Song Yang, Liu Quanda, Shen Hong, Jia Xin, Zhang Hua, Qiao Liang
Emergency Department, Chinese PLA General Hospital, Beijing, China.
Surgery. 2008 Jan;143(1):43-50. doi: 10.1016/j.surg.2007.06.036. Epub 2007 Nov 5.
Misdiagnosis of primary aortoenteric fistula (PAEF) frequently occurs in clinical practice owing to the rarity of this condition. Herein we present the experience of diagnosis and management for PAEF.
Eighteen patients with PAEF at 2 medical centers in China were reviewed. The clinical data, diagnostic procedures, treatment options, and patient outcomes were evaluated.
The fistulas were located at esophagus (5), duodenum (8), jejunum (3), ileum (1), and transverse colon (1). The etiologies include atherosclerotic aneurysms and foreign body. Typical abdominal triad (pain, upper GI bleeding, and abdominal pulsating mass) was found in 27.8% of patients, and Chiari's triad (mid-thoracic pain, sentinel hemorrhage, and massive bleeding after a symptom-free interval) was present in 3 of 5 cases with thoracic aortoesophageal fistulas. All patients had an average of 3.6 (1-9) episodes of gastrointestinal bleeding. The interval between the first sentinel hemorrhage and ultimate exsanguination ranged from 5 hours to 5 months (median, 4 days). Six patients (33.3%) were diagnosed or suggested by diagnostic tools including endoscopy, computerized tomography, and arteriography. Others were diagnosed by surgical exploration (7) and autopsy (5). One to 5 rounds (mean 1.8) of misdiagnosis occurred in 15 patients. Six patients recovered from surgery and remained well during a 36-month follow-up. The surgical options used included in situ replacement with vascular graft (3), aneurysmorraphy and closure of fistula (1), and endovascular stenting (2).
A high index of suspicion is necessary for correct diagnosis and prompt management of PAEF, especially in patients with aortoiliac aneurysms presenting with gastrointestinal bleeding. In situ graft replacement and endovascular stent-graft may be the preferred therapeutic options.
由于原发性主动脉肠瘘（PAEF）较为罕见，临床实践中常发生误诊。在此我们介绍PAEF的诊断和治疗经验。
回顾了中国两家医疗中心的18例PAEF患者。评估了临床资料、诊断程序、治疗方案和患者预后。
瘘管位于食管（5例）、十二指肠（8例）、空肠（3例）、回肠（1例）和横结肠（1例）。病因包括动脉粥样硬化性动脉瘤和异物。27.8%的患者出现典型的腹部三联征（腹痛、上消化道出血和腹部搏动性肿块），5例胸主动脉食管瘘患者中有3例出现奇阿里三联征（胸中部疼痛、前驱性出血和无症状期后大量出血）。所有患者平均有3.6（1 - 9）次胃肠道出血发作。首次前驱性出血与最终失血性休克之间的间隔时间为5小时至5个月（中位数为4天）。6例患者（33.3%）通过包括内镜检查、计算机断层扫描和血管造影等诊断工具得以诊断或提示。其他患者通过手术探查（7例）和尸检（5例）确诊。15例患者发生了1至5轮（平均1.8轮）误诊。6例患者术后康复，在36个月的随访期间情况良好。所采用的手术方式包括血管移植原位置换（3例）、动脉瘤修补术并封闭瘘管（1例）和血管内支架置入术（2例）。
对于PAEF的正确诊断和及时治疗，高度的怀疑指数是必要的，尤其是对于伴有胃肠道出血的主动脉髂动脉瘤患者。血管移植原位置换和血管内支架移植可能是首选的治疗方案。
