Senadhi Viplove, Brown James C, Arora Deepika, Shaffer Rebecca, Shetty Dhiren, Mackrell Peter
Johns Hopkins University/Sinai Hospital Program in Internal Medicine, Department of Internal Medicine, Sinai Hospital, Baltimore, Md., USA.
Case Rep Gastroenterol. 2010 Nov 23;4(3):510-517. doi: 10.1159/000322662.
An 81-year-old male with a history of hypertension, hyperlipidemia, smoking, and peptic ulcer disease (PUD) presented with 2 episodes of maroon stools for 3 days and was found to be orthostatic. His PUD was thought to have accounted for a previous upper gastrointestinal (GI) bleed. A colonoscopy revealed 3 polyps and a few diverticuli throughout the colon that were considered to be the source of the bleeding. Two months later, the patient had massive lower GI bleeding and developed hypovolemic shock with a positive bleeding scan in the splenic flexure; however, angiography was negative. A repeat colonoscopy revealed transverse/descending colon diverticular disease and the patient was scheduled for a left hemicolectomy for presumed diverticular bleeding. Intraoperatively, an aortoenteric (AE) fistula secondary to an aorto-bi-iliac bypass graft placed during an abdominal aortic aneurysm (AAA) repair 14 years prior was discovered and was found to be the source of the bleeding. The patient had an AE fistula repair and did well postoperatively without further bleeding. AE fistulas can present with either upper GI or lower GI bleeding, and are universally deadly if left untreated. AE fistulas often present with a herald bleed before life-threatening bleeding. A careful history should always be elicited in patients with risk factors of AAAs such as hypertension, hyperlipidemia and a history of smoking. Strong clinical suspicion in the setting of a scrupulous patient history is the most important factor that allows for the diagnosis of an AE fistula. There are numerous diagnostic modalities for AE fistula, but there is not one specific test that universally diagnoses AE fistulas. Nuclear medicine scans and angiography should not be completely relied on for the diagnosis of AE fistulas or other lower GI bleeds for that manner. Although the conventional paradigm for evaluating lower GI bleeds incorporates nuclear medicine scans and angiography, there is evidence that early endoscopy with enteroscopy may have a better role in severe lower GI bleeding.
一名81岁男性，有高血压、高脂血症、吸烟和消化性溃疡病（PUD）病史，出现3天内2次暗红色大便，并被发现有体位性低血压。他的PUD被认为是之前上消化道（GI）出血的原因。结肠镜检查发现整个结肠有3个息肉和一些憩室，被认为是出血的来源。两个月后，患者发生大量下消化道出血，并发展为低血容量性休克，脾曲部出血扫描呈阳性；然而，血管造影结果为阴性。再次结肠镜检查发现横结肠/降结肠憩室病，患者因推测的憩室出血而计划进行左半结肠切除术。术中发现14年前腹主动脉瘤（AAA）修复期间放置的主动脉双髂动脉旁路移植继发的主动脉肠瘘（AE），并发现其为出血源。患者接受了AE瘘修复术，术后恢复良好，未再出血。AE瘘可表现为上消化道或下消化道出血，若不治疗则普遍致命。AE瘘在危及生命的出血之前常先出现先兆出血。对于有AAA危险因素（如高血压、高脂血症和吸烟史）的患者，应始终仔细询问病史。在严谨的患者病史背景下进行强烈的临床怀疑是诊断AE瘘的最重要因素。AE瘘有多种诊断方法，但没有一种特定的检查能普遍诊断AE瘘。核医学扫描和血管造影不能完全依赖于诊断AE瘘或其他下消化道出血。虽然评估下消化道出血的传统模式包括核医学扫描和血管造影，但有证据表明早期小肠镜检查在严重下消化道出血中可能有更好的作用。
