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Difficulty: MediumCardiothoracic and Vascular Surgery

A 72-year-old man is brought to the emergency department by ambulance due to a massive episode of hematemesis and hematochezia. He reports that earlier today he had a smaller episode of bloody emesis which he ignored. His medical history is significant for hypertension, hyperlipidemia, and an open abdominal aortic aneurysm repair with a synthetic Dacron graft performed four years ago. On arrival, he is lethargic and pale. Vital signs are temperature 37.1°C (98.8°F), blood pressure 75/40 mm Hg, heart rate 132/min, and respiratory rate 22/min. Physical examination reveals a soft, non-distended abdomen without guarding. Intravenous access is established and a massive transfusion protocol is initiated, but his blood pressure remains 78/42 mm Hg. Which of the following is the most appropriate next step in the management of this patient?

  1. Immediate exploratory laparotomyAnswer
  2. B
    Computed tomography angiography of the abdomen and pelvis
  3. C
    Esophagogastroduodenoscopy
  4. D
    Intravenous pantoprazole and octreotide infusion
  5. E
    Mesenteric angiography with embolization

Answer

Immediate exploratory laparotomy
The correct answer is immediate exploratory laparotomy. This patient presents with catastrophic gastrointestinal hemorrhage and hemorrhagic shock. In any patient with a history of an abdominal aortic aneurysm repair (particularly with a synthetic graft) who presents with massive GI bleeding, a secondary aortoenteric fistula (AEF) must be suspected. AEFs typically form between the proximal aortic suture line and the third portion of the duodenum. The classic presentation includes a self-limiting 'herald' bleed followed hours or days later by massive, often fatal, hemorrhage. Because this patient is hemodynamically unstable despite aggressive resuscitation, immediate surgical exploration is required to gain source control and prevent exsanguination.

Step-by-Step Solution

1
Identify the primary clinical problem and key risk factor.
Massive gastrointestinal bleeding and hemorrhagic shock in a patient with a history of an abdominal aortic aneurysm repair using a synthetic graft.
Recognizing the association between prior aortic grafts and delayed gastrointestinal bleeding is critical.
2
Formulate the most likely diagnosis.
Secondary aortoenteric fistula (AEF).
The combination of a 'herald' bleed followed by massive hemorrhage in a patient with a prior aortic graft is the classic presentation of an AEF.
3
Assess the patient's hemodynamic status.
The patient is hemodynamically unstable (blood pressure 78/42 mm Hg) despite the initiation of a massive transfusion protocol.
Hemodynamic stability dictates the algorithm for diagnostic and therapeutic interventions.
4
Select the appropriate next step in management.
Immediate exploratory laparotomy.
Unstable patients with a high suspicion for an aortoenteric fistula require emergent surgical exploration for life-saving hemorrhage control.

Key Concept

Secondary aortoenteric fistula (AEF) classically presents with a 'herald' gastrointestinal bleed followed by massive hemorrhage in a patient with a prior aortic graft. Hemodynamically unstable patients require immediate surgical exploration.
Estimated Time:1m 0s
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Topics

Cardiothoracic and Vascular Surgery

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