Vacca Giovanna, De Berardinis Claudia, Cappabianca Salvatore, Vanzulli Angelo
Department of University of Campania "Luigi Vanvitelli", Caserta, Italy.
Department of Radiology, University "La Statale" of Milan, Milan, Italy.
BJR Case Rep. 2021 Oct 20;8(1):20210143. doi: 10.1259/bjrcr.20210143. eCollection 2022 Jan 1.
Although gastrointestinal hemorrhage from aorto-enteric fistulae (AEF) secondary to previous aortic grafts are well known, a primary aorto-enteric fistula (PAEF) without aortic aneurysm is an extremely rare event resulting in poor prognosis and outcome. PAEF is a rare cause of gastro-intestinal (GI) bleeding that radiologists should consider because often its presence is not easily guessed by clinical features. It is difficult to detect at CT examination therefore PAEF might be not diagnosed until a laparotomy. We report a case of a 74-year-old Italian male who presented to our Emergency Department (ED) with brightly red rectal bleeding that occurred from some hours and a pre-syncopal episode. There was no history of analgesic abuse, peptic ulceration, alcohol excess, and weight loss. Standard resuscitation was commenced with the hope that common sources of bleeding such as peptic ulcers or varices would eventually be discovered by endoscopy and treated definitely. An upper GI endoscopy showed brightly red blood in the stomach and in the first portions of duodenum, but no source of active bleeding was found. Diagnosis of PAEF was made by CT and after confirmed during surgical intervention. Both the duodenum and the aorta were successfully repaired by direct suture and synthetic graft replacement, respectively. Diagnosis of primary aortic duodenal fistula (ADF) has been very difficult in this case especially because our patient did not have abdominal aortic aneurism (AAA) history confirmed by CT examination. Radiologist should remember that upper GI bleeding could however be determined by primary ADF also if atherosclerotic damage is severe as in this case. A technically good and complete exam is mandatory to achieve this rare and complex diagnosis. Particularly, an ultra-tardive acquisition phase (5 min after contrast administration) could be helpful to suspect the presence of PADF: the appearance of contrast into the duodenal lumen is an evocative sign useful to increase clinical and radiological suspicious of ADF. Gl bleeding should be assumed to be caused from a PAEF unless another source can be identified without delay. A timely and accurate diagnosis of primary AEF may be challenging due to insidious episodes of GI bleeding, which are frequently under diagnosed until the occurrence of massive hemorrhage.
虽然继发于既往主动脉移植的主动脉肠瘘（AEF）导致的胃肠道出血已为人熟知，但无主动脉瘤的原发性主动脉肠瘘（PAEF）是一种极其罕见的情况，预后和结局较差。PAEF是胃肠道（GI）出血的罕见原因，放射科医生应予以考虑，因为其存在往往不易通过临床特征推测出来。在CT检查中很难检测到，因此PAEF可能直到剖腹手术时才被诊断出来。我们报告一例74岁的意大利男性，他因数小时来出现鲜红色直肠出血和一次晕厥前期发作而就诊于我们的急诊科（ED）。他没有镇痛药物滥用、消化性溃疡、酗酒和体重减轻的病史。开始进行标准复苏，希望通过内镜检查最终发现并明确治疗诸如消化性溃疡或静脉曲张等常见出血来源。上消化道内镜检查显示胃和十二指肠起始段有鲜红色血液，但未发现活动性出血源。PAEF通过CT诊断，并在手术干预中得到证实。十二指肠和主动脉分别通过直接缝合和人工血管置换成功修复。在这种情况下，原发性主动脉十二指肠瘘（ADF）的诊断非常困难，尤其是因为我们的患者经CT检查未证实有腹主动脉瘤（AAA）病史。放射科医生应记住，即使如本例中动脉粥样硬化损伤严重，上消化道出血也可能由原发性ADF引起。要做出这种罕见而复杂的诊断，必须进行技术上良好且完整的检查。特别是，延迟采集期（注射造影剂后5分钟）可能有助于怀疑PADF的存在：造影剂进入十二指肠腔的表现是一个提示性征象，有助于增加对ADF的临床和放射学怀疑。除非能立即确定其他出血源，否则应假定胃肠道出血是由PAEF引起的。由于胃肠道出血发作隐匿，原发性AEF的及时准确诊断可能具有挑战性，在发生大出血之前，这些出血常常未被诊断出来。
