Arteriocolic Fistula: An

Unusual

Cause of Gastrointestinal-tract

CHRISTOPHER J . LONGAKER,

M.D.,

Bleeding*

MELVIN P. BUBRICK,

M.D.,

JOSEPH C. KISER, M . D .

Minneapolis, Minnesota

T h e following report describes a successfully managed case of an lilac-artery aneurysm to a sigmoidal fistula developing after surgical resection for diverticulitis.

O N E OF THE RARE CAUSES Of gastrointestinal bleeding is a fistula between a m a j o r artery and the gastrointestinal tract. Although clinical and radiographic findings are often minimal, such fistulas are usually lethal. Arterio-enteric fistulas have been described to occur most frequently following vascular reconstructive procedures, s Communications between the aorta and duoden u m or small bowel have been the type usually encountered. Scattered reports of fistula, either spontaneous or secondary to previous operation, involving the aorta a n d esophagus, the aorta and cecum, or the aorta and sigmoid colon may be found in medical literature, s, 10, 11 Reports of arterio-enteric fistulas arising from an lilac-artery aneurysm have been rare. Review of the recent literature has revealed only eight cases of fistulous connections between an lilac-artery aneurysm and the gastrointestinal or urinary tract.l, 2, 4, 6 - 9 . 1 1 O[ these eight cases, only three represent an lilac-artery aneurysm to a sigmoidal fistula.2, 6, 7 I n only one case, described by Foster and Vetto, 6 was there evidence of previous diverticular disease. No survivor has been reported in any of these cases.

Report

of a

Case

A 71-year-old man was admitted to the hospital with a history of rectal bleeding of bright red blood for a week prior to admission. On the morning of admission, the patient had passed a large quantity" of bright red blood per rcctum. He denied any' abdominal discomfort or change in bowel habits. Past history revealed that the patient had undergone sigmoidal resection for diverticulitis seven months previously. At that operation, an aneurysm 2.5 cm in diameter had been found in thc left c o m m o n iliac artery. T h e operation was described as routine and the patient had made an uneventful recovery with no reported complication. Physical examination revealed that the patient was well-developed, slightly obese, and in no distress. Blood pressure was 150/90 m m Hg, pulse rate 88/min, and temperature 99 F. Examination of the head and neck revealed no abnormality. T h e heart and lungs were normal. T h e a b d o m e n was p r o t u b e r a n t but soft, and the previous operative scar was nontender. T h e r e was diffuse fullness in the left lower quadrant, which was slightly tender, but no mass or pulsation could be appreciated. T h e bowel sounds were hyperactive. Femoral pulses were palpable and equal bilaterally. Bruits could not be heard over either the femoral or iliac areas. Rectal examination revealed gross blood without tenderness or suggestion of a mass. Proctosigmoidoscopy to 25 cm showed the rectum to be filled with clotted blood, with a small a m o u n t of fresh blood coming from above. T h e remainder of the physical examination was unremarkable. On admission, hemoglobin was 13.5 g/1O0 ml. P r o t h r o m b i n time, partial t h r o m b o p l a s t i n time, platelet count, serum electrolytes, blood urea nitrogen, and glucose were within normal limits. Urinalysis disclosed no abnormality. T h e EKG

* Read at the meeting of the American Society of Colon and Rectal Surgeons, New Orleans, Louisiana, May 2 to 6, 1976. Address r e p r i n t requests to Dr. Bubrick: Dep a r t m e n t of Surgery, H e n n e p i n County Medical Center, 701 Park Avenue, Minneapolis, Minnesota 55415.

135 Dis. Col. & Reet. March, 1977

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showed nonspecific T-wave changes. Chest x-ray revealed borderline cardiomegaly. Nasogastric aspiration was negative for gross a n d occult blood. T h e bleeding persisted after admiss[on, a n d i n t r a v e n o u s a d m i n i s t r a t i o n of fluids a n d wholeblood r e p l a c e m e n t were started. A superior mesenteric a r t e r i o g r a m was perfomed t h o u g h a right femoral-artery catheter and was interpreted as s h o w i n g a possible vascular lesion in the ascending colon. Because of this finding, vasopressin infusion t h r o u g h the same catheter was instituted. T h e .patient ceased bleeding for a p p r o x i m a t e l y 24 h o u r s , b u t heavy bleeding r e s u m e d shortly thereafter a n d exploratory laparotomy was performed. T h e findings at opeation were as follows: T h e a b d o m i n a l aorta was n o r m a l t h r o u g h o u t its length an a n e u r y s m of the left c o m m o n lilac artery, 7.5 cm in diameter, was f o u n d e x t e n d i n g deep into the pelvis; the previous sigmoidal suture line was fixed to the anterior border of t h e a n e u r y s m (Fig. I). No lesion could be d e m o n s t r a t e d in the rem a i n d e r of the colon. At operation, after gaining p r o x i m a l a n d distal vascular control, the sigmoid colon overlying the a n e u r y s m was resected in c o n t i n u i t y with the anterior surface of the wall of the a n e u r y s m . T h e iliac artery was t h e n ligated proximally and distally to exclude the aneucysm from the circulation (Fig. 2). T h e p r o x i m a l colon was exteriorized as an end-on colostomy and the distal rectal s t u m p was oversewn as a H a r t m a n n ' s pouch. T h e posterior wall of the a n e n r y s m was left in place and the a b d o m e n was closed (Fig. 3). T h e colostomy was then isolated a n d the entire a b d o m e n and i n g u i n a l areas were re-prepped a n d draped. A f e m o r a l - f e m o r a l arterial bypass was t h e n constructed using a knitted Dacron prosthesis 1.2 cm in diameter (Fig. 3, inset). Massive doses of antibiotics were given intraoperatively a n d in the postoperative period. All w o u n d s healed p r i m a r i l y w i t h o u t complication. However, on the t e n t h postoperative day, the patient s u s t a i n e d an u p p e r gostrointestinal tract h e m o r r h a g e , w h i c h necessitated surgica! intervention, b u t he subsequently m a d e an u n e v e n t f u l recovery. He was discharged 2~ days after admission with excellent blood flow to both lower extremities a n d a well.functioning colostomy. A year later the colostomy was taken down w i t h o u t complication. T h e patient has r e m a i n e d well.

Discussion

Pathogenesis" Arterio-enteric fistulization may occur spontaneously as a result of an expanding aneurysm, causing inflammation, fixation, and eventual perforation into a fixed portion of the bowel. A more likely explanation in this case, however, would be that surgical trauma to a pre-existing aneu-

D:s. Col. & Rect. ~Iarch, 1977

rysm, possibly accompanied by a localized colonic suture line separation, led to a localized abscess and subsequent fistula formation. A similar pathogenesis has been proposed by Foster and Vetto. 6 Diagnosis: It would be most unusual to consider a diagnosis of iliac aneurysm to intestinal fistula preoperatively as a cause of gastrointestinal hemorrhage. T h e usual diagnostic procedures, such as sigmoidoscopy, barium-enema examination, and arteriography, may not be helpful or, as in this case, may divert attention away from the proper diagnosis. For these reasons, an arterio-enteric fistula should be considered in any case in which the patient has acute gastrointestinal bleeding and a history of aortoiliac aneurysm or previous aortoiIiac surgery and any known inflammatory process in close proximity to the vascular lesions. Many investigators have f o u n d a prolonged interval between the initial hemorrhage and final, sudden, fatal exsanguination. 5 A high index of clinical suspicion leading to early surgical intervention during this intervaI is essential for survival of the patient. T r e a t m e n t : Certain guidelines must be followed in the management of an arterioenteric fistula to insure a satisfactory outcome. Massive doses of antibiotics should be given before operative manipulation or dissection is started. T h e bowel contents and aneurysmal vascular supply should be controlled proximally and distally before the aneurysm is opened. T h e area around the aneurysm should be packed off to prevent gross contamination. Once vascular control is obtained, partial resection of the aneurysmal wall in continuity with the segment of involved bowel helps to minimize the residual contaminated surface area. Adherence of one or both ureters to the aneurysmal wall will often preclude the possibility of safely excising the entire aneurysm.

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Number 2

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FISTULA

137

C A U S I N G GI B L E E D I N G

",/

Fro. 1. Operative findings: Iliac-artery a n e u r y s m with previous sigmoidal stature line fixed to anterior surface a n d with fistula between a n e u r y s m and posterior wall of colonic s u t u r e line. Inset: Lateral view, showing bowel d r a p e d over a n e u r y s m . FIG. 2. Vascular control a n d s u t u r e ligation p r o x i m a l a n d distal to the aneur:~sm. FIe. 3. Partial resection of a n e u r y s m a l wall, proximal end-on colostomy and distal closure of rectum, lnset: Completed procedure after f e m o r a l - f e m o r a l bypass.

LONGAKER, ET AL.

138

S u t u r e l i g a t i o n of the i n d i v i d u a l vessels w i t h n o a t t e m p t at direct r e c o n s t r u c t i o n is the safest surgical o p t i o n . A t t e m p t s at rec o n s t r u c t i o n w i t h a n y type of graft m a t e r i a l have b e e n d o o m e d to f a i l u r e because of the heavy c o l o n i c c o n t a m i n a t i o n . Similarly, p r i m a r y i n t e s t i n a l anastomosis s h o u l d n o t be a t t e m p t e d . A f t e r the fistula has b e e n resected a n d the a b d o m e n closed, vascular r e c o n s t r u c t i o n c a n be p e r f o r m e d i n a clean field outside the c o n t a m i n a t e d tissues. T h e r e c o n s t r u c t i o n m a y be a f e m o r a l - f e m o r a l bypass, as i n this case, or a n a x i l l a r y - f e m o r a l bypass. Summary A n u n u s u a l case of acute g a s t r o i n t e s t i n a l h e m o r r h a g e secondary to a n lilac-artery a n e u r y s m to a sigmoidal fistula is presented. Diagnosis a n d p a t h o g e n e s i s are discussed, a n d a p l a n for t r e a t m e n t is proposed.

References 1. Abramson PD, Jameson JB: Rupture of iliac aneurysm into duodenum: An unusual cause of upper gastrointestinal hemorrhage. Arch Surg 71: 658. 1955

Dis. Col. & Rect. March, 1977

2. Atin HL: Rupture of an iliac-artery aneurysm into the sigmoid colon: Report of a case. N Engl J Med 258: 366, 1958 3. Ammann J, Gosser V, Vogt B: Aorto-intestinat fistulae: Very rare cause of gastrointestinal bleeding. Swiss Med J 103:873, 1973 4. Beaugie JM: Fistula between external iliac artery and ileal conduit. Br J Urol 43: 450, 1971 5. Elliott JP Jr, Smith RF, Szilagyi DE: Aortoenteric and paraprosthetic-enteric fistulas: Problems of diagnosis and management. Arch Surg 108: 479, 1974 6. Foster JH, Vetto RM: Aortic intra-aneurysmal abscess .caused by sigmoid-aortic fistula. Am J Surg 104: 850, 1962 7. Jackman RJ, McQuarrie HB, Edwards JE: Fatal rectal hemorrhage caused by aneurysm of the internal iliac artery: Report of a case. Mayo Cliuic Proc 23: 305, I948 8. Reiner RJ, Conway GF, Threlkeld R: Ureteroarterial fistula. J Urol 113: 24, 1975 9. Reintoft AI, Baunsgaard P: Haematemeses og melaena forarsaget of fistel mellem tarm og aorta eller a. iliaca. Ugeskr Laeger 136: 1578, 1974 10. Schramek A, Weisz GM, Erlik D: Gastro-intestinal bleeding due to arterio-enteric fistula. Digestion 4: 103, 1971 11. Shucksmith HS: Duodenal, sigmoid, and ureteric fistulas resulting from aorta-iliac grafts or endarterectomy. Br J Surg 55: 402, 1968

Memoir GRi~co, REVNOI~D M., Williamsport, Pennsylvania; born October 27, 1903, Lock Haven, Pennsylvania; University of Pittsburgh Medical School, 1927; internship Misericordia Hospital, Philadephia. Dr. Grieco joined the American Society of Colon and Rectal Surgeons in 1944 and was elevated to Associate Fellowship in 1959. He was a member of the American Medical Association, the Pennsylvania State Medical Society, Lycoming County Medical Society, the Philadelphia College of Physicians; on the staffs of Divine Providence and Williamsport Hospitals. Dr. Grieco died March 30, 1976.

Arteriocolic fistula: an unusual cause of gastrointestinal-tract bleeding.

Arteriocolic Fistula: An Unusual Cause of Gastrointestinal-tract CHRISTOPHER J . LONGAKER, M.D., Bleeding* MELVIN P. BUBRICK, M.D., JOSEPH C...
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