DUODENAL INVOLVEMENT RELATED TO VASCULAR COMPLICATIONS: DIAGNOSED BY UPPER GASTROINTESTINAL ENDOSCOPY

Envolvimento duodenal relacionado a complicações vasculares: diagnosticadas por endoscopia digestiva alta

The vascular enteric fistulae are severe. Late diagnosis causes high mortality¹. The aortoduodenal fistulae are the most frequent (80%) and occur due to an aortic aneurysm². The inferior caval vein filter (ICVF) is indicated when anticoagulation is contraindicated due to the risk of bleeding³. Its implantation is not free from short or long term complications⁴. The authors report two cases of vascular enteric fistulae, one derived from an aortic aneurysm and the other by ICVF, both perforated into the duodenum and detected by upper gastrointestinal endoscopy.

A 76-year-old man with abdominal pain, hematemesis and melena for 5 days. He reports aortic aneurysm. He arrived in serious condition, hypotensive (systolic pressure 90 mmHg) and with tachycardia (120 bpm). The rectal examination revealed the pre­sence of living blood. After hemodynamic stabilization, the endoscopy showed a deep and pulsatile ulcer in the second duodenal portion, circumferentially affecting the organ’s lumen, covered by fibrin and clots, compatible with aortoduodenal fistulae (Figure 1 and E-VIDEO). Computed tomography scan confirmed the finding of an infrarenal aortic aneurysm (7.5 cm) with rupture, in close contact with the duodenum, determining focal compression of the inferior vena cava. There was a new hemodynamic instability a few hours after admission with massive hematemesis and there was no time for surgical approach. He was referred to the intensive care unit and died 24 hours later.

FIGURE 1
A) Hematic residues inside the stomach. B) Aortoduodenal fistula.

Female, 54 years old, with abdominal pain, abdominal distension and postprandial fullness for 2 months. Physical examination revealed pain on deep palpation in the right flank and epigastrium. Eight years ago abdominal trauma with splenic injury. She had deep venous thrombosis in her lower limb, requiring ICVF implantation. Submitted to endoscopy that revealed an ICVF strut perforating the duodenum wall (E-VIDEO). Computed tomography scan showed the ICVF positioned below the confluence of the renal veins, and with its struts perforating the duodenum, right psoas muscle and attached to the L3 vertebral body (Figure 2). The patient underwent surgery, which identified the ICVF (Figure 3.A). The ICVF was removed and the duodenal wall sutured (Figure 3). The patient evolved well and was discharged on the eighth postoperative day.

FIGURE 2
A) CT-scan showing inferior vena cava with its larger componetns perforating adjacent structures (duodenum, right psoas muscle and L3 vertebral body) . B) CT-coronal view.

FIGURE 3
Intra-operatory view. A) Adherence between the 2^nd duodenal portion and the vena cava. B) Perforation site in the 2^nd duodenal portion. C) Suture of the duodenal wall. D) Recovered vena cava filter.

We emphasize the importance of valuing complaints reported by patients with these antecedents, in addition to performing a detailed physical examination. The diagnostic iconography must be precise, so that the treatment can be abbreviated. Remember that the close anatomical relationship of the retroperitoneal vascular organs and structures favors the appearance of complications in this topography.

REFERENCES

• ¹
  Chung J. Management of Aortoenteric Fistula. Adv Surg. 2018;52:155-77. doi: 10.1016/j.yasu.2018.03.007.
  » https://doi.org/10.1016/j.yasu.2018.03.007
• ²
  Geraci G, Pisello F, Li Volsi F, Facella T, Platia L, Modica G, Sciume C. Secondary aortoduodenal fistula. World J Gastroenterol. 2008;14:484-6. doi:10.3748/wjg.14.484.
  » https://doi.org/10.3748/wjg.14.484
• ³
  Chassin-Trubert L, Prouse G, Ozdemir BA, Lounes Y, Alonso W, Clapiès M, et al. Filter-Associated Inferior Vena Cava Thrombosis with Duodenal Perforation: Case Report and Literature Review. Ann Vasc Surg. 2019;58:383.e1-383.e6. doi: 10.1016/j.avsg.2018.11.021.
  » https://doi.org/10.1016/j.avsg.2018.11.021
• ⁴
  Vandy F, Rectenwald JE, Criado E. Late gastrointestinal complications of inferior vena cava filter placement: case report and literature review. Perspect Vasc Surg Endovasc Ther. 2011;23:261-4. doi: 10.1177/1531003511409058.
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• E-VIDEO: https://youtu.be/swTFnJuXwOE
• Disclosure of funding: no funding received

Publication Dates

• Publication in this collection
  15 Apr 2022
• Date of issue
  Jan-Mar 2022

History

• Received
  03 Sept 2021
• Accepted
  30 Sept 2021