Aorto-digestive fistula: a rare cause of gastrointestinal bleeding

<p>Aorto-digestive fistulas are a rare but extremely dangerous cause of massive gastrointestinal bleeding with a high risk of death. The aim of the review was to examine the modern principles of aorto-digestive fistula diagnosis and optimal treatment modalities.</p><p>Scientific publications and their reference lists were searched on PubMed database, Google Scholar and Russian Science Citation Index. Articles relevant to the topic, published over the past 25 years (1996-2021), were included and they were searched and categorised using the following key words: ‘gastrointestinal bleeding’, ‘aorto-digestive fistulas’, ‘diagnosis’ and ‘treatment’. Inclusion criteria were limited to gastrointestinal bleeding associated with aorto-digestive fistulas.</p><p>Patients with aortic aneurysms or those who have undergone prosthetics should have increased alertness regarding the formation of aorto-digestive fistulas. With a presence of gastrointestinal bleeding and exclusion of other sources based on multispiral computed tomography data with intravenous bolus contrast enhancement, this will allow for quick verification of the diagnosis and also enable timely medical measures to be taken. In an emergency situation, to achieve rapid hemostasis in unstable patients, endovascular aortic replacement is most justified. Open reconstruction of the aorta in situ with simultaneous elimination of the hollow organ defect and sanitation of fistula-associated foci of infection should be considered as a radical intervention for aorto-digestive fistulas.</p><p>Received 19 May 2021. Revised 7 July 2021. Accepted 9 July 2021.</p><p><strong>Funding:</strong> The study did not have sponsorship.</p><p><strong>Conflict of interest:</strong> Authors declare no conflict of interest.</p><p><strong>Contribution of the authors:</strong> The authors contributed equally to this article.</p>

Multicenter Epidemiological Survey of Pneumatosis Intestinalis in Japan

Background Pneumatosis intestinalis (PI) is a rare condition characterized by gas collection in the intestinal wall. We aimed to determine the etiology and affected segments associated with complications, treatment, and outcome. Methods We conducted a multicenter epidemiological survey using a standardized data collection sheet in Japan. Complicating PI was defined as strangulation or bowel necrosis, bowel obstruction, adynamic ileus, sepsis, shock, and massive gastrointestinal bleeding. Results We enrolled 167 patients from 48 facilities. Multivariate analysis revealed that older age (adjusted OR, 1.05 and 95% confidence intervals [CI], 1.02-1.09, P=0.0053) and chronic kidney disease (adjusted OR, 13.19 and 95% CI, 1.04-167.62, P=0.0468) were independent predictors of the small-bowel-involved type. Complicating PI was associated with the small-bowel-involved combined type (adjusted OR, 45.49 and 95% CI, 8.34-248.13, P<0.0001), the small-bowel-only type (adjusted OR, 7.90 and 95% CI, 1.92-32.56, P=0.0042), and allopurinol/benzbromaron (adjusted OR, 31.07 and 95% CI, 1.70-567.28, P=0.0204). Oxygen therapy was performed in patients with a past history of bowel obstruction (adjusted OR, 13.77 and 95% CI, 1.31-144.56, P=0.0288) and surgery was performed in patients with complicating PI (adjusted OR, 8.93 and 95% CI, 1.10-72.78, P=0.0408). Antihypertensives (adjusted OR, 12.28 and 95% CI, 1.07-140.79, P=0.0439) and complicating PI (adjusted OR, 11.77 and 95% CI, 1.053-131.526; P=0.0453) were associated with exacerbation of PI. The complicating PI was the only indicator of death (adjusted OR, 14.40 and 95% CI, 1.09-189.48, P=0.0425). Discussion This study provides evidence supporting the association between the small-bowel-involved type and complications and poor prognosis.

1228 Massive Gastrointestinal Bleeding Secondary to Bleeding Jejunal Diverticulum

Usually, the Jejunal diverticula appeared multiple and vary in size. These false diverticula lack the muscular coat of the normal intestinal walls, and most patients presented with it were asymptomatic. Although 10% of all patients develop complications such as perforation, obstruction, or bleeding, which then requires surgical intervention, but bleeding is relatively rare among these complications. A case of 74 years old lady was referred to our hospital because of persistent hematemesis and fresh melena. Her previous and recent upper gastrointestinal endoscopy both revealed only gastric erosions without any active bleeding. Also, previous, and recent colonoscopy was done but not completed due to the presents of fresh blood and blood clots along the colon, which led to improper visualization. Her selective mesenteric angiography was done together with upper and lower endoscopy, but none of them revealed the source of bleeding. Emergency exploratory laparotomy was undertaken, and a prominent single jejunal diverticulum with a prominent vessel entering it was noted, and no bleeding from other sites detected. Enterotomy was performed, and enteroscopy confirmed ulceration at the jejunal diverticulum site. Resection of the portion containing the diverticulum and primary anastomosis was done, and this cured the patient. The histopathological examination of the specimen showed an ulcerative lesion with an exposed vessel suggestive of the source of bleeding. Although jejunal diverticula incidence is rare, it is important to look for such lesions in patients with intestinal bleeding. Keywords: jejunal diverticulum, small intestine, intestinal bleeding.

Crohn’s disease manifested with massive colonic bleeding (review and a clinical case)

Massive gastrointestinal bleeding (GIB) is a rare complication of Crohn’s disease (CD). For the recent decades a number of medical and surgical methods to control the GIB have been introduced. However, the unified algorithm and approach to this subset of patients is still lacking, mostly due to the absence of adequately powered and wellconducted RCTs. Determining the optimal treatment approach to inflammatory bowel disease (IBD) in patients who develop a GIB is still a valid research target.

Crohn’s disease manifested with massive colonic bleeding (review and a clinical case)

Massive gastrointestinal bleeding (GIB) is a rare complication of Crohn’s disease (CD). For the recent decades a number of medical and surgical methods to control the GIB have been introduced. However, the unified algorithm and approach to this subset of patients is still lacking, mostly due to the absence of adequately powered and wellconducted RCTs. Determining the optimal treatment approach to inflammatory bowel disease (IBD) in patients who develop a GIB is still a valid research target.

Surgical approach to recurrent secondary aortoenteric fistulas: A case report

The increasing number of abdominal aortic grafts due to abdominal aortic aneurysms has caused secondary aortoenteric fistulas to be seen more frequently as a cause of gastrointestinal bleeding. High index of suspicion plays a significant role in the diagnosis in patients having clinical symptoms ranging from fecal occult blood to massive gastrointestinal bleeding, accompanied by hemorrhagic shock. A 65-year-old male patient developed two secondary aortoenteric fistulas consecutively. The first one was aortic graft-jejunal and the second one was aortic graft-duodenal in a short period. Secondary aortoenteric fistula developed after aortobifemoral bypass. The patient underwent graft revision and jejunal repair. He was reoperated three months later due to the newly developed aortic graft-duodenal fistula. The duodenal defect was closed, and an extra-anatomic aortoiliac bypass was performed to avoid graft-related enteric fistula. The patient was discharged uneventfully and was free from any complication at nine months after surgery.

Non-Occlusive Mesenteric Ischemia After Resuscitative Endovascular Balloon Occlusion of the Aorta for Out-of-Hospital Cardiac Arrest due to Massive Gastrointestinal Bleeding

Background: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been used as a method of controlling intra-abdominal bleeding in case of hemorrhagic shock and an adjunct to improve traditional advanced cardiac life support in nontraumatic cardiac arrest. Partial REBOA is proposed as an alternative method that regulates low volume continuous blood flow across the area of occlusion with the aim of minimizing ischemia-reperfusion injury. Case Presentation: An 82-year-old male suffered an out-of-hospital cardiac arrest due to massive gastric bleeding. He was initially resuscitated with partial REBOA but died of non-occlusive mesenteric ischemia (NOMI). The possible causes of NOMI were the patient’s age, the low flow state with prolonged cardiopulmonary resuscitation, the lower proximal-to-distal gradient of partial REBOA, and the longer time of total occlusion. Conclusion: Further studies may be required to determine the optimal distal pressure during partial REBOA to limit the burden of mesenteric ischemia.