous Pancreas-Kidney Transplantation

Introduction: Simultaneous pancreas-kidney (SPK) transplantation is a treatment for patients with type1 diabetes (DM) and end-stage renal disease (ESRD). Complications of SPK transplantation include peripancreatic abscess, enterocutaneous fistula, and rarely, gastrointestinal bleeding (GIB). We report a case of an adult patient with SPK transplantation who presented with massive GIB caused by Meckel’s diverticulum. Case Report: A 40-year-old male presented 3 years after SPK transplantation to an outside hospital with maroon-colored stool and dizziness. His co-morbidities included DM, ESRD, coronary artery disease, hepatitis C, nonalcoholic steatohepatitis, and cirrhosis. He was hypotensive (94/43), but otherwise, vitals were within reference range. His exam was significant for a soft abdomen with normoactive bowel sounds and mild confusion without any focal deficits or asterixis. Labs were notable for a hemoglobin of 5.9 g/dL, creatinine 1.73 mg/dL (baseline 1.1 mg/dL), BUN 64 mg/dL, and liver function tests within reference range. An esophagogastroduodenoscopy (EGD) revealed presumed Dieulafoy’s lesion, which was cauterized and clipped. Colonoscopy showed mild inflammation, but no obvious source of bleeding. Biopsies were negative for infection or inflammatory bowel disease. The patient was transferred to our center for management of persistent GIB (requiring 26 units of blood total) and worsening renal function. At our center, EGD, colonoscopy, push enteroscopy, tagged RBC scan, and provocative angiography were negative for the source of bleeding. Video capsule endoscopy showed a large amount of red blood in the small bowel without adequate identification of the source lesion. Exploratory laparotomy with intraoperative small bowel endoscopy was performed, which demonstrated a healthy appearing anastomosis with a more distal Meckel’s diverticulum full of clotted blood. The diverticulum was excised without recurrent bleeding. Discussion: The differential for lower GIB is vast, but in adult patients, Meckel’s diverticulum is a rare cause. Patients status-post SPK transplantation have additional considerations for GIB, including anastomotic site ulcer, pseudoaneurysm, arterioenteric fistula, severe graft rejection, and cytomegalovirus infection. This is a rare case of GIB secondary to Meckel’s diverticulum in patients with SPK transplantation. Clinicians should be aware of Meckel’s diverticulum as a cause of massive GIB in SPK transplant patients. A high index of suspicion and timely evaluation can improve morbidity and mortality.

Delayed Gastrointestinal Bleeding in a Case of Failed Graft Pancreatic and Kidney Transplant: Presidential Poster

Introduction: Arterioenteric fistulae and pseudoaneuryms, although rare, are potentially lifethreatening complications of simultaneous kidney and pancreatic transplants (SPAK). We describe a case of a 53-year-old white man, a recipient of SPAK transplant in 2003, who presented to the emergency department with near syncope following 2 episodes of maroon-colored stools. The kidney and pancreas grafts failed, and he was being treated with insulin and hemodialysis, respectively. The transplanted kidney was resected in 2009, following an infection. A screening colonoscopy done in 2010 was unremarkable. Upon presentation, he was resuscitated with intravenous fluids and multiple blood transfusions for hypovolemic shock from acute blood loss. (Hemoglobin had decreased from 11 gm/dL 1 month ago to 6.9 gm/dL on admission.) Abdominal exam was unremarkable. Gastric lavage revealed bilious fluid, but no blood. Rectal exam revealed maroon stool. An emergent CT angiography showed a 12 mm x 20 mm pseudoaneurysm arising from the right external iliac artery. An emergent stent-assisted coil embolization was performed by interventional radiology; hemostasis and hemodynamic stability were achieved. Three days after the index embolization, he had further episodes of hematochezia,warranting an emergent pelvic angiogram, which demonstrated continued patency of the pseudoaneurysm. Occlusion of the right external iliac artery with a covered stent was subsequently performed. A colonoscopy on day 4 revealed only a few scattered sigmoid diverticula and ulcerated mucosa of the ileocecal valve without active bleeding. An elective exploratory laparotomy revealed the site of the fistula. The renal graft remnant was found to be anastamosed to the iliac artery. Bowel was dissected from the underlying graft, and a 5-cm resection of the bowel was performed. The patient had no further episodes of bleeding and was stable at the time of discharge. Arterial pseudoanerysms and areterio-enteric fistuale are known complications of SPAK transplants. Most of these occur early in the post-operative period. Fistulae are seen in the setting of pancreatic graft failure. This can occur because of anatomic apposition of the arterial and enteric anastomoses or a result of proteolytic enzymes released from the pancreatic graft. Lower gastrointestinal bleeding in patients with failed SPAK transplants should raise a high suspicion for arterioenteric fistulae, and early diagnosis with angiography can be life-saving. Multimodality treatment with percutaneous stenting, coil embolization, and operative correction usually achieve satisfactory results.

Arterio-Enteric Fistula in Failed Enteric-Drained Pancreas Transplants: An Impending Danger

Enteric drainage is the preferred method of exocrine diversion in simultaneous kidney-pancreas transplantation. Because of improvements in immunosuppression, enteric drainage has become the preferred method of pancreas transplantation in general. Although associated with less potential complications than bladder-drained pancreas, potentially lethal arterio-enteric fistulas in the setting of nonfunctioning allografts represent a constant threat. We herein present a case report, a review of the literature, and a call for caution.

Massive Gastrointestinal Bleed from Arterioenteric Fistula due to Graft Pancreas Iliac Artery Aneurysm in a Patient with Pancreas-Kidney Transplant

Massive Gastrointestinal Bleed from Arterioenteric Fistula due to Graft Pancreas Iliac Artery Aneurysm in a Patient with Pancreas-Kidney Transplant

A Primary Arterio Enteric Fistula with Takayasu Arteritis

Arterio enteric fistulas (AEFs) are rare. We herein report a case of a primary arterio enteric fistula of the rectum associated with Takayasu arteritis. A 77-year-old woman presented with acute massive hematochezia and was taken to our hospital. Colonoscopy revealed pulsatile extrinsic rectal wall compression with an exposed blood vessel. Transvaginal ultrasonography and Doppler ultrasound revealed a localized vascular growth laying on the dorsal surface of the uterus that showed an arterial blood-flow signal. We diagnosed the patient to have a pelvic aneurism that had formed a fistula within the rectal wall. We eliminated the aneurysm by ligating the drainage and feeder arteries. Following surgery, the patient did not experience any relapses of hematochezia.

Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft

We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI) hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD) and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC) imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population.

Vascular catastrophes following pancreas transplantation: an evolution in strategy at a single center

Complications of pancreas transplantation involving the arterial anastomosis are potentially life threatening. In this report, we review our experience with such vascular catastrophes. Pancreas transplants performed between January 2003 and December 2009 were reviewed. All cases of pseudoaneurysm (PA) or arterioenteric fistula (AEF) were included. Of 346 pancreas transplants, 10 vascular catastrophes in nine recipients were identified. There were five PAs, one involving the pancreas allograft, one involving the donor iliac artery Y-graft stump following allograft pancreatectomy, two involving the kidney allograft, and one involving the bifurcation of the Y-graft. The latter was treated with coil embolization, but subsequently developed into an AEF. There were five AEFs including the recipient mentioned above. Four had a failed allograft and three had discontinued immunosuppression. The final case had a clamp injury to the proximal common iliac artery that fistulized to the donor duodenum. The management, course and outcome of all nine recipients are described in detail. Vascular catastrophes such as PA and AEF are potentially life-threatening complications of pancreas transplantation. Immediate treatment at the time of bleeding is essential and covered stenting of the involved artery may provide immediate vascular control in these situations.