Ramsay Amy C, Ramsay Michael P, Meekins Pauline E
Division of Emergency Medicine, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
J Emerg Med. 2013 Oct;45(4):533-6. doi: 10.1016/j.jemermed.2013.04.019. Epub 2013 Jun 15.
Aortoenteric fistula (AEF) is a rare diagnosis that is often considered only in older patients with histories of abdominal aortic aneurysm.
To remind emergency physicians that traumatic injury and repair put patients at risk for formation of AEF.
We 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%.
This 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.
主动脉肠瘘（AEF）是一种罕见的诊断，通常仅在有腹主动脉瘤病史的老年患者中考虑。
提醒急诊医生创伤性损伤和修复会使患者有发生AEF的风险。
我们讨论一例25岁男性患者，其在腹部刺伤数周后发生了主动脉十二指肠瘘。AEF可发生于胃肠道的任何部位，因此可表现为上消化道或下消化道出血。遗憾的是，疼痛、搏动性肿块和胃肠道出血这一典型三联征很少出现，导致诊断困难。患者常出现自限性前驱出血，在数小时至数天内发展为致命性失血。在出现前驱出血时诊断瘘管可能很困难，但却能挽救生命。影像学检查常常具有误导性，只会延误确定性手术治疗。即使及时诊断和治疗，死亡率也很高；不进行修复则死亡率为100%。
本病例强调了仅根据病史和体格检查怀疑并快速识别AEF的重要性。在进行广泛的术前影像学检查以确诊后，该患者在手术室险些死亡，当时外科医生在试图分离粘连以找到瘘管进行修复。
