A Unusual Case Of Higher Obstructive Syndrome

A Unusual Case Of Higher Obstructive Syndrome

February 22, 2008
TC scan displaying an area with the characteristics of inflammatory tissue including air bubbles between the duodenum and aortic-bi-femoral prosthesis adherent to the third duodenal portion. Credit score: World Journal of Gastroenterology
Aorto-duodenal fistulae (ADF) are probably the most frequent aorto-enteric fistulae (eighty%) and essentially the most frequent presenting sign of ADF is higher gastrointestinal bleeding (UGI). A 59-year-old male patient, who underwent an aortic-bi-femoral bypass 5 years ago, was admitted to the Emergency Room after five days of persistent occlusive syndrome with dyspepsia and biliary vomiting.
Computed tomography (CT) scan showed in the third duodenal section the presence of an space with the characteristics of inflammatory tissue, including air bubbles between the duodenum and aortic-bi-femoral prosthesis adherent to the third duodenal portion (¡°comma signal¡±). Microbiological cultures and scintigraphy had been unremarkable. Esophago-gastro-duodenoscopy showed the aortic prosthesis crossing the third segment of duodenal wall occluding the intestinal lumen. At laparotomy, after viscerolisis, the prosthesis was detached from duodenal wall and the intestine failed to shut transversely.
To guard the intestinal wall, a pediculated fragment of the higher omentum was positioned between the duodenum and aortic bypass. Furthermore, a gastrojejunal Roux anastomosis was employed. The prosthesis was not modified as a result of there were no local or systemic indicators of an infection. The publish-operative course was uneventful.
These findings have been published within the January 21, 2008 edition of the World Journal of Gastroenterology. ADF may be primarily as a result of a spontaneous communication between the lumen of aortic aneurysm and intestinal loop, or secondarily because of surgical restore of aneurysms with prosthetic implants. Clinical suspicion is crucial in the prognosis of ADF and probably the most generally used techniques for its diagnosis are esophago-gastro-duodenoscopy (EGDS) and CT.
In any other case, secondary ADF is an uncommon (0.three% - 2%) and life-threatening lengthy-time period complication of aortic reconstructive surgery, with only hypothetic and speculative pathogenesis (mechanical erosion, lack of interposed retroperitoneal tissue, extreme pulsation of redundantly placed grafts, septic procedures by Staphylococcus epidermidis ¡°biofilm¡± infection, insufficient prosthetic materials).
In our case, ADF formation was associated to graft pulsation on the duodenal wall.
The presentation is commonly subtle, with herald bleeding adopted by a period of grace, or catastrophic bleeding, or rarely an episode of intestinal obstruction. The third or fourth duodenal phase is probably the most incessantly involved site. In Dacron prosthesis patients, fistula develops within the proximal graft tract opening in the third section of duodenum.
Due to the excessive mortality and morbidity associated with secondary aorto-enteric fistula, surgical remedy is always really helpful. Explorative laparotomy is the remedy of alternative. Within the case of non-treated aortic-enteric fistula presenting with massive UGI-bleeding, the mortality rate is near 100%. Morbidity (limb loss in 10% - 40%) and mortality associated to treated ADF are also excessive (seventy five%) and require preventive measures, including more notably delicate surgical procedure and antibiotic therapy in case of infection. A number of surgical procedures are possible.
Supply: World Journal of Gastroenterology
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