How is upper gastrointestinal bleeding (UGIB) caused by aortoenteric fistula treated?

Updated: Aug 12, 2019
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Answer

Patients with an aortoenteric fistula most often present with a self-limiting sentinel hemorrhage that is then followed by an exsanguinating, massive gastrointestinal (GI) bleed. For the warning lesser sentinel bleed in a patient with a history of an abdominal aortic aneurysm repair or a known aortic aneurysm, the possibility of a graft-enteric fistula should be considered.

An upper endoscopy is the procedure of choice to help diagnose the fistula. It should be performed to the ligament of Treitz. Upper endoscopy findings also help to exclude other sources of upper GI bleeding (UGIB).

Once the diagnosis of aortoenteric fistula is confirmed or seriously considered, emergency surgical intervention is required. In most instances, the aortic graft is removed after debridement and closure of the duodenum, followed by an extra-anatomic vascular bypass in order to bypass the ligated aorta and revascularize the lower extremities.

Perioperative mortality is 22%-75%, [68] and major complications are common. Published opinions state that graft excision is not necessary as long as no gross contamination and purulence are present at the time of laparotomy. [69] Under these circumstances, antibiotics are administered long-term.

Another option in the surgical literature is the use of endovascular stents to repair the fistula. [70, 71] Endovascular stent management is technically feasible and may be used as a bridge to more definitive treatment after hemodynamic stabilization in high-risk surgical patients. Stent grafting controls hemorrhage immediately; however, because the device is placed in an infected field, adjunctive measures, such as long-term antibiotic use, percutaneous drainage, and bowel diversion, may be required. [72]

Although endovascular stents have been shown to be effective in treating aortoenteric fistulas, case reports have described aortoenteric fistulas in patients with abdominal aortic aneurysm treated initially with stent grafts as well. [73]


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