Upper gastrointestinal emergencies
Alexander Trevatt, Richard Boulton, Daren Francis, Nishanthan Mahesan in Take Charge! General Surgery and Urology, 2020
This is defined as bleeding proximal to the duodenojejunal flexure and can present as haematemesis or melaena. Rarely a large UGI bleed will present with fresh PR blood and haemodynamic instability (see Chapter 3). This is usually managed by the on-call medical team, but the general surgeon must be able to deal with an acute UGI bleed as surgery may be required in refractory cases. It is a potential complication of benign/malignant peptic ulcer disease but can be secondary to other conditions such as: Oesophageal varices: Severe, massive-volume blood loss.Oesophageal trauma: Mallory−Weiss tear due to repeated vomiting or retching, or oesophageal rupture in Boerhaave's syndrome.Vascular malformations (e.g. telangiectasia or Dieulafoy lesion – solitary large tortuous submucosal arteriole).Aortoenteric fistula: Severe, massive-volume blood loss.
Complications of Open Arterial Vascular Surgery
Stephen M. Cohn, Matthew O. Dolich in Complications in Surgery and Trauma, 2014
Aortoenteric fistula (AEF) is a late appearing complication seen in less than 0.5% of cases [28]. Aortoduodenal fistulas are more common than aortosigmoid fistulas. Mortality remains high. Any patient with a prior aortic graft and any form of upper GI bleeding should be evaluated for this complication. In addition to a CT scan, workup usually entails an upper endoscopy to reach the fourth portion of the duodenum. The patient may or may not exhibit signs or symptoms of graft infection. The communication does not necessarily involve the suture line, in which case, the patient likely will have chronic low-grade blood loss from mucosal erosions. If the suture line is involved, the bleeding will be more brisk, although it is not infrequent for the patient to present with a first herald bleeding episode. AEF is best treated [29], with extra-anatomic bypass followed by total graft excision and aortic closure. If the patient is unstable at presentation, temporization can be obtained by placing a covered stent across the bleeding suture line to allow semi-elective treatment. There are case reports of long-term treatment with covered stent and antibiotics. Prevention requires careful interposition of tissues between the graft and bowel. Omentum may be used when there is not enough tissue in the retroperitoneum. Any native aortic wall should also be used to wrap the graft.
Peripheral Vascular Disease
Gozie Offiah, Arnold Hill in RCSI Handbook of Clinical Surgery for Finals, 2019
Clinical Features➢ Most are asymptomatic: <50% detected on exam by a pulsatile and expansile mass in abdomen.➢ 40% detected incidentally on imaging for other reason.➢ There is an associated increased risk of peripheral aneurysms, particularly popliteal aneurysm➢ Symptoms arise from aneurysm expansion, rupture or peripheral embolism include: Abdominal/back/flank pain.Distal peripheral embolization or ischaemia.Upper G.I. Bleeding from aortoenteric fistula.Syncope or shock with large pulsatile mass, ecchymoses or death from a ruptured AAA.
Ileal artery pseudoaneurysm: a rare cause of gastrointestinal bleed
Published in Journal of Community Hospital Internal Medicine Perspectives, 2019
Farah Kassamali, Atul (Ryan) Sharma
Our patient had a primary aortoenteric fistula, likely due to her history of colon cancer, metastatic endometrial cancer to the colon, and abdominal radiation treatments. Additionally, she had a complex abdominal history and multiple insults to the bowel in the setting of abdominal and pelvic surgeries such as nephrostomy stenting, vascular interventions, and sepsis. This case is exceptionally unique due to the rare involvement of the ileal artery rather than mesenteric vessels causing a fistulous communication between the pseudoaneurysm and bowel, leading to intermittent hemorrhage. In our literature search, cases of an ileal artery fistula have mostly been reported as uretero-arterial fistulas secondary to an ileal conduit following cystectomy or cystoprostatectomy, unlike our case of ileo-enteric fistula.
Chronic Q fever vertebral osteomyelitis, an underrecognized clinical entity
Published in Infectious Diseases, 2021
S. B. Buijs, J. M. Weehuizen, J. J. Oosterheert, S. E. van Roeden
The findings of Ghanem-Zoubi et al. stress that chronic Q fever is a notoriously difficult diagnosis to confirm. Patients may present with atypical symptoms and fever or raised inflammatory markers may be absent [3]. Symptoms may be present for months or even years, which is atypical for vertebral osteomyelitis in general [4]. Microbiological assays for chronic Q fever are difficult to interpret on their own, and a combination of serology, PCR and radiological investigations is key in diagnosing chronic Q fever [5,6]. Moreover, infections may be polymicrobial – even in cases without aortoenteric fistula. In a significant proportion of patients with chronic Q fever, concomitant pathogens are identified [7]. In the national Dutch chronic Q fever database, in which 531 patients are currently registered, 9% proven chronic Q fever patients had a dual pathogen infection [unpublished data]. The risk for a diagnostic delay of chronic Q fever in patients with other pathogens identified is high. Inappropriate diagnosis may lead to delayed start of adequate treatment [8]. Moreover, in patients with vertebral osteomyelitis with another bacterial pathogen identified besides C. burnetii it may be challenging to determine which pathogen is most relevant, in particular when diagnosis of chronic Q fever relies on serology only, and PCR is negative. Positive serology could also reflect a past Q fever infection without actual infection. Therefore, it is important to assess each case individually.
Arterial-enteric fistula after pelvic lymphadenectomy in secondary cytoreductive surgery for recurrent ovarian cancer
Published in Journal of Obstetrics and Gynaecology, 2019
Francesco Cosentino, Luigi Carlo Turco, Anna Fagotti, Stefano Cianci, Valerio Gallotta, Andrea Rosati, Francesco Corbisiero, Giovanni Scambia, Gabriella Ferrandina
The second gynaecologic oncology report is published by Lawlor et al. (2004) describing the case of a 58-year-old woman with a history of FIGO stage-II cervical cancer treated with radiotherapy. One year after radiotherapy, the patient presented sudden symptoms of a melena and upper gastrointestinal bleeding. After a CT-scan and a subsequent urgent laparotomy, an abdominal aortic aneurysm was diagnosed with a large retroperitoneal tumour mass encasing the infrarenal aorta, involving the duodenum. The tumour mass was unresectable but the primary aortoenteric fistula could be treated instantly.