Aortoenteric Fistula ‘Herald Bleed’ ne Mogya a Ɛtɔɔ Kɛse wɔ Upper GI mu wɔ Aortic Graft Oprehyɛn akyi¶

Aortoenteric fistula (AEF) yɛ abusuabɔ a ɛnteɛ a ɛyɛ hu, a ɛde nkwa to asiane mu ntɛm ara a ɛda yafunu mu aorta a nhyɛso kɛse wom ne yafunu mu kwan a ɛbɛn hɔ no ntam, mpɛn pii no ɛyɛ duodenum no fã a ɛto so abiɛsa anaa anan a ɛtwam fa akyi berɛmo no so tẽẽ. Bɛboro ɔha biara mu nkyem 90 yɛ aortoenteric fistulas a ɛto so abien a ɛba asram kosi mfe 15 wɔ oprehyɛn a wɔabue mu Dacron graft repair anaa endovascular stent-graft repair (EVAR) a wɔde siesie yafunu mu aortic aneurysm (AAA) akyi, bere a mfiri a ɛbɔ ne graft infection a ɛba fam no sɛe tokuru bi fa duodenal fasu no mu tẽẽ kɔ aortic suture no mu line. Esiane sɛ aortoenteric fistula a wɔansa no kum ɔha biara mu nkyem 100 nti, nkwa a wobenya no gyina ne ayaresabea kɔkɔbɔ sɛnkyerɛnne a ɛda nsow a wobehu so koraa: "herald bleed" (sentinel bleed). Wɔ ayarefo a wɔboro ɔha biara mu nkyem 60 kosi 80 mu no, mogya a wɔayi afi mu a ɛyɛ hu no di anim ne adeyɛ ketewaa bi a ɛte sɛ nea ɛyɛ nea ɛto ne ho anohyeto a ɛne sɛ wɔbɛfe mogya kɔkɔɔ a ɛhyerɛn anaa ade a wɔde kɔfe ayɛ (hematemesis), a wɔde fa nsu a ɛyɛ tuntum a ɛyɛ maroon anaa tarry tuntum (melena anaa hematochezia), anaasɛ obi nya bere tiaa bi a ɛma obi totɔ piti (syncope) a ɛno ankasa gyae koraa bere a mogya a ɛtɔ bere tiaa bi no siw fistula kwan ketewaa no ano na mogya mmoroso so tew no. Wɔ ** nnɔnhwerew kosi nna kakraa bi** mu no, aduan mu enzymes ne mogya mmoroso a ɛkɔ soro no tew anaasɛ ɛbɔ saa thrombus plug a ɛyɛ mmerɛw no, na ɛde mogya a ɛtɔ kɛse a wontumi nsiw ano ba ntini mu kɔ dwensɔtwaa no mu. Sɛ obi a **wɔayɛ pɛn yafunu mu aortic aneurysm repair, aortic bypass graft, anaa yafunu mu aortic aneurysm a wonim no nya biara yafunu mu mogya, nsu tuntum, anaasɛ ɔtotɔ piti a wontumi nkyerɛkyerɛ mu a, frɛ wo mpɔtam hɔfo nɔma ahorow a egye ntɛmpɛ ntɛm ara. Bere a woretwɛn ambulance akwantu no, hwɛ akwankyerɛ ahorow a ɛfa ntɛmpɛ ho a ɛfa aortic dissection ne yafunu mu aortic aneurysm a apaapae, . mogya a ɛba yafunu mu, mogya a ɛfe, ne melena, na esophageal a ɛpaapae (Boerhaave syndrome) ne Mallory-Weiss nusu.

Esiane sɛ standard upper endoscopy (EGD) duodenum no fã a edi kan ne nea ɛto so abien nkutoo (a mpɛn pii no ɛyera fistula a ahintaw kɔ akyiri wɔ duodenum no fã a ɛto so abiɛsa no mu) na esiane sɛ nsu a wɔde fa ntini mu denneennen betumi ama mogya mmoroso akɔ soro araa ma abɔ thrombus plug a ɛbɔ ho ban a ɛwɔ herald bleed no mu no mu nti, adeyɛ a ɛho hia sen biara a wobɛyɛ ansa na woakɔ ayaresabea ne sɛ wobɛ da adi pefee ka nsɛm pɔtee no kyerɛ 911 dispatcher, ayarehwɛfo, ne oduruyɛfo a ɔhwɛ ntɛmpɛ so no: "Ɔyarefo yi wɔ yafunu mu aortic graft na ɔrenya GI mogya; pow aortoenteric fistula herald mogya."

Yɛ eyi mprempren¶

1. Frɛ wo mpɔtam hɔ ntɛmpɛ nɔma ntɛm ara na fa to gua sɛ wosusuw sɛ Aortoenteric Fistula Herald Bleed. Trɛ 911 wɔ United States ne Canada, 112 wɔ European Union nyinaa, 999 wɔ United Kingdom, 000 wɔ Australia, anaa hwɛ yɛn list of nɔma ahorow a egye ntɛmpɛ. Ka no pefee: "Aduruyɛ mu ntɛmpɛ: yafunu mu mogya tu wɔ ɔyarefo bi a ɔwɔ abakɔsɛm a ɛkyerɛ sɛ wɔasiesie yafunu mu aortic aneurysm graft. Wosusuw sɛ aortoenteric fistula herald mogya."
2. Sɛ mogya a wɔfe anaa mogya a ɛtɔ kɔ akyi berɛmo mu no agyae koraa mpo na onipa no te nka sɛ ɔha biara mu nkyem 100 asan aba ne kan tebea mu a, fa no sɛ oprehyɛn a egye ntɛmpɛ ntɛm ara. Mfa no da sɛ nsu a ɛyɛ tumm a ɛbae pɛnkoro anaa mogya kuruwa ketewaa bi a wɔafe no yɛ yafunu mu akisikuru, akisikuru, anaa yafunu mu yare a n’ankasa gyaee ara kwa. Saa nnaadaa bere a ɛyɛ komm no ne ayaresabea nkyerɛase pɔtee a ɛfa herald bleed (beae a ɛkame ayɛ sɛ vasospasm ne bere tiaa mu mogya a ɛtwetwe no ntumi nsiw yafunu mu aorta no nhyɛso nyinaa ano).
3. Fa ɔyarefo no to n’akyi tratraa (anaasɛ wobobɔw no kɔ ne benkum so wɔ tebea a ɛma ne ho tɔ no mu sɛ ɛyɛ nnam a ɛyɛ akisikuru anaasɛ ɔfe a) na bara sɛ obegyina hɔ, ɔbɛtra ase, anaasɛ ɔbɛnantew nyinaa. Sɛ wosɔre a, ɛma amemene mu nsu a wɔde ma no kɔ fam na ɛma yafunu no fasu mu nhyɛso yɛ kɛse, a ebetumi akanyan syncope anaasɛ ɛde mfiri ahaw thrombus plug a ɛyɛ mmerɛw a ɛkata fistula no ntam wɔ aortic graft no ntam no ne duodenum a ɛwɔ akyi no.
4. Hyɛ NPO a ɛyɛ katee (biribiara nni ano: nsu a ɛnyɛ hwee, aduan biara nni mu, nnuru a wɔde ko tia asikre a wɔnom nni hɔ, ne nnuru a ɛma mogya yɛ mmerɛw anaa ɛyaw nnuru biara nni mu). Nsu anaa aduan a wɔmene no kanyan yafunu mu acid, bile, ne dwensɔtwaa mu proteolytic enzymes (trypsin ne chymotrypsin) ma hwie gu duodenum no fã a ɛto so abiɛsa mu, baabi a wɔde nnuru di bere tiaa mu fibrin no clot a ɛtow aortic fistula no ano na ɛkanyan mogya a wɔde fi nipadua no mu ntɛm ara.
5. MMA mia, mfa wo nsa nka, anaa mfa nhyɛ yafunu no mu. Obi a ɔhwɛ yafunu no mu anaa oduruyɛfo a ɔrepiapia yafunu no mfinimfini akɔ akyiri ahwɛ sɛ ɛyɛ mmerɛw anaasɛ ɛrebɔ no betumi apia duodenum no honam fam wɔ prosthetic aortic graft a ɛwɔ ase no so na ayi sentinel clot no afi hɔ.
6. Hwehwɛ ɔyarefo no oprehyɛn a wɔde hyɛ nipadua no mu krataa anaa ayaresabea a wogyaee no ho nsɛm tiawa a ɛkyerɛ da ne ɔkwan a wɔfaa so yɛɛ aortic oprehyɛn, na fa ma nnuruyɛfo a wɔboa no no tẽẽ. Sɛ wunim sɛ ebia ɔyarefo no wɔ aortobifemoral Dacron bypass graft a wɔabue, interposition tube graft, anaa endovascular aortic stent-graft (EVAR) a, ɛbɔ ayaresabea a wɔresan agye no kɔkɔ sɛ wɔbɛma Vascular Surgery team ne CT Angiography scanner no nyinaa ayɛ adwuma ansa na ɔyarefo no mpo akɔ apon no mu.

Gyinaesi dua: acute hematemesis, melena, anaa mogya a ɛtɔ wɔ ɔfe akyi triage¶

flowchart TD
    Start["Mogya a Ɛfe a Ɛyɛ Den (Hematemesis), Kafe a Wɔayam, Black Tarry Stool (Melena), anaa Maroon Stool"] --> CheckAorta{"Anamɔn 1: So Ɔyarefo no Wɔ Abakɔsɛm a Ɛfa Yafunu mu Aortic Aneurysm (AAA) a Wosiesie (Open Graft anaa EVAR Stent), Aortoiliac Bypass, AAA a Wonim, anaa Pulsating Abdominal Mass ho?"}

    CheckAorta -->|"YIW (Sɛ mpo oprehyɛn no yɛ mfe 5 kosi 15 a atwam ni na mogya no sua anaasɛ wogyaee a) ."| HeraldAEF["WOSUSUW sɛ AORTOENTERIC FISTULA (AEF) HERALD MOGYA TUO: Frɛ 911 / 112 / 999 Ntɛm ara; Kɔkɔ Ntini Oprehyɛn + Hyehyɛ Ntɛm ara Multiphasic CT Angiogram (CTA) Ansa na Wɔbɛyɛ Endoscopy Biara"]

    CheckAorta -->|"Aortic graft anaa aneurysm biara nni hɔ a wonim"| CheckVomitContext{"Anamɔn 2: So Mogya no Fi ase Tui Bere a Ɔde Ahoɔden Retching Anaasɛ Ɔfefe no Awiei Ntɛm ara?"}

    CheckVomitContext -->|"YIW: Ná akisikuru a ɛyɛ den anaasɛ ɔfe no dii sɛnkyerɛnne ahorow no anim"| CheckMackler{"Anamɔn 3: Hwɛ Boerhaave Rupture vs. Mallory-Weiss Tear: So ɛyaw a ɛyɛ yaw 10/10 a ɛtetew koko anaa akyi, ahome a ɛyɛ tiaa, anaa mframa a ɛyɛ mmerɛw wɔ kɔn honam ani (crepitus) ase?"}

    CheckMackler -->|"YIW: Koko/akyi yaw a emu yɛ den, ɔhome a ɛyɛ den, anaa kɔn mu a ɛyɛ mmerɛw"| Boerhaave["WOSUSUW sɛ BOERHAAVE SYNDROME (TRANSMURAL ESOPHAGEAL RUPTURE): Frɛ Dwumadibea a Ɛhwɛ Ntɛmntɛm So Ntɛm ara; NPO a ɛyɛ katee (Ɛnyɛ Nsu 1 mpo), Tena Semi-Upright 30 kosi 45 Degrees"]

    CheckMackler -->|"ƐYƐ koko mu yaw anaasɛ ɔhome a ɛyɛ den biara nni hɔ: Mogya kɔkɔɔ a ɛhyerɛn ba bere a woafe mpɛn pii a ɛfata akyi"| MalloryWeiss["Wosusuw sɛ Mallory-Weiss Mucosal Tear: Kɔ so yɛ NPO katee; Wɔde Kɔ Dwumadibea a Ɛho Hia Ntɛmntɛm kɔhwɛ Hemoglobin, IV Proton Pump Inhibitor, ne Endoscopic Nhwehwɛmu"]

    CheckVomitContext -->|"NO prior retching: Mogya, kɔfe a wɔayam, anaa nsu tuntum a wɔfe a ɛnyɛ yaw a ɛba ara kwa"| CheckCirrhosis{"Anamɔn 4: So Ɔyarefo no Wɔ Mmerɛbo mu Yare, Portal Hypertension, anaa NSAID/Ulcer Abakɔsɛm a emu yɛ duru?"}

    CheckCirrhosis -->|"Cirrhosis / Jaundice / Ascites ANAA Mogya a Ɛtɔ So Kɛse"| VaricesUlcer["WOSUSUW sɛ ESOPHAGEAL VARICES RUPTURE ANAA ARTERIAL PEPTIC ULCER BLEED (DIEULAFOY): Frɛ Nnwuma a Ɛho Hia Ntɛmntɛm; Gyinabea a Wɔsan Yɛ, NPO a Ɛyɛ Katee"]

    HeraldAEF --> AEFProtocol["AEF Resuscitation Protocol a Wɔyɛ no Ntɛm ara: Mpa so Ahomegye a Ɛyɛ Den, Yafunu a Wɔbɛbɔ no Zero, NPO a Ɛyɛ Katee, Permissive Hypotension (Target Systolic BP 80 kosi 100 mmHg ma enti Clot Plug no Mfra), Emergent Endovascular Stent-Graft Relining (EVAR Bridge) anaa Open Aortic Control"]

Anatomy ne pathophysiology: nea enti a aortic graft no sɛe kɔ duodenum no fã a ɛto so abiɛsa no mu¶

Sɛ yɛbɛte sɛnea ntini kɛse bi a ɛwɔ akyi berɛmo no mu no di nkitaho tẽẽ kɔ aduan mu ntini no mu, ne nea enti a mogya no ba wɔ akwan horow abien a ɛsono emu biara mu (mogya a ɛbɔ amanneɛ a ɛyɛ komm a sanguination a ɛyɛ asiane di akyi no ase a, ɛboa sɛ yɛbɛhwehwɛ yafunu no mfinimfini nipadua no mu:

1. Anatomical crossways a ɛwɔ duodenum no fã a ɛto so abiɛsa (D3) .¶

Wɔ nnipa nipadua mu no, yafunu mu aorta no tu mmirika kɔ fam tẽẽ kɔ akyi berɛmo no anim wɔ akyi berɛmo no mu. Wɔ adwene no ntini ahorow no mfiase (baabi a yafunu mu aortic aneurysms ɔha biara mu nkyem 95 ba ne baabi a wɔpam oprehyɛn prosthetic grafts kɔ baabi no) ase pɛɛ no, duodenum no fã a ɛto so abiɛsa (a ɛkɔ soro) no twam tẽẽ fi nifa kɔ benkum fa yafunu mu aorta no anim ne proximal graft suture line (anastomosis), a srade a ɛwɔ akyi ne akyi berɛmo mu a ɛyɛ tratraa te sɛ krataa nkutoo na ɛtetew mu.

• Aortoenteric Fistula a Ɛho Hia (Ɛnyɛ, . <10% of cases): Ɛba ɔyarefo bi a ɔwɔ yafunu mu aortic aneurysm a wɔansa no yare, a wɔanyɛ oprehyɛn (mpɛn pii no ɛyɛ "mycotic" aneurysm a ɛwɔ ɔyare mmoawa, nsamanwaw anaa syphilitic aortitis, opira a mframa de ba, anaasɛ pancreatic/duodenal tumor) a aneurysm kotoku a ɛretrɛw no petepete duodenum no so tẽẽ kosi sɛ afasu abien no bɛka abom na mpaapaemu kɔ wɔn ho wɔn ho mu.
• Aortoenteric Fistula a Ɛto so Abien (Ɛtaa, . >90% of cases): Ɛba asram kosi mfe 15+ (mfinimfini mfe 3 kosi 5) bere a wɔde oprehyɛn a wɔabue ano asiesie yafunu mu aortic aneurysm a wɔde Dacron anaa PTFE prosthetic graft a wɔapam anaa wɔanwene ayɛ akyi, anaasɛ endovascular aneurysm repair (EVAR) a wɔde dade stent-graft asiesie akyi. Akwan abien a ɛyɛ adwuma bom no twaa ɔkwan bi fi aorta no mu kɔɔ dwensɔtwaa no mu:
• Relentless Mechanical Pulsation Pressure Necrosis: Sɛ ntini a ɛyɛ tratraa a wɔde kyekyere nipadua a wɔde ayɛ nipadua no ne akyi berɛmo no ntam wɔ oprehyɛn a edi kan no mu no yɛ teateaa a, nhama a ɛyɛ den na ɛbɔ a ɛwɔ aduru a wɔde ahyɛ nipadua no mu no proximal suture line no bɔ akyi fasu a ɛwɔ akyi ɔfasu a ɛwɔ akyi ɔfasu a ɛto so abiɛsa a ɛyɛ pintinn no so mpɛn 100,000 da biara. Mfe pii akyi no, saa mfiri jackhammering yi ma nhyɛso ischemia ne akuru ba duodenal fasu no mu kosi sɛ synthetic graft fibers a ɛda hɔ kwa no bɛda adi wɔ dwensɔtwaa no mu tẽẽ.
• Low-Grade Perigraft Bacterial Infection: Bere bi a dwensɔtwaa mu mmoawa nketenkete (Escherichia coli, Enterococcus, Staphylococcus epidermidis, Streptococcus, Bacteroides, ne Candida ahorow) dan fa duodenal mucosa a wɔayɛ no teateaa no so kɔ synthetic no so Dacron graft, wɔyɛ biofilm a enni sabea twa graft anastomosis no ho hyia, na wogyae bacterial proteases a ɛpete host aortic wall stitches na ɛma fistula channel tẽẽ (paraprosthetic-enteric anaa aorto-duodenal fistula).

2. Anatomical mmeae a ɛka wɔ Aortoenteric Fistula mu¶

Bere a yafunu no fã biara a ɛka aorta no betumi asɛe no, nipadua mu nkyekyɛmu no yɛ kɛse wɔ duodenum a emu dɔ no mu:

1. Duodenum no Afã a Ɛto so Abiɛsa ne Anan (D3 / D4): ɔha biara mu nkyem 75 kosi 80 wɔ nsɛm no nyinaa mu (efisɛ wɔde Treitz ntini no kyekyere D3 a entumi nkɔ proximal aortic graft anastomosis no so).
2. Jejunum ne Ileum (Adwensɔtwaa): ɔha biara mu nkyem 10 kosi 15 wɔ nsɛm a ɛba no mu.
3. Sigmoid Colon anaa Cecum: ɔha mu nkyekyɛmu 3 kɔsi 5 (titiriw berɛ a aortobifemoral bypass limb bi twetwe kɔ sigmoid colon a ɛwɔ benkum pelvis no mu).
4. Yafunu anaa Esophagus: ɔha biara mu nkyem 2 kosi 5 (thoracic aortic stent-grafts a ɛporɔw kɔ esophagus mfinimfini, a wonim no sɛ aortoesophageal fistula, a ɛde Chiari's triad ba: mid-thoracic pain, sentinel arterial hematemesis a egyae, ne fatal exsanguination nnɔnhwerew akyi).

3. "Herald Bleed" (Sentinel Bleed) no biomechanics ne nea enti a egyae n'ankasa¶

Ayarefo, mmusua, ne ayaresabea adwumayɛfo a wonni osuahu mpo taa ma wɔn ho dwiriw wɔn wɔ mogya a ɛbɔ ho dawuru no ho: "Ɛbɛyɛ dɛn na tokuru bi a ɛwɔ yafunu mu aorta titiriw no mu atumi ama mogya kuruwa biako pɛ akɔ mogya na afei agyae ne ho koraa?" Nipadua mu akwan anan kyerɛkyerɛ saa nnaadaa home yi mu:

1. Microscopic initial mucosal pinhole: Sɛ aortic suture line anaa pseudoaneurysm a ɛresɛe no di kan bubu muscularis ne mucosa a ɛwɔ duodenum a ɛto so abiɛsa no mu a, mpɛn pii no, nea ɛbue no trɛw yɛ millimita 1 kosi 3 pɛ sen sɛ ɛbɛtetew mu kɛse.
2. Aterial vasospasm ne transient hypotension: Mogya a ɛtɔ mpofirim a ɛyɛ mililita 200 kosi 500 (ounces 7 kosi 17) a ɛpae kɔ duodenum no mu no ma mogya mmoroso a ɛwɔ nhyehyɛe mu no so tew (ɛtaa ma obi totɔ piti bere tiaa bi anaasɛ ɛma obi ti popo) na ɛkanyan reflex smooth-muscle vasospasm a emu yɛ den twa fistula no ho hyia kratawa ne duodenal fasu.
3. Bere tiaa mu mogya nkwammoaa-fibrin thrombus plug a ɛba: Bere a mogya mmoroso kɔ fam na fistula no reyɛ teateaa no, mogya nkwammoaa ne fibrin twetwe ntɛmntɛm wɔ tortuous tract a ɛda synthetic graft ne duodenal mucosa ntam no mu, na ɛma tokuru no to mu te sɛ nea wɔde siw toa mu.
4. Thrombus plug no a wɔyam ne nea ɛbɔ): Sɛ mogya no gyae a, ɔyarefo no mogya mmoroso san kɔ sɛnea na ɛte kan no (anaasɛ sɛ ayaresabea kuw bi de nsu a wɔde fa ntini mu ntɛmntɛm boluses ma anaasɛ wɔde mogya ma de "ma nsɛnkyerɛnne a ɛho hia no yɛ nea ɛfata" a, ɛkɔ soro mpo). Bere koro no ara mu no, yafunu mu nsu a acid wom, bile, ne dwensɔtwaa mu enzymes a ano yɛ den (trypsin, elastase, ne lipase) hohoro mogya a ɛtɔ no fã a ɛda adi no so bere nyinaa, na ɛde nnuru tew fibrin plug no. Bere a mfɛnsere a ahintaw a efi nnɔnhwerew kakraa bi kosi nna pii (wɔ ɔha biara mu nkyem 50 mu wɔ ** nnɔnhwerew 6 kosi 24** akyi, ne ɔha biara mu 90 mu wɔ adapɛn 1 kosi 2 akyi no, clot plug no bɔ koraa, na ebue afiri a ɛkɔ tẽẽ a nhyɛso kɛse wom fi aorta no mu kɔ dwensɔtwaa no mu a ebetumi ama mogya lita 1 kosi 2 simma biara.

Nsonsonoe a ɛda 4 High-Stakes Upper GI Bleed & Post-Vomiting Emergencies no mu¶

Esiane sɛ mogya a ɛtɔ wɔ yafunu no atifi ne koko/yafunu mu ntɛmpɛ a ɛba wɔ ɔfe akyi hwehwɛ sɛ wɔde wɔn ho gye mu ntɛm ara a ɛsono emu biara koraa (efi mogya mmoroso a wɔma ho kwan ne CT angiography a wɔde ma aortoenteric fistula so kosi oprehyɛn a wɔde ma ntɛm ara wɔ koko mu ma Boerhaave syndrome so) nti, fa ayaresabea ntotoho pon yi di dwuma:

Ayaresa frankaa kɔkɔɔ: Classic Triad ne subacute "Graft Sepsis" kɔkɔbɔ nsɛnkyerɛnne¶

Bere a adesua nhoma ahorow ka Classic Triad of Aortoenteric Fistula a ɛyɛ (1) Yafunu mu mogya, (2) Yafunu anaa akyi yaw, ne (3) Yafunu mu akisikuru a ɛbɔ a wotumi de wɔn nsa ka ho asɛm no, nhwehwɛmu ahorow kyerɛ sɛ nsɛnkyerɛnne abiɛsa no nyinaa bom pue wɔ ayarefo ɔha biara mu nkyem 11 kosi 25 pɛ mu (efisɛ oprehyɛn akyi akuru ntini anaa endovascular stent-grafts taa mma wontumi nte ade bi a wotumi de wɔn nsa ka nka). Mmom no, hwɛ yiye wɔ wiase ankasa ayaresabea nhyehyɛe ahorow yi ho:

1. "Herald Bleed + Syncope" Nhwɛso (Wɔhu wɔ nsɛm 60% kosi 80% mu) .¶

• Ɔyarefo no te nka mpofirim sɛ ne ho yɛ hyew, ne ho yɛ no yaw, ne ti yɛ no yaw, anaasɛ ne ti yɛ hare, na obetumi atotɔ piti bere tiaa bi (syncope) wɔ aguaree fam.
• Wɔfe mogya kɔkɔɔ kakraa bi anaasɛ "kɔfe a wɔayam" tuntum, ANAA wɔde mogya a ɛyɛ tumm maroon anaa jet-black, tarry stool (melena) a ɛyɛ huam biako twam.
• Wɔ simma 15 kosi 30 mu no, wɔn kɔla san ba, mogya no gyae, na wosi so dua sɛ wɔn ho ye na wɔmpɛ sɛ wɔkɔ ayaresabea. Eyi ne bere pɔtee a kar a wɔde fa nneɛma a egye ntɛmpɛ gye wɔn nkwa.

2. "Asumansɛm Graft Infection + Akyi Ɛyaw" Prodrome no¶

Wɔ ayarefo pii a wɔwɔ aortoenteric fistula a ɛto so abien mu no, adapɛn anaa asram ansa na mogya a edi kan a ɛda adi no ada adi no, duodenum a ɛresɛe no ma mmoawa kɔ prosthetic aortic graft no so, na ɛde chronic perigraft sepsis ba: - Atiridiinini a ɛba bere ne bere mu a wontumi nkyerɛkyerɛ mu, fifiri a ɛba anadwo, anaasɛ ɛyɛ katee (wɔtaa hu no yiye adapɛn pii sɛ ɔyare mmoawa, nsu mu yare, anaa atiridii a wonnim mfiase). - akyi ɛyaw foforo, a emu dɔ, a ɛyɛ mfonoe a ɛwɔ akyi berɛmo mfinimfini anaa yafunu a ɛwɔ akyi (a ɛnam akyi berɛmo mu ɔfe ne pseudoaneurysm ntrɛwmu a ɛpiapia akyi berɛmo no so na ɛba). - Septic emboli to the legs or toes ("Blue Toe Syndrome"): Ntini nketenkete a ɔyare mmoawa wom a ɛpaapae colonized aortic graft no na ɛtɔ kɔ fam kɔ ​​nan no mu, na ɛde nsensanee kɔkɔɔ a ɛyɛ yaw ba nansoaa no so anaasɛ nan nnompe mu yare wɔ ɔfã biako. - Bacteremia a ɛwɔ awotwaa mu mmoawa: Mogya amammerɛ a ɛrenyin Escherichia coli, Enterococcus, Streptococcus bovis/anginosus, Bacteroides, anaa Candida wɔ ɔyarefo biara a ɔwɔ aortic graft mu no yɛ pathognomonic ma aortoenteric fistula anaa graft infection.

Ayaresabea afiri abien a edi awu: "Standard Endoscopy Trap" ne "Over-Resuscitation Trap".¶

Sɛ woka wo dɔfo bi a wadi kan ayɛ aortic graft ho akɔ dwumadibea a wɔhwɛ ntɛmpɛ so a, sɛ wunim ayaresabea afiri abien a ɛho hia a Society for Vascular Surgery (SVS) ne European Society for Vascular Surgery (ESVS) kamfo kyerɛ a, ebetumi aboa ma wɔahwɛ ahu sɛ ɔhwɛ a wɔyɛ no ntɛmntɛm na wɔayɛ no biako no bɛba:

Afiri 1: Nea enti a Upper Endoscopy (EGD) a wɔde di dwuma daa no taa hwere Aortoenteric Fistula¶

Wɔ mogya a ɛba yafunu no atifi a wɔtaa tu no mu no, nnuruyɛfo a wɔhwɛ yafunu mu yare a egye ntɛmpɛ frɛ yafunu mu oduruyɛfo ma ɔnyɛ esophagogastroduodenoscopy (EGD). Nanso, wɔayɛ gastroscope a wɔahyɛ da ayɛ no sɛnea ɛbɛyɛ a ebedu duodenum no fã a edi kan ne nea ɛto so abien (D1 ne D2) nkutoo, na egyina Vater ampulla no ho pɛɛ. Esiane sɛ aortoenteric fistulas ɔha biara mu nkyem 75 kosi 80 wɔ duodenum no fã a ɛto so abiɛsa ne anan (D3 ne D4) no mu tɔnn nti, EGD a wɔyɛ no daa no te sɛ nea ɛteɛ koraa wɔ aortoenteric fistula a ɛba nyinaa mu bɛboro fã mu.

Asiane afoforo abien wɔ hɔ bere a wɔreyɛ endoscopy no: - The "Coincidenttal Ulcer" Trap: Ntini mu ayarefo a wɔn mfe akɔ anim taa nom aspirin anaa nnuru a ɛma mogya yɛ mmerɛw da biara na wɔtaa nya yafunu mu yare a emu nyɛ den, yafunu mu akisikuru nketenkete, anaasɛ yafunu mu akisikuru ketewaa bi a asa wɔ yafunu mu. Sɛ oduruyɛfo a ɔhwɛ yafunu mu hu yafunu mu yare a emu nyɛ den na ogyae nhwehwɛmu no a wanhwɛ mu akosi duodenum no fã a ɛto so anan no nyinaa mu (anaasɛ wanhyɛ sɛ wɔnyɛ CT angiogram) a, wobetumi adi atoro aka sɛ mogya a ɛbae wɔ yafunu mu no fi yafunu mu yare bere a aortic fistula no te hɔ kɔ akyiri nsateakwaa bi a ayɛ krado sɛ ɛbɛpaapae no. - Dislodging the Herald Clot inside the GI Lab: Sɛ endoscopist pia mmofra colonoscope tenten anaa push-enteroscope kɔ akyiri kɔ duodenum no fã a ɛto so abiɛsa mu, hu mogya a ɛyɛ tumm a ɛrebɔ a ɛbata duodenal fasu no ho, na ɔbɔ mmɔden sɛ ɔbɛhohoro, biopsy no, anaasɛ ɔbɛtwitwa no standard endoscopy suite mu a, wobetumi atwe plug no fi yafunu mu aorta no mu na ɛkanyan mogya a ɛba ntɛm ara a edi awu a ɛne oprehyɛn dan ntam kwan ware. Enti, sɛ wɔyɛ endoscopy de hwɛ D3/D4 a, ntini mu oprehyɛn akwankyerɛ kyerɛ sɛ ɛsɛ sɛ wɔyɛ no wɔ oprehyɛn dan mu a wɔahohoro ntini mu oprehyɛn kuw no mu na wɔasiesie wɔn ho ama aortic clamping ntɛm ara.

Afiri 2: Nea enti a "Permissive Hypotension" gye nkwa ansa na wɔasɔ aorta no ano¶

Wɔ mfɛnsere a ahintaw mu wɔ mogya a wɔde bɔ amanneɛ akyi no, mogya nkwammoaa-fibrin a ɛyɛ mmerɛw a ɛyɛ mmerɛw nkutoo ne akwanside biako pɛ a ɛtetew aortic mogya a nhyɛso kɛse wom ne dwensɔtwaa no mu a ɛbue no ntam. Sɛ nnuruyɛfo a wɔboa nkurɔfo anaa ayaresabea adwumayɛfo de nkyene bolus a wɔde fa ntini mu ntɛmntɛm lita pii ma anaasɛ wɔde mogya mu nkwammoaa kɔkɔɔ a wɔahyɛ no ma akuwakuw pii ma na ama ɔyarefo no mogya mmoroso a ɛwɔ nipadua no mu no akɔ soro akodu 130 to 150 mmHg, saa hydrostatic pressure spike no bɛma pop clot plug no afi fistula tract no mu pɛɛ (te sɛ nea ɛte wɔ yafunu mu aortic aneurysm a apaapae mu no).

• Mmara a ɛma mogya mmoroso a wɔma ho kwan: Bere tenten a ɔyarefo no ani da hɔ, n’ani da hɔ, na ɔrekasa (a ɛkyerɛ sɛ mogya kɔ amemene ne koma no mu sɛnea ɛsɛ) no, ntini mu ahodwiriw ne akwankyerɛ a wɔde ma obi nya nkwa no de n’ani si mogya mmoroso a wɔma ho kwan a wɔahyɛ so (mogya mmoroso a ɛba nipadua mu a ɛyɛ bɛyɛ sɛ systolic 80 to 100 mmHg) de nsu a wɔde ahwɛyiye, a wɔahyɛ no titrated di dwuma kosi sɛ ntini mu oprehyɛn ho oduruyɛfo no bɛfa endovascular stent-graft anaa aortic cross-clamp so akata aorta no so.

Ayaresabea mu nhwehwɛmu a edi mũ ne oprehyɛn a wɔde gye nkwa: CTA, EVAR bridge, ne reconstruction¶

Sɛ ɔyarefo bi a wosusuw sɛ ɔwɔ aortoenteric fistula du dwumadibea a wɔhwɛ ntɛmpɛ so a, ayaresabea no ma ntini mu oprehyɛn kwan bi a ɛkɔ ntɛmntɛm yɛ adwuma:

1. Gold-Standard First Test: Multiphasic CT Angiography (CTA) of Abdomen and Pelvis: Wɔyɛ a anom nsonsonoe pa (a ɛbɛma mogya a ɛretu denneennen asie wɔ duodenum no mu), CTA gye nea ennu simma 5, ɛwɔ ɔha biara mu nkyem 85 kosi 95 nkate, na ɛda ɔyare ho sɛnkyerɛnne adi:
2. Ectopic perigraft gas: Mframa a ɛbɔ atwa aortic graft no ho ahyia (ɛyɛ nea ɛnteɛ bere nyinaa bɛboro adapɛn 4 kosi 6 wɔ oprehyɛn no akyi).
3. Aorto-duodenal fat plane no a ɛyera: Duodenum a ɛtɔ so mmiɛnsa no a wɔkyekyere no tẽẽ kɔ anim graft fasuo no mu anaasɛ anastomotic pseudoaneurysm.
4. Active contrast extravasation: Nsonsonoe a wɔde fa ntini mu fi aorta no mu kɔ duodenal lumen no mu.
5. Stage 1 Rescue: Endovascular Stent-Graft Relining ("EVAR Bridge to Surgery"): Wɔ SVS ne ESVS akwankyerɛ ase no, sɛ́ anka wɔbɛyɛ laparotomy a wɔabue ntɛm ara (a ɛde owu ɔha biara mu nkyem 50 kosi 70 ba bere a mogya tu a ɛyɛ nnam) no, ntini mu oprehyɛn ho animdefo tow asen mu ntini a ɛwɔ akyi berɛmo mu na wɔde endovascular aortic a wɔakata so di dwuma stent-graft wɔ graft dedaw no mu wɔ fistula no so (anaasɛ fa REBOA aortic balloon gu mu wɔ kyere mu). Wɔ simma 20 mu no, mogya a ɛretu no gyae na mogya mmoroso no gyina. Wofi ase de nnuru a ekum ɔyare mmoawa a ɛwɔ IV mu a ɛtrɛw (piperacillin-tazobactam anaa meropenem + vancomycin) ne IV a ekum fungal (fluconazole anaa micafungin) ka ho ntɛm ara.
6. Stage 2 Definitive Repair: Sɛ wɔsan nya nkwa wie a, nnuruyɛfo a wɔyɛ oprehyɛn no yi duodenum a ɛto so abiɛsa no mu na wosiesie, wɔde omentum kɛse a ɛyɛ den a ɛwɔ dwensɔtwaa ne aorta ntam, twa synthetic graft a ɔyare no wom no, na wɔsan de mogya no san fa extra-anatomic axillobifemoral bypass anaa in-situ so aortic reconstruction a wɔde autogenous femoral-popliteal vein (NAIS), homograft a wɔakora so wɔ cryo mu, anaa Dacron a wɔde rifampin/dwetɛ ahyɛ mu ma di dwuma.

Mpɔtam hɔ ntɛmpɛ nɔma ne adwumakuw no nhyehyɛe ahorow¶

Sɛ wosusuw sɛ aortoenteric fistula no hwehwɛ sɛ wɔde ambulance kɔ ayaresabea a ɛto so abiɛsa Vascular Surgery Center a wɔde Nnɔnhwerew 24 CT Angiography, Hybrid Endovascular Operating Rooms, Massive Transfusion Protocol, ne Surgical Intensive Care ahyɛ mu ntɛm ara:

• United States ne Canada: Frɛ 911. Ka kyerɛ nnuruyɛfo a wɔboa ɔyarefo no sɛ wɔasiesie ɔyarefo no yafunu mu aortic aneurysm na ohia ayaresabea kɛse a 24/7 Vascular Surgery (ɛnyɛ ER a egyina hɔ ankasa anaa mpɔtam hɔ ayaresabea da). Wɔahwɛ so wɔ Society for Vascular Surgery (SVS) Practice Guidelines a ɛfa Ayarefo a wɔwɔ Abdominal Aortic Aneurysm a Wɔhwɛ wɔn** ne American Heart Association (AHA) Vascular Graft Infection Nyansahu Nsɛm ase.
• United Kingdom: Frɛ 999 na woanya Category ½ ambulance ntɛm ara akɔ ɔmantam bi a wɔakyerɛ sɛ Arterial Vascular Hub. Wɔhwɛ so wɔ Ɔman Asoɛe a Ɛhwɛ Akwahosan ne Ɔhwɛ So (NICE NG156) ne Vascular Society of Great Britain and Ireland (VSGBI) nhyehyɛe ahorow ase.
• Europa Aman Nkabom: Dial 112. Wɔhwɛ so wɔ Europa Fekuw a Ɛhwɛ Ntini Oprehyɛn So (ESVS) 2020 Ayaresabea Nneyɛe Akwankyerɛ a Ɛfa Ntini a Wɔde Si Ntini Mu ne Endograft Nyarewa Ho Nhwehwɛmu Ho ase.
• Australia ne New Zealand: Frɛ 000 wɔ Australia anaa 111 wɔ New Zealand. Wɔhwɛ so wɔ Australia ne New Zealand Fekuw a Ɛhwɛ Ntini Oprehyɛn So (ANZSVS) nhyehyɛe ahorow ase.
• India ne Asia-Pacific: Trɛ 112 (anaasɛ 108 wɔ India), 995 wɔ Singapore, 119 wɔ Japan ne South Korea, anaa 999 wɔ Malaysia ne Hong Kong. Bisa adwumayɛbea a ɛto so abiɛsa a ɛwɔ endovascular ne cardiothoracic/vascular oprehyɛn tumi.

Nsɛm a wɔtaa bisa¶

Dɛn ne "herald bleed" (sentinel mogya) wɔ aortoenteric fistula mu?¶

Herald mogya yɛ nnaadaa kwan so, a ɛto ne ho ano hye a ɛba yafunu mu mogya (te sɛ mogya anaa kɔfe a wɔayam kakraa bi a wɔfe, tarry tuntum anaa maroon nsu a ɛyɛ tuntum biako a wɔfe, anaasɛ bere tiaa bi a wɔtotɔ piti) a ɛba ayarefo a wɔwɔ aortoenteric fistula ɔha biara mu nkyem 60 kosi 80 mu ansa na mogya a ɛyɛ hu aba. Sɛ aortic graft a ɛresɛe no di kan yɛ pinhole bue kɔ duodenum no mu a, mogya mmoroso a ɛkɔ fam bere tiaa bi ne ntini mu ntini a ɛtwetwe no ma mogya ketewaa bi siw tokuru no mu, na ɛma mogya no gyae koraa nnɔnhwerew kakraa bi kosi nna kakraa bi. Sɛ yafunu mu acid, dwensɔtwaa mu enzymes, ne mogya mmoroso a ɛkɔ soro no tew anaasɛ ɛbɔ saa mogya a ɛtɔ a ɛyɛ mmerɛw no mu pɛ a, mogya a ɛtɔ kɛse a ɛde ne nkwa to asiane mu fi ase. Sɛ wɔbɛfrɛ adwumayɛfo a wɔhwɛ ntɛmpɛ so wɔ bere a herald mogya mfɛnsere a ɛyɛ komm no mu no ne ade biako pɛ a ɛkyerɛ sɛ obi benya nkwa.

So aortoenteric fistula betumi asi wɔ mfe 10 anaa 15 akyi wɔ yafunu mu aortic aneurysm oprehyɛn akyi?¶

Aane. Bere a aortoenteric fistulas a ɛto so abien bi ba wɔ asram kakraa bi akyi wɔ open aortic graft oprehyɛn anaasɛ endovascular stent-graft repair (EVAR) akyi no, sɛ wɔkyekyem pɛpɛɛpɛ a, bere a efi aorto oprehyɛn a edi kan no so kosi fistula a ɛbae no yɛ mfe 3 kosi 5, na nsɛm a wɔakyerɛw ho asɛm yiye taa ba wɔ mfe 10, 15, anaa 20 mpo akyi wɔ aneurysm a wɔasiesie no akyi. Wɔ ɔyarefo nkwa nna nyinaa mu wɔ yafunu mu aortic graft anaa stent biara a wɔayɛ akyi no, ɛsɛ sɛ wɔsa mogya a ɛbɛfe, nsu a ɛyɛ tuntum a ɛyɛ tarry, mogya a ɛtɔ wɔ akyi berɛmo mu a ɛyɛ maroon, anaa atiridiinini a wontumi nkyerɛkyerɛ mu a ɛyɛ yaw wɔ akyi mfinimfini no ho dwuma sɛ aortoenteric fistula a ebetumi aba kosi sɛ wɔde CT angiogram bɛpow.

Dɛn nti na CT Angiogram (CTA) ye sen Upper Endoscopy (EGD) a wɔtaa de yɛ no sɛ sɔhwɛ a edi kan a wɔde hwehwɛ sɛ obi anya aortoenteric fistula a wosusuw sɛ ɛwɔ hɔ?¶

Wɔayɛ atifi endoscopy scope a wɔtaa de hwɛ aduan no mu, yafunu no, ne duodenum no fã a edi kan ne nea ɛto so abien no, na egyina tie wɔ duodenum no fã a emu dɔ a ɛda fam no fã a ɛto so abiɛsa ne anan a ɛwɔ baabi a aortoenteric fistulas nyinaa ɔha biara mu nkyem 75 kosi 80 wɔ no. Ne saa nti, soro endoscopy a wɔyɛ no daa no ntumi nnya aortoenteric fistulas nyinaa mu bɛboro fã na wobetumi adi mfomso de mogya a ɛtɔ no ho asodi ato yafunu mu yafunu a emu nyɛ den so. Nea ɛne eyi bɔ abira no, multiphasic CT Angiogram (CTA) a wɔde kyerɛ yafunu ne akyi berɛmo no gye nea ennu simma 5, ɛyɛ aorta ne duodenum nyinaa ho mfonini wɔ wɔn adwenem bere koro mu, na ehu fistulas ɔha biara mu nkyem 85 kosi 95 denam mframa a ɛtwetwe a ɛkyere aortic graft no ho a ɛkyerɛ, srade wimhyɛn a ɛyera wɔ graft ne dwensɔtwaa ntam, anaasɛ contrast jetting fi aorta no mu kɔ no so dwensɔtwaa mu.

Dɛn nti na ɛsɛ sɛ nnuruyɛfo a wɔboa nkurɔfo ne nnuruyɛfo a wɔhwɛ ntɛmpɛ kwati sɛ wɔbɛma mogya mmoroso akɔ soro dodo ("permissive hypotension") bere a mogya atu obi a ɔbɔ amanneɛ akyi?¶

Bere a mogya a ɛbɔ dawuru no gyae n’ankasa akyi pɛɛ no, ade biako pɛ a esiw yafunu mu aorta a nhyɛso kɛse wom no kwan sɛ ɛremfa mogya lita pii nkɔ dwensɔtwaa ketewa no mu ne mogya mu nkwammoaa a ɛyɛ mmerɛw a ɛyɛ mmerɛw a ɛtow fistula kwan no. Sɛ nnuruyɛfo akuw de nsu a wɔde fa ntini mu a ano yɛ den ma anaasɛ wɔde mogya ma ntɛmntɛm de pia ɔyarefo no mogya mmoroso a ɛwɔ nipadua no mu no ma ɛkɔ soro kodu nea ɛfata anaasɛ ɛkɔ soro (te sɛ mmHg 130 kosi 150) ansa na oduruyɛfo a ɔyɛ ntini mu oprehyɛn akata aorta no mu a, saa ntini mu nhyɛso a ɛkɔ soro mpofirim no betumi de mfiri abɔ mogya a ɛtɔ gu nipadua no mu no afi tokuru no mu na ama mogya atɔ no a edi awu. Gye sɛ ɔyarefo no wɔ amemene mu ischemia a emu yɛ den, ntini akuw no kura "permissive hypotension" (mogya mmoroso a ɛkɔ soro a ɛyɛ 80 kosi 100 mmHg, a ɛdɔɔso ara kwa sɛ ɛbɛma ɔyarefo no ada na wakasa) kɔ so kosi sɛ endovascular stent-graft anaa oprehyɛn clamp bɛkata aorta no so.

Dɛn nti na ɛnsɛ sɛ obi a wosusuw sɛ mogya tu no herald no nom nsu anaasɛ ɔnom aduru a wɔde sa akuru wɔ anom wɔ fie?¶

Nea edi kan no, nsu a wɔnom, aduan a wodi, anaa nnuru a wɔnom no kanyan yafunu, akisikuru, ne dwensɔtwaa no ma woyi hydrochloric acid, bile, ne protein-yam enzymes a ano yɛ den (trypsin ne chymotrypsin) fi nipadua no mu tẽẽ kɔ duodenum no fã a ɛto so abiɛsa no mu, baabi a wɔde nnuru bɛpete mogya a ɛbɔ ho ban a ɛto aortic fistula no mu. Nea ɛto so abien no, ɔyarefo no behia CT scan a ɛkyerɛ nsonsonoe ntɛm ara ne aduru a wɔde kum nipadua no ntɛm ara de yɛ endovascular anaa aortic oprehyɛn a wɔabue mu, baabi a sɛ nsu anaa aduan wɔ yafunu mu a, ɛde asiane kɛse ba sɛ ɔbɛfe na watwe akɔ ahurututu mu bere a wɔde intubation rehyɛ mu no.

Dɛn ne "EVAR bridge" na ɔkwan bɛn so na ama nkwa a wonya wɔ aortoenteric fistula mu no atu mpɔn?¶

Bere bi a atwam no, ɔkwan biako pɛ a na wobetumi afa so asiw aortoenteric fistula a mogya retu denneennen no ano ne laparotomy a wobue ntɛm ara (a wobetwa yafunu no nyinaa mu, atwitwa akuru a ɛyɛ den mu, na wɔakyekyere aorta no), a ɛde owu ɔha biara mu nkyem 50 kosi 70 ba esiane mogya a wɔhwere ne ahodwiriw nti. Ɛnnɛ, ntini mu oprehyɛn ho animdefo de "EVAR bridge" di dwuma: ɛdenam ade ketewaa bi a wɔato mu wɔ asen mu ntini no mu so no, wɔde endovascular stent-graft a wɔakata so no kɔ soro wɔ aortic graft dedaw no mu na wɔde fa tokuru no mu wɔ nea ennu simma 20 mu. Eyi ma mogya a ɛtɔ kɔ nipadua no mu no gyae ntɛm ara na ɛma ɔyarefo no gyina pintinn sɛnea ɛbɛyɛ a wobetumi asiesie duodenum ne graft a ɔyare no wom no koraa dwoodwoo bere a wɔama ɔyarefo no anya nkwa koraa no.

Fibea ne aban akwankyerɛ¶

• European Society for Vascular Surgery (ESVS, Europe): ESVS 2020 Ayaresabea Adeyɛ Akwankyerɛ a ɛfa Vascular Graft ne Endograft Infections a Wɔhwɛ So (Chakfe ne afoforo, European Journal of Vascular and Endovascular Surgery, Ɔfã a ɛfa Secondary Aortoenteric Fistula ho, herald bleed recognition, multiphasic CTA as ɔkwan a edi kan a wɔfa so hwehwɛ yare, endovascular EVAR bridging wɔ ayarefo a wontumi nnyina pintinn mu, ne in-situ vs. extra-anatomic reconstruction).
• Society for Vascular Surgery (SVS, United States): Fakuw a ɛhwɛ Ntini mu Oprehyɛn so Adeyɛ Akwankyerɛ a ɛfa Ayarefo a wɔwɔ Yafunu mu Aortic Aneurysm a Wɔhwɛ wɔn ho (Chaikof ne afoforo, Journal of Vascular Surgery, aortoenteric erosion ne fistula a edi kan ne nea ɛto so abien a wɔhwehwɛ ne nea wodi ho dwuma ntɛm).
• Amerika Koma Fekuw (AHA, United States): Vascular Graft Infections, Mycotic Aneurysms, ne Endovascular Infections: Nyansahu mu Asɛm a efi Amerika Koma Fekuw (Circulation, microbiology, biofilm pathogenesis, antimicrobial ne antifungal coverage, ne oprehyɛn a wɔde di aortoenteric fistulae ho dwuma).
• American College of Gastroenterology (ACG) & European Society of Gastrointestinal Endoscopy (ESGE): Ayaresabea Akwankyerɛ a Ɛfa Acute Upper Gastrointestinal Bleeding a Wɔhwɛ So (aortoenteric fistula a wohu wɔ ayarefo a wɔwɔ prosthetic aortic grafts mu, anohyeto ahorow a ɛwɔ standard EGD mu wɔ D3/D4 a wodu ho, ne CTA a wɔde di kan).
• Ɔman Asoɛe a Ɛhwɛ Akwahosan ne Ɔhwɛ a Ɛyɛ Paara So (NICE, United Kingdom): Yafunu mu Aortic Aneurysm: Nhwehwɛmu ne Nea Wɔde Di Dwuma (NICE Akwankyerɛ NG156).

Akwankyerɛ ahorow a ɛfa ho¶

• Aortic dissection ne yafunu mu aortic aneurysm a apaapae
• Mogya a ɛba yafunu mu, mogya a ɛfe (hematemesis), ne melena
• Esophageal a ɛpaapae (Boerhaave syndrome), Mallory-Weiss nusu, ne koko mu yaw a ɔfe
• Esophageal varices a ɛpaapae, mogya a ɛtɔ wɔ cirrhosis mu, ne mmerɛbo mu amemene mu yare
• Shock mmoa a edi kan ne mogya a ɛkɔ nipadua no mu a ɛhwe ase a wohu