Lin Tzu-Chieh, Tsai Chung-Lin, Chang Yao-Tien, Hu Sung-Yuan
Department of Emergency Medicine, Taichung Veterans General Hospital, No. 1650 Taiwan Boulevard Sect. 4, Taichung, 40705, Taiwan.
College of Public Health, China Medical University, Taichung, Taiwan.
BMC Cardiovasc Disord. 2018 Jun 7;18(1):113. doi: 10.1186/s12872-018-0852-y.
Primary aortoduodenal fistula (ADF) is a rare cause of gastrointestinal (GI) bleeding and is difficult to diagnose as the clinical presentation is subtle. Clinicians should keep a high level of suspicion for an unknown etiology of GI bleeding, especially in older patients with or without abdominal aortic aneurysm (AAA). Computed tomographic angiography (CTA) can be used to detect primary ADF. Open surgery or endovascular aortic repair (EVAR) for ADF with bleeding will improve the survival rate.
We report a rare case of AAA complicating ADF with massive GI bleeding in a 73-year-old Taiwanese man. He presented with abdominal pain and tarry stool for 5 days and an initial upper GI endoscopy at a rural hospital showed gastric ulcer only, but hypotension with tachycardia and a drop in hemoglobin of 9 g/dl from 12 g/dl occurred the next day. He was referred to our hospital for EVAR and primary closure of fistula defect due to massive GI bleeding with shock from ADF caused by AAA. Diagnosis was made by CTA of aorta.
A timely and accurate diagnosis of primary ADF may be challenging due to insidious episodes of GI bleeding, which are frequently under-diagnosed until the occurrence of massive hemorrhage. Clinical physicians should keep a high index of awareness for primary ADF, especially in elderly patients with unknown etiology of upper GI bleeding with or without a known AAA.
原发性主动脉十二指肠瘘（ADF）是胃肠道（GI）出血的罕见原因，由于临床表现不明显，诊断困难。临床医生对于不明原因的胃肠道出血应保持高度怀疑，尤其是在有或无腹主动脉瘤（AAA）的老年患者中。计算机断层血管造影（CTA）可用于检测原发性ADF。对伴有出血的ADF进行开放手术或血管腔内主动脉修复（EVAR）可提高生存率。
我们报告了一例罕见的AAA合并ADF并导致一名73岁台湾男性大量胃肠道出血的病例。他因腹痛和柏油样便就诊5天，在一家乡村医院进行的初次上消化道内镜检查仅显示胃溃疡，但第二天出现低血压、心动过速，血红蛋白从12g/dl降至9g/dl。由于AAA导致ADF并伴有大量胃肠道出血和休克，他被转诊至我院接受EVAR及瘘口缺损的一期闭合术。通过主动脉CTA确诊。
由于胃肠道出血发作隐匿，原发性ADF的及时准确诊断可能具有挑战性，在发生大出血之前，其常常被漏诊。临床医生应对原发性ADF保持高度警惕，尤其是在不明原因上消化道出血的老年患者中，无论其有无已知的AAA。
