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Difficulty: MediumCardiothoracic and Vascular Surgery

A 72-year-old man is brought to the emergency department by ambulance after losing consciousness at home. His wife reports that he had a brief episode of vomiting bright red blood earlier in the morning, which stopped spontaneously. However, just before the ambulance arrived, he experienced a massive episode of hematemesis and collapsed. His medical history is significant for hypertension, hyperlipidemia, tobacco use, and an open infrarenal abdominal aortic aneurysm repair four years ago. On arrival, he is diaphoretic and pale. His temperature is 37.1°C (98.8°F), blood pressure is 75/40 mmHg, pulse is 132/min, and respirations are 22/min. The abdomen is soft, non-tender, and mildly distended. Peripheral pulses are weak but symmetric. Two large-bore intravenous lines are placed and fluid resuscitation is initiated. Which of the following is the most appropriate next step in management?

  1. Emergent exploratory laparotomyAnswer
  2. B
    Computed tomography angiography of the abdomen
  3. C
    Esophagogastroduodenoscopy
  4. D
    Intravenous administration of octreotide and ceftriaxone
  5. E
    Administration of broad-spectrum antibiotics and blood cultures

Answer

Emergent exploratory laparotomy
The correct answer is emergent exploratory laparotomy. This patient is presenting with a classic 'herald bleed' (an initial, self-limiting episode of hematemesis) followed by massive upper gastrointestinal hemorrhage and hypovolemic shock. Given his history of an open abdominal aortic aneurysm repair, this presentation is highly suspicious for a secondary aortoenteric fistula. This complication typically occurs when the proximal anastomosis of the aortic graft erodes into the third portion of the duodenum. In any patient with massive hemorrhage and hemodynamic instability, definitive surgical control (laparotomy) is the most appropriate next step. Diagnostic delays are contraindicated.

Step-by-Step Solution

1
Identify the key clinical triad
Patient presents with prior aortic graft, an initial small 'herald bleed', and subsequent massive gastrointestinal hemorrhage causing shock.
Recognizing this classic presentation is essential for diagnosing a secondary aortoenteric fistula.
2
Assess hemodynamic stability
Blood pressure is 75/40 mmHg with a heart rate of 132/min, indicating severe hemorrhagic shock.
Hemodynamic instability dictates that immediate life-saving intervention takes precedence over diagnostic imaging.
3
Determine the most appropriate intervention
Select emergent exploratory laparotomy.
Surgical control of the bleeding graft is the only definitive treatment for an actively bleeding aortoenteric fistula in an unstable patient.

Key Concept

Secondary aortoenteric fistula is a life-threatening complication of aortic reconstructive surgery that presents with a 'herald bleed' followed by massive hemorrhage; hemodynamically unstable patients require immediate exploratory laparotomy.
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Topics

Cardiothoracic and Vascular Surgery

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