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Difficulty: MediumCardiothoracic and Vascular Surgery

An ambulance arrives at the emergency department with a 75-year-old male who collapsed at home after a massive episode of hematemesis. His wife states he has been experiencing intermittent lower back pain and low-grade fevers for the past two weeks. His surgical history is significant for an abdominal aortic aneurysm repair with a synthetic graft five years ago. Currently, he is lethargic with cool, clammy extremities. Vital signs show a temperature of 37.2°C (99.0°F), a heart rate of 135/min, and a blood pressure of 74/42 mmHg. Fluid resuscitation with packed red blood cells and crystalloids is underway through two large-bore intravenous lines, but his systolic blood pressure remains below 85 mmHg. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Perform a multiphase scan of the abdomen and pelvis
  2. B
    Admit for strict bowel rest and serial examinations
  3. Transfer to the operating room for exploratory laparotomyAnswer
  4. D
    Administer intravenous furosemide and request a bedside echocardiogram
  5. E
    Initiate empiric broad-spectrum antibiotics and await blood cultures

Answer

Transfer to the operating room for exploratory laparotomy
The correct action is to transfer the patient to the operating room for an exploratory laparotomy. This patient's presentation of massive hematemesis, hemodynamic instability, and a history of an abdominal aortic aneurysm repair with a synthetic graft is highly suspicious for a secondary aortoenteric fistula. This rare but catastrophic complication typically occurs when the aortic graft erodes into the third portion of the duodenum. In a hemodynamically unstable patient with a suspected aortoenteric fistula, immediate surgical intervention is required to control the life-threatening hemorrhage.

Step-by-Step Solution

1
Identify the primary clinical problem and vital signs.
The patient has massive upper gastrointestinal bleeding (hematemesis) and is in profound hemorrhagic shock (blood pressure 74/42 mmHg) unresponsive to initial fluid resuscitation.
Establishing the patient's hemodynamic status dictates whether immediate intervention or further diagnostic workup is required.
2
Synthesize the clinical presentation with the patient's past medical history.
The combination of massive hematemesis, back pain, and a history of an abdominal aortic aneurysm repair with a synthetic graft is the classic triad for a secondary aortoenteric fistula.
Recognizing this specific triad allows for rapid diagnosis of a highly lethal vascular complication.
3
Determine the appropriate management for this specific condition.
Because the patient is hemodynamically unstable and actively exsanguinating, diagnostic imaging must be bypassed in favor of immediate surgical exploration and control of the bleeding.
Delaying definitive surgical control in an unstable patient with an aortoenteric fistula leads to mortality.

Key Concept

Secondary aortoenteric fistula should be suspected in any patient with a history of prior aortic graft repair who presents with massive gastrointestinal bleeding. Hemodynamically unstable patients require immediate exploratory laparotomy.
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Topics

Cardiothoracic and Vascular Surgery

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