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Difficulty: MediumCardiothoracic and Vascular Surgery

Paramedics rush a 68-year-old male to the trauma bay following an episode of massive hematemesis at his residence. His wife, who arrived separately, reports to the staff that he experienced a smaller episode of bloody vomiting yesterday but refused medical evaluation at that time. The electronic health record shows a history of hypertension, tobacco use disorder, and an open surgical repair of an infrarenal abdominal aortic aneurysm thirty-six months ago. Currently, the patient is lethargic, diaphoretic, and extremely pale. Vital signs include a temperature of 36.8∘C36.8^\circ \text{C} (98.2∘F98.2^\circ \text{F}), blood pressure of 70/40 mm Hg70/40 \text{ mm Hg}, heart rate of 142/min142\text{/min}, and respiratory rate of 28/min28\text{/min}. Physical examination reveals a well-healed midline abdominal scar. The abdomen is soft and non-distended without guarding or rebound tenderness. Bilateral femoral pulses are palpable but weak. Arterial blood gas analysis reveals a pH of 7.157.15, pCO2\text{pCO}_2 of 30 mm Hg30 \text{ mm Hg}, and HCO3−\text{HCO}_3^- of 10 mEq/L10 \text{ mEq/L}. Despite the rapid administration of two units of uncrossmatched O-negative packed red blood cells through two large-bore intravenous lines, his blood pressure remains critically low at 74/42 mm Hg74/42 \text{ mm Hg}. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Computed tomography angiography of the abdomen and pelvis
  2. Immediate exploratory laparotomyAnswer
  3. C
    Administration of intravenous sodium bicarbonate
  4. D
    Delaying intervention to obtain informed consent from the wife
  5. E
    Conservative management with nasogastric decompression

Answer

Immediate exploratory laparotomy
The patient's presentation of a 'herald bleed' followed by massive hematemesis, combined with a history of open abdominal aortic aneurysm (AAA) repair, is highly suspicious for a secondary aortoenteric fistula. Because the patient is in severe hemorrhagic shock and remains unresponsive to aggressive blood product resuscitation, immediate surgical exploration (exploratory laparotomy) is required for hemorrhage control and graft management.

Step-by-Step Solution

1
Identify the primary clinical syndrome based on the presentation.
The patient has a history of open abdominal aortic aneurysm (AAA) repair and presents with a 'herald bleed' (minor bleeding episode) followed by massive hematemesis, which is the classic presentation of a secondary aortoenteric fistula.
Recognizing the triad of prior aortic grafting, gastrointestinal bleeding, and shock is critical for establishing the diagnosis.
2
Assess the patient's hemodynamic status and response to initial resuscitation.
The patient remains in profound hemorrhagic shock (74/42 mm Hg74/42 \text{ mm Hg}) despite receiving aggressive fluid and blood product resuscitation.
Hemodynamic stability dictates the next management step. Stable patients can undergo diagnostic imaging, while unstable patients require immediate intervention.
3
Determine the most appropriate definitive management for an unstable patient with an aortoenteric fistula.
The patient must be taken immediately to the operating room for an exploratory laparotomy to obtain surgical control of the bleeding.
Surgical hemorrhage control (cross-clamping the aorta, excising the infected graft, and performing extra-anatomic bypass) is the only definitive life-saving treatment for a ruptured aortoenteric fistula in an unstable patient.

Key Concept

Management of aortoenteric fistula in a hemodynamically unstable patient
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Topics

Cardiothoracic and Vascular Surgery

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