Correspondence

Aortoenteric Fistula

N Engl J Med 1993; 329:578-579August 19, 1993

Article

To the Editor:

The photograph of the aortoenteric fistula detected by endoscopy, shown in Images in Clinical Medicine (April 22 issue1), is dramatic. The accompanying computed tomographic scan is interesting and confirms the diagnosis, but I am surprised to see it.

This endoscopic finding in a patient known to have an aortic graft would have prompted me to rush the patient to emergency surgery before the aneurysm ruptured. The potential for rupture is so great in these cases that any delay may be fatal.

Herbert Rakatansky, M.D.
Brown University, Providence, RI 02912

1 References

1. 1

   Zachary PE Jr, Campbell DR. Aortoenteric fistula. N Engl J Med 1993;328:1166-1166
   Full Text | Web of Science

Author/Editor Response

The authors reply:

To the Editor: The gastroenterologists and surgeons were confident that this lesion, as visualized with a side-viewing duodenoscope, represented an aortoenteric fistula and agreed that the patient should undergo prompt surgical correction before an exsanguinating hemorrhage occurred. Experts1,2 recommend that patients who are hemodynamically stable undergo a deliberate and orderly, yet expeditious, evaluation to establish this diagnosis. Because the patient's condition was stable, computed tomography was performed, without delay, to define the suspected infectious process in more detail. Detection of a false aneurysm, renal-artery involvement, or suprarenal aneurysmal dilatation (the patient had undergone aortobifemoral grafting seven years earlier) might have influenced the surgical approach. Computed tomography should not be performed in an unstable patient suspected of having an aortoenteric fistula. Studies such as computed tomography and angiography complement upper endoscopy and provide information that can alter the surgical approach to patients with aortoenteric fistulas. The attending surgeon must make the final decision about the benefit to be gained from such studies as compared with the risk entailed by delaying surgery.

Paul E. Zachary, Jr., M.D.
University of Kansas School of Medicine, Kansas City, KS 66160

Donald R. Campbell, M.D.
Veterans Affairs Medical Center, Kansas City, MO 64128

2 References

1. 1

   Hermreck AS. Prevention and management of surgical complications during repair of abdominal aortic aneurysms. Surg Clin North Am 1989;69:869-894
   Web of Science | Medline

2. 2

   Ernst CB. Aortic graft enteric fistula. In: Ernst CB, Stanley JC, eds. Current therapy in vascular surgery. 2nd ed. Philadelphia: B.C. Decker, 1991:440-5.