Herald Bleeding Research Articles

Too big to fail?-An aggressive strategy for a dire problem.

Tracheo-innominate fistula (TIF) is a reported complication of tracheostomy that typically presents with a herald bleed. The phenomenon of an aortotracheal fistula has similar pathology and presentation to TIF, but no standard surgical repair. In the manuscript by Musgrove et al. in the Journal of Cardiac Surgery, the authors propose a surgical treatment that is reproducible for the correct anatomic configuration-an ascending and aortic arch replacement, pericardial patch of the tracheal defect, and omental flap coverage. While this intervention is a large undertaking for a small defect, it is a safe and durable repair.

AORTO-GASTRIC FISTULA: A CATASTROPHIC CONNECTION

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aorto-gastric/esophageal fistula is an abnormal communication between the gastrointestinal tract and the aorta. A high level of suspicion is required to diagnose it, as routine tests to diagnose upper gastrointestinal bleeding (UGIB) only detect one-third of the cases. We present a fatal case of aorto-gastric fistula. CASE PRESENTATION: A 60-year-old male presented to the hospital with multiple episodes of hematemesis with epigastric pain lasting for a day. He has a past medical history of esophageal adenocarcinoma treated with esophagectomy and adjuvant radiation twenty years back. The patient reported that since the last four weeks, he started taking an escalating dose of ibuprofen for new-onset lower back pain. On presentation, he was hemodynamically stable with a blood pressure of 120/70 mm Hg and a heart rate of 80 beats/minute. Physical examination was notable for epigastric tenderness. Labs revealed hemoglobin of 13gm/dl, normal electrolytes, liver, and renal function tests. He was started on intravenous fluids and intravenous pantoprazole. While we were planning for an upper endoscopy, he had an episode of large volume hematemesis leading to profound hypotension. He underwent an urgent computerized tomography scan of the chest that revealed an aorto-gastric fistula to the descending thoracic aorta. He was emergently taken to the operating room for an endovascular repair with successful repair of the fistula; however, the patient suffered a massive ischemic stroke post-procedure. Upon discussion with his family, his goals of care were transitioned to comfort. DISCUSSION: Aorto-gastric/esophageal fistula is a rare but catastrophic cause of UGIB. It can be secondary to foreign body ingestion, descending thoracic aneurysm, or malignancy. It is also seen as an early complication of esophagectomy and often presents 2-3 weeks after esophagectomy (1). The exact incidence is unknown, as a vast majority of people die before a definitive diagnosis is made. The patients present with the usual triad of symptoms called the Chiari’s triad that is characterized by midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval. Initial bleeding causes a drop in blood pressure that leads to a temporary cessation of bleeding due to clot formation (2). However, once the fluid resuscitation begins, there is clot dislodgment and rebleeding. CT arteriogram can show active extravasation from the aorta. Once the fistula is diagnosed, it should be treated emergently with aortic stenting and repair to control the bleeding. CONCLUSIONS: Gastrointestinal bleeding due to aorto-gastric fistula is a devastating and life-threatening complication of esophagectomy. It should be kept in mind that this often presents as a herald bleed, and causes massive bleeding after a symptom-free interval. Hence, timely intervention is essential. Reference #1: Molina-Navarro C, Hosking SW, Hayward SJ, Flowerdew AD. Gastroaortic fistula as an early complication of esophagectomy. Ann Thorac Surg. 2001;72(5):1783-8. Reference #2: Kokatnur L, Rudrappa M. Primary aorto-esophageal fistula: Great masquerader of esophageal variceal bleeding. Indian J Crit Care Med. 2015;19(2):119-21. DISCLOSURES: No relevant relationships by Ayesha Azmeen, source=Web Response No relevant relationships by Dimitrios Drekolias, source=Web Response No relevant relationships by Raymond Foley, source=Web Response No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Anantha Sriharsha Madgula, source=Web Response No relevant relationships by Mahati Paravathaneni, source=Web Response

AORTOESOPHAGEAL FISTULA PRESENTING AS HEMATEMESIS AFTER UPPER ENDOSCOPY

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aortoesophageal fistulas (AEFs) are a rare and deadly cause of upper gastrointestinal bleeds. Prior repair of the thoracic aorta, primary aortic aneurysms, foreign body ingestion and thoracic cancer account for more than 90% of AEFs. Here we present the case of a patient developing AEF after a diagnostic esophagogastroduodenoscopy (EGD). CASE PRESENTATION: A 72-year-old male smoker with a history lung cancer status post right lobectomy presented with months of progressive solid dysphagia. In the past months he underwent two EGDs with balloon dilation of esophageal strictures, of which the most recent one was complicated by a distal esophageal perforation requiring an esophageal stent. Weeks after stent removal his dysphagia returned, prompting a repeat EGD to obtain biopsies of his stricture [Figure 1A-B]. The post-operative course was complicated by a small episode of hematemesis, for which the patient was offered admission for observation but declined. After eating his first meal at home, the patient had a second episode of hematemesis which prompted him to present to the emergency department. On admission, the patient was noted to have hematemesis necessitating a rapid response activation. He underwent emergent endotracheal intubation for airway protection and was started on pantoprazole and octreotide infusions. A massive transfusion protocol was initiated, and the patient was transferred to the intensive care unit where he was started on multiple vasopressors for his hypovolemic shock. A stat computed tomography angiogram (CTA) of the chest was suspicious for an underlying aorto-esophageal fistula [Figure 2A-C]. Thoracic surgery was consulted and given the patient’s age and complexity of the procedure; he was deemed a poor surgical candidate. Ultimately the patient’s family decided to pursue comfort care and the patient passed shortly thereafter. DISCUSSION: The presentation of AEF is characterized by a triad of midthoracic pain, sentinel arterial hemorrhage, and massive hemorrhage after a symptom-free interval. While initial clot formation tamponades the fistula, GI contents rapidly weaken this clot. Evaluation for AEF should done with a CTA-Chest as it has been found to be more sensitive than EGD. Initial therapy should focus on achieving hemodynamic stability via thoracic endovascular aneurysm repair or aortic graft replacement. AEF outcomes are improved when the esophageal pathology can be addressed with esophagectomy, stenting, or fistula repair, and with use of post-operative broad-spectrum antibiotics. Prompt surgical intervention increases one-year survival up to 50%. CONCLUSIONS: AEF should be included in the differential of hematemesis after instrumentation for an EGD. Limited time exists between the herald bleed and massive hemorrhage to confirm the diagnosis and plan for a surgical approach. CTA-Chest should be obtained first, followed by an EGD when imaging is inconclusive. Reference #1: Takeno S, Ishii H, Nanashima A, Nakamura K. Aortoesophageal fistula: review of trends in the last decade. Surg Today. December 2019:1-9. Reference #2: Uittenbogaart M, Sosef MN, van Bastelaar J. Sentinel bleeding as a sign of gastroaortic fistula formation after oesophageal surgery. Case Rep Surg. 2014;2014:614312. Reference #3: Vu QDM, Menias CO, Bhalla S, Peterson C, Wang LL, Balfe DM. Aortoenteric fistulas: CT features and potential mimics. Radiographics. 2009;29(1):197-209. DISCLOSURES: No relevant relationships by Hareen Chela, source=Web Response No relevant relationships by Ethan Karle, source=Web Response No relevant relationships by Adam Letvin, source=Web Response No relevant relationships by Tarang Patel, source=Web Response No relevant relationships by Shyam Shankar, source=Web Response

Aortoenteric and Enterocaval Fistulas Secondary to a Duodenal Erosion Caused by a Prosthetic Vascular Graft

Aortoenteric and enterocaval fistulas represent uncommon complications following vascular surgery. These typically occur secondary to intestinal wall erosion by the prosthetic grafts and materials, and it is associated with regional inflammation and infection. We herein present a patient who developed both of these rare complications caused by a polytetrafluroethylene inferior vena cava (IVC) graft a year after the resection of a rare metastatic Sertoli-Leydig retroperitoneal tumor and concomitant aortocaval reconstruction. The patient presented with herald gastrointestinal bleeding and gram-negative bacteremia; and a duodenotomy, graft removal followed by IVC ligation and repeat right aortoiliac reconstruction were performed. The patient recovered well and following the appropriate postoperative care he was discharged 6 days after surgery without any further vascular or gastrointestinal complications and with neoadyuvant chemotherapy.

Aortoenteric Fistula: A Rare Cause of Gastrointestinal Bleed Requiring Emergent Surgical Intervention

Introduction Aortoenteric fistula is a rare life-threatening diagnosis that may initially present as a minor gastrointestinal bleed, but will inevitably become a surgical emergency. This case highlights the need for a high clinical index of suspicion of aortoenteric fistulas in patients with a history of prior aortic surgery to avoid diagnostic delay, which is often fatal. Case A 81-year-old male with a past medical history significant for an abdominal aortic aneurysm repair and partial colon resection who presented to the Emergency Department complaining of bright red blood per rectum over the past 24 hours. Upon arrival, his blood pressure was 133/60, pulse 101, RR 18, temperature 97.7, and O2 saturation of 98% on room air. On physical exam, he had no abdominal tenderness. He was found to have a hemoglobin of 7.8 from a baseline of 10.2. The patient was started on pantoprazole and an emergent upper endoscopy was performed, which showed evidence of necrotic tissue in the D2 portion of the duodenum. Surgery was consulted. An emergent exploratory laparotomy was done, which revealed a fistula between the duodenum and the aorta. GI surgery mobilized the duodenal fistula by removing adhesions, and vascular surgery transected the aorta and removed the graft. The patient was stable after the excision of aorto-duodenal fistula and oversewing of the aorta. Discussion Aortoenteric fistulas (AEFs) are uncommonly encountered but are important to consider in the differential diagnosis of gastrointestinal bleeding in patients who have had prior aortic surgery. Primary AEFs arise de novo between the aorta and bowel, while secondary AEFs (SAEFs) are usually caused by prosthetic vascular grafts eroding into the intestine as in this patient. Pulsation of vascular grafts against the intestine may cause erosion of the duodenal wall, leading to hemorrhage. Any part of the gastrointestinal tract may be involved, but most commonly it is the third part of the duodenum. SAEFs may present as gastrointestinal bleeding and occasionally as sepsis. Patients initially have “herald bleeding” - intermittent episodes of bleeding due to thrombus formation -followed by massive hemorrhaging. A CT abdomen with contrast is the best diagnostic test if an AEF is suspected; AEFs may also be detected on endoscopy as in this patient. Emergency exploratory laparotomy is warranted immediately upon diagnosis, as mortality is 100% if not surgically treated.

Submitted, Not Presented: Clinical Vignettes/Case Reports-GI Bleeding.

Aortoenteric fistula (AEF) is a pathological communication between the aorta and the gastrointestinal tract. We report a rare presentation of a secondary AEF diagnosed by esophagogastroduodenoscopy (EGD), after going unidentified on computed tomography angiography (CTA), in a patient with a history of bilateral aortoiliac bypass for peripheral arterial disease (PAD) who had a one month history of unexplained, intermittent gastrointestinal bleeding. An 85 year-old male, nursing home resident, with extensive history including dementia and PAD with remote bilateral aortoiliac bypass graft presented to the medical intensive care unit with one month of intermittent hematochezia and new onset hematemesis. The month prior, he had several admissions to a local hospital for hematochezia and anemia in which he was evaluated with both EGD and colonoscopy which failed to identify the source of bleeding. This presentation, patient had hematochezia and hematemesis. His presenting hemoglobin (Hgb) was 6.6 g/dL and nasogastric tube returned 550 mL of bright red blood. Upon transfer, his post transfusion Hgb was 12 g/dL and vitals were stable. CTA showed findings concerning for infected aortobifemoral bypass graft. Urgent EGD revealed a normal esophagus, stomach, duodenal bulb and second portion of the duodenum, but an exposed aortic graft was encountered in the third portion of the duodenum without active bleeding (Image 1 and 2). After further discussion with the patient's family detailing the risks and benefits of surgery, the decision was made to provide the patient with comfort measures only and inpatient hospice. He died one day later. An AEF is a conduit between the aorta and the gastrointestinal lumen. Primary AEF forms in patients with no preexisting aortal surgeries, while a secondary AEF occurs in patients with previous history of reconstructive surgery to the aorta. The most common presentation of an AEF is gastrointestinal bleeding. This can vary from herald bleeding to hemorrhagic shock. The diagnosis of AEF can be made using computed tomography. In our case, a secondary AEF was unidentified on CTA and a subsequent EGD was useful in the final diagnosis. Early recognition and diagnosis of AEF is essential as a delay is diagnosis and surgical exploration is almost always fatal (1).Figure: Secondary Aortoenteric Fistula.Figure: Secondary Aortoenteric Fistula.

Aortoenteric Fistula Masquerading as Intermittent GI Bleeding

SESSION TITLE: Critical Care 2 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Secondary aortoenteric fistula usually occurs in patients with AAA repair, with an incidence of 0.4-3.1%. It is a life-threatening complication, with a mortality rate of 100% if left untreated. CASE PRESENTATION: A 77 y/o male presented with 2 L of bloody bowel movement. He had an AAA repair five years ago. His vitals and physical examination were unremarkable. However, his haemoglobin dropped from 12.5 mg/dL to 11.8 mg/dL. CT abdomen with contrast showed recto-sigmoid diverticulosis and a stable surgical aortic graft. Colonoscopy revealed diverticulosis in sigmoid colon. Over the next 7 days, he had intermittent episodes of large bloody bowel movements, during which haemoglobin decreased to 6-7 mg/dL and he was transfused. Angiogram and tagged red blood cell scan were negative. On the 7th day, he had abdominal pain with large bloody bowel movement. EGD revealed a defect on the posterior wall of the proximal jejunum, extruding a continuous high-pressure jet of blood, which represented a possibility of an aortoenteric fistula. He remained stable for the next two days. Then he developed hypotension and was started on vasopressors. A repeat EGD at this time did not show a bleeding source in the jejunum. He underwent explorative laparotomy, which showed the proximal small bowel plastered to the aortic graft with a questionable ulcer in the jejunum. No aortoenteric fistula was found. No intervention was undertaken. Subsequently, in the next few days he developed abdominal pain and then lost consciousness. He underwent emergent laparotomy that revealed an intraperitoneal haemorrhage from the distal aspect of the aortic graft anastomosis, which was opposed to the jejunum previously. The bleeding from the aorta was controlled and the bowel defect was fixed with an omental patch. Post-op the patient was stable. DISCUSSION: Secondary aortoenteric fistulas mostly occur after AAA repair, mostly at a site proximal to the aortic graft; or graft infection. In intermittent GI bleeding, a thorough history, physical examination along with imaging is useful in >90% of cases. Endoscopy and push enteroscopy have a more diagnostic yield. Definite treatment is open surgical repair or endovascular stent placement. CONCLUSIONS: In patients with a history of aortic repair presenting with intermittent GI bleeding, aortoenteric fistulas should be high on the differential diagnosis, since delay or missed diagnosis can lead to mortality. Reference #1: Marlot, U et al. “Aortoduodenal fistula three years after aortobifemoral bypass: case report and literature review.” Acta Clin Croat. 52.3(2013): 363-368. Reference #2: Senadhi, V et al. “A Mysterious Cause of Gastrointestinal Bleeding Disguising Itself as Diverticulosis and Peptic Ulcer Disease.” Case Rep Gastroenterol. 4.3(2010): 510-517. Reference #3: Yazdanpanah, K., and Mohammad Minakari. “Intermittent Herald Bleeding: An Alarm for Prevention of the Exsanguination of Aortoenteric Fistula before it Arrives.” Int J Prev Med. 3.11(2012): 815-816. DISCLOSURE: The following authors have nothing to disclose: Sidra Khalid, Jyothirmai Seepana, Narendrakumar Alappan No Product/Research Disclosure Information

Predictors of Gastrointestinal Rebleed Events in Patients With a Ventricular Assist Device (VAD)

Introduction: Ventricular assist device (VAD) placement is at the forefront of advanced heart failure treatment as a bridge to cardiac transplant or destination therapy. Gastrointestinal bleeding (GIB) continues to be one of the most common associated adverse events. Nearly 30 to 50% of VAD patients will have recurrent hemorrhage. We provide the first descriptive analysis of potential predictive factors for recurrent GIB in VAD patients. Methods: We conducted a retrospective, single center, observational, cohort study of VAD patients admitted with GIB between 2008-2016. We compared characteristics of those with and without recurrent bleeding to identify predictors of rebleeding. Continuous variables were reported as means, medians, and standard deviations, while categorical variables were reported as frequencies and percentages. Univariable analysis was performed using Fisher's exact test for categorical variables. All analyses were performed using STATA v14 (College Station, TX). Results: 106 VAD patients were identified, of which 26 (24.5%) had an initial bleed. Of those patients, 17 (65.4%) had a second GIB. Patients with repeat GIB had a mean age of 60.1 years, were more likely to be male (76.4%), and on average had 3.5 (2-9) bleed events (Table 1, Figure 1). A majority of rebleed events occurred within the first year of the herald bleed (Figure 2). Those who rebled were significantly more likely to have comorbidities of hypertension (HTN), coronary artery disease (CAD), hyperlipidemia (HLD), post VAD ejection fraction (EF) >30% (Table 1) and likely to be kept on an anticoagulant post initial bleed (Table 1). However, international normalized ratio (INR) levels were not significantly different on days 7 and 14 (P=0.621 & P=0.267, respectively) post initial bleed. On logistic regression, a higher age (odds ratio [OR] 2.58; 95% CI 2.45-2.72; P=0.049) and was associated with a decreased time to a rebleed event.Figure: Bar graph illustrating the total number of gastrointestinal bleed events in patients who have a second bleed.Figure: A Kaplan Meier survival analysis showing a substantial re-bleed rate occurring predominantly within one year of the initial bleed.Table: Table. Demographic and Clinical Parameters of VAD CohortConclusion: We report a substantial rate of recurrent GIB among VAD patients. Though exploratory, we identify potential risk factors associated with recurrent GIB and note no difference in recurrent GIB as related to the INR level. Identifying VAD patients who are at risk for recurrent GIB may help risk stratify VAD candidates. Larger multicenter prospective studies investigating the frequency and predictors of recurrent GIB in VAD patients are necessary.

Significant arterial complications after pancreas transplantation-A single-center experience and review of literature.

Arterial fistulas and pseudoaneurysms are rarely described significant arterial complications associated with pancreas transplantation that sometimes present with herald or catastrophic bleeding. We herein describe our institutional case series with a focus on management and outcomes. Of 2256 pancreas transplants, 24 arterial complications were identified in 23 recipients. Chart review was performed to describe the clinical characteristics, treatments, and outcomes of the complications (pseudoaneurysm, arterial enteric/cystic/ureteric fistula, or arteriovenous fistula). Of these 23 patients, 57% had a failed allograft at the time of the complication. Nine patients underwent primary surgical repair of 10 complications, 13 were treated by endovascular methods, and one patient by medical management. In total, 3 embolized patients rebled, 2 of which had failed allografts prior to treatment. Of those with graft function that were treated by embolization alone, all retained graft function. Diagnosis of arterial complications requires a high degree of suspicion and should involve early systemic angiography to evaluate the pancreatic vasculature. Management can be endovascular or surgical and should be individualized. We report our center's evolution from a predominantly surgical to endovascular approach as a definitive vs stabilizing therapy, with selective coiling mostly reserved for well-defined peripheral lesions in patients with a functioning allograft.

Secondary Aortoenteric Fistula Causing Intermittent Gastrointestinal Bleeding

Introduction: Aortoenteric fistula (AEF) is a pathological communication between the aorta and the gastrointestinal tract (1). We report a rare presentation of a secondary AEF diagnosed by esophagogastroduodenoscopy (EGD) in a patient with a history of bilateral aortoiliac bypass for peripheral arterial disease (PAD) who had a one month history of unexplained, intermittent gastrointestinal bleeding.Figure 1Figure 2Case Presentation: An 85 year-old male, nursing home resident, with extensive history including dementia and PAD with remote bilateral aortoiliac bypass graft presented to the medical intensive care unit (MICU) with one month duration of intermittent hematochezia and new onset hematemesis. The month prior, he had several admissions to a local hospital for hematochezia and anemia in which he was evaluated with both EGD and colonoscopy which failed to identify the source of bleeding. This presentation, patient had hematochezia and hematemsis. His presenting hemoglobin (Hgb) was 6.6 g/dL and nasogastric tube returned 550 mL of bright red blood. Upon transfer, his post transfusion Hgb was 12 g/dL and vitals were stable. Computed tomography angiogram (CTA) showed findings concerning for infected aortobifemoral bypass graft. Urgent EGD revealed a normal esophagus, stomach, duodenal bulb and second portion of the duodenum, but an exposed aortic graft was encountered in the third portion of the duodenum without active bleeding (Image 1 and 2). After further discussion with the patient's family detailing the risks and benefits of surgery, the decision was made to provide the patient with comfort measures only and inpatient hospice. He died one day later. Discussion: An AEF is a conduit between the aorta and the gastrointestinal lumen. Primary AEF forms in patients with no preexisting aortal surgeries (2). A secondary AEF occurs in patients with previous history of reconstructive surgery to the aorta (3). In about one third of cases, the abdominal aorta forms a channel with the duodenum (4, 5). The most common presentation of an AEF is gastrointestinal (GI) bleeding which can vary from herald bleeding to hemorrhagic shock (6-7). The diagnosis of AEF can be made using computed tomography (CT) (9). An EGD is useful in patients with a history of surgical repair to the aorta who present with acute overt gastrointestinal bleeding (7 and 10). Early recognition and diagnosis of AEF is essential as a delay is diagnosis and surgical exploration is almost always fatal (11, 12).

The Importance of Early Diagnosis and Treatment of Patients with Aortoenteric Fistulas Presenting with Herald Bleeds

Massive bleeding in patients with aortoenteric fistula (AEF) may be preceded by minor, intermittent gastrointestinal (GI) blood loss, termed the "herald bleed." The aims of this retrospective study were to: (i) analyze the interval between the herald bleed and onset of major GI hemorrhage and/or diagnosis of AEF and (ii) to evaluate the diagnostic roles of endoscopy and computed tomography imaging. Analysis of all patients diagnosed with AEF or iliac-enteric fistulas between 1994 and 2013 in a single institution. In 31 of a total of 34 fistula cases, GI bleeding was the presenting symptom. Of these, 17 of 31 presented with herald bleed while 14 of 31 presented with massive GI bleeding. In patients with a herald bleed, median time from first bleeding to diagnosis was 14 (2-137) days. In 5/17 patients, herald bleeding preceded major hemorrhage with a median of 6 (4-92) days before a diagnosis of AEF was made or intervention could be initiated. CT angiography (CTA) showed abnormalities associated with a fistula in 27 (79%) cases, of which in 12 (35%) cases a fistula was actually identified. Esophagogastroduodenoscopy (EGD) demonstrated a fistula in 8 (25%) patients, while 50% of EGDs were completely normal. Any patient with history of aortic surgery and GI bleeding should be considered to have an AEF until proven otherwise. The sensitivity of CTA for detecting AEF is substantially greater than that of EGD. The time interval between herald bleed and subsequent massive hemorrhage associated with AEF is unpredictable but may be as short as 4 days.

Herald bleeding from a ruptured primary hepatic angiosarcoma: A case report.

Primary hepatic angiosarcomas (PHAs) are rare tumours with an estimated annual incidence of 0.05 per million in the Caribbean, which is similar to that reported in Western countries. Although a number of cases are detected post-mortem, the most common clinical presentation is with tumour rupture and herald bleeding. This is the case report of a 60-year old female patient who presented with vague upper abdominal pain, found via imaging examinations to be due to a ruptured hepatic tumour in segment III of the liver. The tumour was removed via laparoscopic left lateral sectionectomy, with clear resection margins. The histopathological and immunohistochemical examination established the diagnosis of PHA. Therefore, an index of suspicion should be maintained in selected patients and, when detected ante-mortem, PHAs should be treated aggressively with complete surgical resection to achieve microscopically clear margins, as the response of these tumours to other forms of adjuvant therapy may be unpredictable.

Aortoenteric Fistula

BackgroundAortoenteric fistula is a communication between the aorta and adjacent bowel. It is rare, potentially fatal, and is difficult to diagnose and manage. These patients often present with a “herald bleed,” followed by massive gastrointestinal hemorrhage. Patient and methodsA 67 year old man presented with right upper quadrant pain, hematochezia and hypotension. Two months ago, the patient underwent elective open repair of an abdominal aortic aneurysm. On upper endoscopy, fresh blood and adherent clots were seen in the third/fourth portion of the duodenum. After some of the clots were gently washed off with water flushing, a fistula opening was seen on posterior superior wall of the duodenum. The fistula opening was surrounded by edematous duodenal mucosal. An aortoenteric fistula was highly suspected and the patient went to emergent laparotomy. ResultsDuring surgery, significant inflammation was noted surrounding the aorta with friable tissues of the aorta itself. A definite aortoenteric fistula was seen arising in the native aorta. Unfortunately, the patient expired due to cardiac vascular collapse. ConclusionsDiagnosis of aortoenteric fistula requires a high index of suspicion and careful history-taking. Endoscopic findings include adherent clots or bleeding at the fistula opening and/or eroded vascular graft or stent into the bowel.

Herald Bleeding: A Hidden Catastrophe

Purpose: The word “herald” means to indicate or sign that something is about to happen. Herald bleeding is defined as an episode of hemorrhage, often accompanied by abdominal pain, which may precede, by hours to weeks, a catastrophic hemorrhage. Case Report: A 57-year old male with past medical history of abdominal aortic aneurysm repair around 15 years ago and peptic ulcer disease diagnosed 10 years ago, presented to the hospital with maroon-colored stool of 2 weeks' duration, along with a few days' onset of melena, coffee ground emesis, and sharp epigastric pain. Medications included Plavix, Protonix, Tramadol, and occasional NSAIDs. Physical examination revealed normal vital signs, and epigastric tenderness without any peritoneal signs. Laboratory analysis showed hemoglobin of 7.1 mg/dL, platelets of 355,000 /μL, and INR of 1.2. A CT scan of abdomen and pelvis with IV contrast showed 1.6 x 1.6 x 1.8 cm saccular aneurysm originating from the termination of the distal abdominal aorta without adjacent acute findings, and 3.1 cm aneurysm infrarenal abdominal aorta with circumferential thrombus. Upper gastrointestinal endoscopy showed L.A. grade B esophagitis and hiatal hernia. Colonoscopy showed a scant amount of blood in colon without any obvious bleeding source. Tagged RBC scan was negative. Second look endoscopy was performed with pediatric colonoscope, revealing 3- 4 mm clean-based ulcer over the fourth portion of duodenum, and two vascular clips were placed. Vascular surgery was consulted and, based on the location of the ulcer on the lateral wall of the abdominal aorta, along with CT finding of induration and inflammation of the aortic graft right at the renal arteries, suspicion was made for aortoenteric fistula (AEF). The patient underwent emergent laparotomy and was found to have AEF. The patient then underwent repair of AEF with a successful outcome. Discussion: AEF is a direct connection between abdominal aorta and gut, most commonly duodenum. It occurs in 0.3-4% of patients who underwent open AAA repair. The most common clinical manifestations are upper or lower gastrointestinal bleeding (herald bleeding; 64%), abdominal pain (32%) and a pulsatile abdominal mass (25%). The proposed theories for the formation of primary ADF are direct wear and inflammatory destruction triggered by infection, foreign bodies or erosions. The characteristic site of formation is the third or fourth part of the duodenum. AEF should be considered in all patients with GI bleeding and a history of AAA or previous aortic revascularization with prosthetic graft. A high index of suspicion is the key. The mortality rate of untreated AEF is 100%. Surgical intervention is mandatory for survival and successful outcome.

Vacuum‐assisted closure therapy for vascular graft infection (Szilagyi grade III) in the groin—a 10‐year multi‐center experience

The aim of the study was to evaluate the benefit of vacuum-assisted closure (VAC) therapy in the management of deep, alloplastic graft infections (Szilagyi grade III) in the groin. From 2000 to 2009, we identified and included in our study 72 deep inguinal infections in 68 patients, involving native as well as synthetic graft or patch material. There were 29 early graft infections (<30 days after implantation) and 43 late infections (≥30 days after implantation). Among these, 17 cases involved native grafts/patches (12 grafts and 5 patches), while 55 cases involved non-native grafts/patches [26 polytetrafluorethylene (PTFE) grafts and 24 Dacron grafts (Haemashield, Meadox Medical, Boston Scientific Corporation, Natick, NY; Gelsoft graft, Vascutek, Inchinnan, Renfrewshire, Scotland, UK; Intervascular, Mahwah, NJ); INVISTA, and 5 Vascu-Guard(™) bovine pericardial patches; Synovis Surgical Innovation]. All patients were treated with multiple wound debridements, graft salvage, sartorius myoplasty, intravenous antibiotics and VAC therapy until thorough surface healing was achieved. Exclusion criteria were an alloplastic graft infection with proximal expansion above the inguinal ligament, blood culture positive for septicaemia or septic anastomotic herald or overt bleeding. Nine months after initiation of therapy, overall, graft/patch salvage was achieved in 61 of 72 (84·7%) cases. Of the native graft/patch group, infected graft material was replaced with an autogenous great saphenous vein graft or patch in four patients (23·5%). In the non-native group, vein or synthetic graft preservation without revision was achieved in 48 of 55 (87·3%) patients. The mean duration of VAC therapy was 16 ± 7·7 days, and postoperative mean hospital stay was 25·3 ± 8·5 days. In 23 of 72 (31·9%) cases, a secondary closure of the wound was achieved; in the other 49 cases, wound healing was achieved by meshed split-thickness skin grafting. Mean wound healing time for all wounds was 24·3 ± 12·5 days. Specific complications during VAC therapy were wound fluid retention in 2 cases and an increased need for analgesics in 12 cases (16·66%). Negative pressure wound therapy (NPWT) has been reported to be useful in the treatment of severe wound infections. Even in the presence of synthetic vascular graft material, NPWT can greatly simplify challenging wound-healing problems leading to wound dehiscence and its sequelae. Our long-term experience demonstrates the safety and effectiveness of VAC therapy in the management of deep graft infections.

Aortoenteric Fistula in A 25-Year-Old Man

BackgroundAortoenteric fistula (AEF) is a rare diagnosis that is often considered only in older patients with histories of abdominal aortic aneurysm. ObjectivesTo remind emergency physicians that traumatic injury and repair put patients at risk for formation of AEF. Case ReportWe discuss the case of a 25-year-old man who developed an aortoduodenal fistula weeks after a stab wound to the abdomen. AEF can occur anywhere along the gastrointestinal tract and can therefore present as either upper or lower tract bleeding. The expected triad of pain, pulsatile mass, and gastrointestinal bleeding is unfortunately rarely present, making diagnosis difficult. Patients often present with a self-limited herald bleed that precedes the fatal exsanguination by hours to days. Diagnosing the fistula at the time of the herald bleed can be difficult but lifesaving. Imaging studies are often misleading and only delay definitive operative treatment. Even with prompt diagnosis and treatment, mortality is high; without repair, it is 100%. ConclusionThis case highlights the importance of suspecting and quickly recognizing AEF based on history and physical examination alone. After extensive preoperative imaging to confirm the diagnosis, this patient nearly died in the operating room as surgeons took down adhesions trying to reach the fistula to repair it.

A Case of Primary Aortoenteric Fistula Mimicking Ulcer Bleeding

Primary aortoenteric fistula (PAEF) is a rare disease with a high mortality rate due to massive hemorrhaging and diagnostic difficulties. Although hemorrhagic regions can be identified by endoscopy, it is difficult to diagnose PAEF by this method. If PAEF is suspected, endoscopic procedure should be terminated and abdominal CT should be performed. Overlooking the herald bleeding of PAEF can lead to massive bleeding and death. An 85-year-old previously healthy male presented with a complaint of melena. Gastrointestinal endoscopy identified a hemorrhagic site in the third portion of the duodenum and endoscopic hemostasis was performed. However, during the procedure, it became apparent that the hemorrhage was probably not the result of a simple duodenal ulceration and abdominal CT was performed immediately. An aortic aneurysm connected to the duodenum was identified, confirming the diagnosis of PAEF. However, the patient died of massive hemorrhaging before an operation could be performed.

A Case of Secondary Aortoenteric Fistula with Herald Bleed and Sepsis

A Case of Secondary Aortoenteric Fistula with Herald Bleed and Sepsis

Targeting Early Deaths Following Pancreaticoduodenectomy to Improve Survival

IntroductionThere is increasing focus on disease-specific outcomes. This study was undertaken to analyze early mortality after pancreaticoduodenectomy as part of a strategy to improve long-term outcome. MethodsOne thousand thirty-one patients who underwent pancreaticoduodenectomy from 1992 to 2010 were studied. Median data are reported. ResultsFifty-eight (5.6 %) patients died within 90 days after pancreaticoduodenectomy. All patients had at least one significant comorbidity, commonly cardiorespiratory in nature (76 %). Sixty percent of patients had depressed serum albumin levels, and 43 % were jaundiced. The American Society of Anesthesiologists class was: 17 % class II, 72 % class III, and 10 % class IV. Seventy-four percent had malignant disease. Twenty-two percent of patients underwent a major vascular resection at the time of pancreaticoduodenectomy. Causes of death were vascular/bleeding related (26 %), cardiorespiratory causes (17 %), multiorgan failure (12 %), leak/perforation (10 %), cancer progression (9 %), infection (7 %), or indeterminate (19 %). ConclusionsDeath within 90 days after pancreaticoduodenectomy is uncommon, occurs in relatively older deconditioned patients, and is generally not causally related to underlying malignancy. Early death is generally associated with vascular or bleeding complications. Strategies to minimize early death should focus on careful patient selection and prompt recognition and management of herald bleeding or vascular thrombosis, as it can often result in perioperative death following pancreaticoduodenectomy.

Herald Bleeding: A Diagnosis of Aorto-Duodenal Fistula Treated with Graft Within a Graft Repair

Purpose: Introduction: An aortoenteric fistula is a communication between the aorta and an adjacent loop of the bowel. Secondary aortoenteric fistula is an uncommon but very important complication of abdominal aortic reconstruction. Herald bleeding sometimes precedes a catastrophic bleed. We report a case with this rare complication with typical herald bleeding treated with endovascular graft repair. Case report: An 80-year-old Caucasian male with a history of abdominal aortic aneurysm repair 18 years ago with a tube graft, presented with back pain, and vomiting “bloody slime.” He was on aspirin, but denied taking non-steroidal anti-inflammatory drugs or blood thinners. On examination, he was afebrile, his heart rate was 108/min and blood pressure was 101/53 mm Hg. His hemoglobin was 6.4 g/dL. He received packed red cells transfusion. An endoscopy was performed which revealed a large adherent clot in the third portion of the duodenum. This was not removed as there was a concern for aorto-enteric fistula. A review of previous CT scan revealed a closely adherent tube graft to the duodenum. Patient was deemed to be a poor surgical candidate and an endovascular graft repair was performed using a stent graft with CO2 angiography. A repeat upper endoscopy after removal of the adherent clot showed the previous aortic graft eroding through the duodenal wall, but there was no active bleeding. Patient had no further episodes of bleeding and was discharged with a close follow up. Discussion: Aorto-duodenal fistulas (ADF) after endovascular abdominal aneurysm repair are rare. Secondary ADF is an uncommon (0.3-2%) and life-threatening, long-term complication of aortic reconstructive surgery. The classic presentation of an aortoduodenal fistula is that of a “herald bleed” (brief, with spontaneous resolution), followed anywhere from hours to weeks later by a massive upper gastrointestinal bleed. Untreated cases have a mortality rate of up to 100%. In our patient, intermittent hematemesis was a warning symptom. Though laparotomy with repair is the treatment of choice, our patient was treated with graft within a graft repair in view of the comorbidities. In summary we report a rare case of aorto-duodenal fistula treated with endovascular graft repair.Figure: Visible aortic graft in the duodenum.