Aortoenteric fistula 'Herald Bleed' na nnukwu GI Hemorrhage mgbe ịwa ahụ Aortic Graft.¶

Aortoenteric fistula (AEF) bụ ọdachi, ozugbo na-eyi ndụ egwu na-adịghị mma njikọ dị n'etiti eriri afọ abdominal dị elu na akụkụ eriri afọ dị n'akụkụ, nke na-abụkarị akụkụ nke atọ ma ọ bụ anọ nke duodenum ebe ọ na-agafe kpọmkwem n'elu ọkpụkpụ azụ. Ihe karịrị pasent 90 nke ikpe bụ ** nke abụọ aortoenteric fistulas ** nke na-etolite ọnwa ruo afọ 15 mgbe emepechara ịwa ahụ Dacron graft ma ọ bụ nrụzi stent-graft (EVAR) nke abdominal aortic aneurysm (AAA), mgbe mkpụkọ akwara na ọrịa obere ọkwa na-emebi oghere ozugbo site na mgbidi duodenal suture. N'ihi na ọrịa fistula aortoenteric a na-agwọghị na-egbu pasent 100, nlanarị na-adabere kpamkpam n'ịghọta akara ịdọ aka ná ntị ahụike ya: "Herald bleed" (ọbara ọbara sentinel). N'ihe ruru pasent 60 ruo 80 nke ndị ọrịa , mkpochapụ ọdachi na-ebute ihe dị ka obere, ihe na-egbochi onwe ya nke ịgba agbọ ntakịrị ọbara ọbara ọbara na-egbuke egbuke ma ọ bụ ihe ala kọfị ( hematemesis), na-agafe maroon gbara ọchịchịrị ma ọ bụ stool ojii ojii (**melena*o ma ọ bụ ** hematochezia)) nke na-akwụsị kpamkpam n'onwe ya mgbe mkpụkọ ọbara nwa oge na-akụnye obere traktị fistula na ọbara mgbali na-agbada. N'ime ** awa ruo ụbọchị ole na ole ***, enzymes digestive na ịrị elu ọbara na-agbaze ma ọ bụ fesa plọg thrombus na-emebi emebi, na-ebute oke mmiri, ọbara ọgbụgba akwara na-enweghị nkwụsị n'ime eriri afọ. Ọ bụrụ na onye ọ bụla nwere ** mgbe ọ bụla nwere nrụzi aortic aneurysm abdominal, aortic bypass graft, ma ọ bụ ahụmahụ abdominal aortic aneurysm mara ** ọ bụla ** ọbara ọgbụgba afọ ọ bụla, stool ojii, ma ọ bụ nkụda mmụọ na-enweghị nkọwa, kpọọ mpaghara gị. nọmba mberede ozugbo. Mgbe ị na-eche njem ụgbọ ihe mberede, nyochaa ntuziaka ihe mberede metụtara aortic dissection na mgbawa abdominal aortic aneurysm, ọbara ọgbụgba nke eriri afọ, vomiting, na melena, na Esophageal rupture (Boerhaave syndrome) na Mallory-Weiss anya mmiri.

N'ihi na ọkọlọtọ endoscopy nke elu (EGD) na-erute akụkụ nke mbụ na nke abụọ nke duodenum (na-efukarị fistula zoro ezo n'ime akụkụ nke atọ nke duodenum) yana n'ihi na ịgbapụta mmiri na-eme ihe ike nwere ike ịkwalite ọbara mgbali elu iji wepụ ihe mgbochi thrombus na-echebe n'ime onye na-agbapụta ọbara, ihe kachasị mkpa tupu ụlọ ọgwụ na-eme ihe bụ iji ** cher11 p.m. "Onye ọrịa a nwere eriri afọ aortic ma na-enwe ọbara ọgbụgba GI; wepụ ọbara ọgbụgba aortoenteric fistula."**

Mee nke a ugbu a¶

1. Kpọọ nọmba mberede mpaghara gị ozugbo wee kwupụta onye a na-enyo enyo Aortoenteric Fistula Herald Bleed. Kpọọ 911 na United States na Canada, 112 gafee European Union, 999 na United Kingdom, 000 na Australia, ma ọ bụ lelee ndepụta nke anyị. nọmba mberede. Kwupụta n'ụzọ doro anya: * "Ihe mberede ahụike: ọbara ọgbụgba nke eriri afọ na onye ọrịa nwere akụkọ ihe mere eme nke nrụzi aka mgbakwasa eriri afọ nke afọ.
2. **Ọbụlagodi na vomiting nke ọbara ma ọ bụ ọbara ọgbụgba akwụsịla kpamkpam ma onye ahụ na-enwe mmetụta 100 na-alaghachi azụ, were ya dị ka ihe mberede ịwa ahụ ozugbo. Oge ahụ dị jụụ na-aghọ aghụghọ bụ nkọwa ụlọ ọgwụ zuru oke nke ** herald bleed ** (ebe vasospasm na obere mkpụkọ ọbara na-adịru nwa oge na-egbochi nrụgide zuru oke nke aorta abdominal).
3. **Dịna onye ọrịa ahụ n'azụ ya (ma ọ bụ tụgharịa n'akụkụ aka ekpe ya n'ọnọdụ mgbake ma ọ bụrụ na ọ na-agba ọgbụgbọ ma ọ bụ ịgba agbọ) ma gbochie onye ọ bụla iguzo ọtọ, ịnọdụ ala, ma ọ bụ ije ije.
4. ** Tinye iwu NPO siri ike (ọ dịghị ihe ọ bụla site n'ọnụ: mmiri efu, nri efu, antacids efu efu, na ọgwụ efu ọbara ma ọ bụ ọgwụ mgbu).* ma kpalite exsanguination ozugbo.
5. Akụnyela aka, kụtụ ọnụ, ma ọ bụ ịhịa aka n'ahụ afọ. Onye nọ n'akụkụ ma ọ bụ dọkịta na-agbanye miri n'ime etiti afọ iji lelee maka ịdị nro ma ọ bụ oke na-akụ ụda nwere ike ịpịkọta duodenum n'akụkụ aka nri prosthetic aortic dị n'okpuru wee wepụ eriri sentinel.
6. ** Chọta kaadị ịwa ahụ nke onye ọrịa ma ọ bụ nchịkọta ọpụpụ ụlọ ọgwụ na-egosi ụbọchị na ụdị ịwa ahụ aortic, ma nyefee ya ozugbo n'aka ndị na-ahụ maka ahụike. otu ** na ** CT Angiography scanner ** tupu onye ọrịa ahụ abanye n'ọnụ ụzọ.

Osisi mkpebi: nnukwu hematemesis, melena, ma ọ bụ nhụta ọbara ọgbụgba mgbe vomiting gasịrị¶

flowchart TD
    Start["Mgbapụta Ọbara (Hematemesis), Kọfị-Ground Emesis, Black Tarry Stool (Melena), ma ọ bụ Maroon Stool"] --> CheckAorta{"Kwụpụ 1: Onye ọrịa ahụ ọ nwere akụkọ ihe mere eme nke ime afọ Aortic Aneurysm (AAA) (Open Graft ma ọ bụ EVAR Stent), Aortoiliac Bypass, Mara AAA, ma ọ bụ Pulsating Abdominal Mass?"}

    CheckAorta -->|"EE (Ọbụlagodi na ịwa ahụ bụ afọ 5 ruo 15 gara aga na ọbara dị ntakịrị ma ọ bụ kwụsị)"| HeraldAEF["AKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWỤKWASỊRỊRỊAKWAKWA Kpọọ 999 Ngwa ngwa; Ịwa ahụ Vascular Alert + Nye iwu ngwa ngwa CT Angiogram (CTA) tupu endoscopy ọ bụla."]

    CheckAorta -->|"Ọ BỤGHỊ akara akaortic ma ọ bụ aneurysm ama ama"| CheckVomitContext{"Kwụpụ 2: Ọbara ahụ ọ̀ malitere ozugbo ọ gbasasịrị ma ọ bụ agbọ agbọ?"}

    CheckVomitContext -->|"EE: Ike retching ma ọ bụ ọgbụgbọ butere mgbaàmà ahụ"| CheckMackler{"Nzọụkwụ 3: Lelee Boerhaave Rupture vs. Mallory-Weiss Tear: Enwere ihe mgbu 10/10 na-adọka obi ma ọ bụ azụ mgbu, mkpụmkpụ ume, ma ọ bụ ikuku na-agbawa n'okpuru akpụkpọ olu (crepitus)?"}

    CheckMackler -->|"EE: oke mgbu obi/azụ, dyspnea, ma ọ bụ crepitus olu"| Boerhaave["BOERHAAVE SYNDROME enyo enyo (TRANSMURAL ESOPHAGEAL RUPTURE): Kpọọ Ọrụ Mberede ozugbo; NPO siri ike (Ọbụghị 1 SIP nke mmiri), Nọdụ ala n'ogo 30 ruo 45"]

    CheckMackler -->|"Ọ BỤGHỊ mgbu obi ma ọ bụ dyspnea: ọbara ọbara na-acha ọbara ọbara na-egbuke egbuke mgbe ọtụtụ vomits gachara"| MalloryWeiss["Mallory-Weiss Mucosal Tear a na-enyo enyo: Debe NPO nke ọma; Ụgbọ njem gaa na Ngalaba Mberede maka nlele hemoglobin, IV Proton Pump Inhibitor, na Nyocha Endoscopic"]

    CheckVomitContext -->|"OGHỊ tupu iweghachite: vomiting na-enweghị mgbu nke ọbara, ebe kọfị, ma ọ bụ stool ojii"| CheckCirrhosis{"Kwụpụ 4: Onye ọrịa nwere Cirrhosis imeju, ọbara mgbali elu, ma ọ bụ akụkọ ihe mere eme NSAID/Ulcer dị arọ?"}

    CheckCirrhosis -->|"Cirrhosis / Jaundice / Ascites ma ọ bụ oke Torrential ọbara"| VaricesUlcer["SUSPECTED ESOPHAGEAL VARICES RUPTURE OR ARTERIAL PEPTIC ULCER BLEED (DIEULAFOY): Call Emergency Services Immediately; Ọnọdụ mgbake, NPO siri ike"]

    HeraldAEF --> AEFProtocol["Protocol Resuscitation AEF ozugbo: ezumike akwa siri ike, palpation nke afọ na-efu, NPO siri ike, hypotension na-ekwe ka (Target Systolic BP 80 ruo 100 mmHg ya mere Clot Plug anaghị afụ ọkụ), Endovascular Stent-Graft Relining (EVARtic Bridge) ma ọ bụ Mepee"]

Anatomi na pathophysiology: ihe kpatara ntinye aortic na-emebi n'ime akụkụ nke atọ nke duodenum¶

Iji ghọta ka otu nnukwu akwara na retroperitoneum si ejikọta ozugbo na tract digestive, yana ihe kpatara ọbara ọgbụgba na-eme n'ụdị abụọ dị iche iche (dị jụụ ** na-agbapụta ọbara ** na-esote ** exsanguination ọdachi **), ọ na-enyere aka inyocha ahụ nke etiti afọ:

1. Okporo ụzọ anatomical na akụkụ nke atọ nke duodenum (D3)¶

N'ime ahụ mmadụ, aorta abdominal na-agba ọsọ na-agbada n'ihu n'ihu ọkpụkpụ azụ n'ime oghere retroperitoneal. Naanị n'okpuru mmalite nke akwara akwara (ebe pasent 95 nke aortic aneurysms abdominal na-eme na ebe a na-akwanye grafts prosthetic grafts n'ime ebe), akụkụ ** nke atọ (nke kwụ ọtọ) nke duodenum (D3) ** na-agafe n'ahịrị site n'aka nri gaa n'aka ekpe ** kpọmkwem n'ihu n'ihu nke abdominal aorta na proximalanastomosis, nke a na-ekewapụ naanị n'ahịrị. oyi akwa nke retroperitoneal abụba na peritoneum.

• ** Fistula nke mbụ (nke na-adịghị ahụkebe, <10% Nke ikpe):** Ọ na-eme na onye ọrịa nwere ** a na-agwọghị ya, nke na-adịghị arụ ọrụ abdominal aortic aneurysm ** (mgbe ọ na-ebute ọrịa "mycotic" aneurysm, tuberculous ma ọ bụ syphilitic aoritis, mmerụ ahụ na-akpata radieshon, ma ọ bụ tumor pancreatic / duodenal) ebe mgbasawanye aneurysm sac sac na-abanye n'ime mgbidi abụọ ahụ ruo mgbe ọ bụla na-adaba n'ime mgbidi abụọ ahụ.
• ** Secondary Aortoenteric Fistula (Ọkarị, >90% nke ikpe):** Na-eme ** ọnwa ruo afọ 15+ (median 3 ruo 5 afọ)** mgbe emepechara ịwa ahụ nke anerysm abdominal aortic nke ejiri akwa akwa ma ọ bụ kpara ** Dacron ma ọ bụ PTFE prosthetic graft , ma ọ bụ mgbe ** endovascular aneurysm nrụzi (EVAR) na ọla stent-graft. Usoro abụọ synergistic nwere ọwara site na aorta banye n'ime eriri afọ:
• ** Ọ bụrụ na eriri anụ ahụ dị mkpa etinyere n'etiti aka prosthetic na duodenum n'oge ịwa ahụ mbụ na-apụ apụ, ahịrị suture nke siri ike, nke na-adọkpụ na-adaba n'azụ mgbidi nke duodenum nke atọ edoziri ugboro 100,000 kwa ụbọchị. N'ime ọtụtụ afọ, jackhammering a na-arụ ọrụ na-akpata ischemia nrụgide na ọnya nke mgbidi duodenal ruo mgbe a na-ekpughere eriri ndị na-emepụta ihe na-emepụta ihe ozugbo n'ime lumen intestinal.
• ** Ọrịa nje nje perigraft dị ala: ** Ozugbo nje bacteria na-akpata microscopic (* Escherichia coli *, * Enterococcus , * Staphylococcus epidermidis , * Streptococcus , * Bacteroides , na * Candida * ụdị) na-agafe n'ofe anụ ahụ na-adịghị ala ala. biofilm gburugburu graft anastomosis, na-ahapụ nje proteases na-agbaze ndị ọbịa aortic mgbidi stitches ma mepụta kpọmkwem fistula ọwa ( paraprosthetic-enteric ** ma ọ bụ ** aorto-duodenal fistula).

2. Ebe anatomical na-emetụta na Aortoenteric Fistula¶

Ọ bụ ezie na akụkụ ọ bụla nke eriri afọ nke na-emetụ aorta nwere ike imebi, nkesa anatomical na-elekwasị anya na duodenum miri emi:

1. ** Akụkụ nke atọ na nke anọ nke Duodenum (D3 / D4): *** ** 75 ruo 80 pasent ** nke ikpe niile (n'ihi na D3 na-ejikọta ya n'enweghị ihe ọ bụla n'ofe anastomosis aortic graft anastomosis site na ligament nke Treitz).
2. Jejunum na Ileum (Obere eriri afọ): ** pasent 10 ruo 15** nke ikpe.
3. ** Sigmoid Colon ma ọ bụ Cecum: *** ** 3 ruo 5 pasent *** (karịsịa mgbe akụkụ aortobifemoral gafere n'ime oghere sigmoid dị na pelvis aka ekpe).
4. ** afọ ma ọ bụ esophagus: ** 2 ruo 5 pasent ** ( thoracic aortic stent-grafts na-asọba n'ime etiti esophagus, nke a maara dị ka ** aortoesophageal fistula **, nke na-enye ** Chiari's triad **: mgbu n'etiti thoracic, sentinel arterial hematemesis na-akwụsị awa ole na ole).

3. The biomechanics nke "Herald Bleed" (Sentinel Bleed) na ihe mere ọ na-akwụsị n'onwe ya.¶

Ndị ọrịa, ezinụlọ, na ọbụna ndị na-ahụ maka ụlọ ọgwụ na-enweghị ahụmahụ na-ejukarị anya site n'ọbara onye mgbasa ozi: * "Olee otú oghere dị n'ime aorta abdominal isi ga-esi agbapụta naanị otu iko ọbara wee kwụsị kpamkpam n'onwe ya?" Usoro usoro ọmụmụ anọ na-akọwa nkwụsịtụ aghụghọ a:

1. Microscopic first mucosal pinhole: Mgbe eriri aortic suture na-emebi emebi ma ọ bụ pseudoaneurysm nke mbụ na-agbaji site na muscularis na mucosa nke duodenum nke atọ, oghere na-abụkarị ** 1 ruo 3 millimeters n'obosara ** karịa akwa akwa mepere emepe.
2. ** Ọkpụkpụ akwara na hypotension na-agafe agafe:** Ụgbọ elu mberede nke 200 ruo 500 milliliters (7 ruo 17 ounces) nke ọbara akwara na-agbaba n'ime duodenum na-adaba ọbara mgbali elu (na-emekarị ka ọ daa mbà n'obi ma ọ bụ dizziness) ma na-akpalite mmetụta dị nro na-egbuke egbuke.
3. ** Nhazi nke platelet-fibrin thrombus plọg na-adịru nwa oge:** Ka ọbara mgbali na-agbada na fistula na-ebelata, platelet na fibrin na-agbakọta ngwa ngwa n'ime traktị ahụ na-ata ahụhụ n'etiti eriri sịntetik na mucosa duodenal, na-emechi oghere ahụ dị ka ihe nkwụsị na karama.
4. ** Mgbari na ịfụ nke plọg thrombus (Ohere Latent):** Ozugbo ọbara ọgbụgba ahụ kwụsịrị, ọbara onye ọrịa na-alaghachi na nkịtị (ma ọ bụ na-ebuli ya elu ma ọ bụrụ na otu ụlọ ọgwụ na-enye boluses mmiri intravenous ngwa ngwa ma ọ bụ mmịnye ọbara ka ọ “gbanwee” akara dị mkpa). N'otu oge ahụ, ihe ọṅụṅụ afọ acidic, bile, na enzymes pancreatic dị ike (*trypsin, elastase, na lipase) na-asachapụ mgbe niile n'akụkụ duodenal nke mkpụkọ ọbara, na-agbazekwa fibrin n'ime mmiri. Mgbe windo latent sitere na ** awa ole na ole ruo ọtụtụ ụbọchị *** (na pasent 50 nke ikpe n'ime ** 6 ruo 24 awa ***, yana na pasent 90 n'ime izu 1 ruo 2 ***), plọg ahụ na-agbaze na-apụ kpamkpam, na-emeghe pipeline nke nrụgide siri ike site na aorta n'ime eriri afọ nke nwere ike ịgbapụta ** 1 ruo 2 lita kwa nkeji.

Ịdịiche 4 High-Stakes Upper GI Bleed & Mgbapụta Mberede¶

N'ihi na ọbara ọgbụgba nke elu eriri afọ na mgbe ọgbụgbọ n'obi / afọ ime na-achọ enyemaka ozugbo dị iche iche (site na hypotension na-enye ohere na CT angiography maka fistula aortoenteric ruo na ịwa ahụ ozugbo maka ọrịa Boerhaave), jiri tebụl ntụnyere ụlọ ọgwụ a:

Ọkọlọtọ na-acha ọbara ọbara nke ụlọ ọgwụ: Triad Classic na akara ịdọ aka na ntị "Graft Sepsis".¶

Ọ bụ ezie na akwụkwọ ọgụgụ na-akọwa ** Triad nke Aortoenteric Fistula ** nke gụnyere ** (1) ọbara ọgbụgba nke eriri afọ, (2) afọ ime ma ọ bụ azụ mgbu, na (3) Ọkpụkpụ afọ na-emetụ n'ahụ, ihe ọmụmụ na-egosi na ihe ịrịba ama atọ niile na-apụta ọnụ na ** naanị 11 ruo 25 pasent nke ndị ọrịa. palpable uka si na-enwe mmetụta). Kama, lezie anya nke ọma maka usoro ụlọ ọgwụ ndị a n'ezie:

1. Ụdị "Herald Bleed + Syncope" (A na-ahụ na 60% ruo 80% nke ikpe)¶

• Onye ọrịa ahụ na-ekpo ọkụ na mberede, ọgbụgbọ, isi ọwụwa, ma ọ bụ isi ọkụ, ma nwee ike ịda mbà n'obi obere oge (syncope)** n'ala ụlọ ịsa ahụ.
• Ha na-agbọpụta obere ọbara ọbara ọbara ma ọ bụ "ebe kọfị kọfị" gbara ọchịchịrị, ma ọ bụ na-agafe otu eriri afọ nke ** ọbara maroon gbara ọchịchịrị ma ọ bụ jet-black, stool na-esi ísì ọjọọ (melena)**.
• N'ime nkeji 15 ruo 30, ụcha ha na-alọghachi, ọbara ọgbụgba ahụ kwụsịrị, ha na-ekwusi ike na ahụ dị ha mma na ha achọghị ịga ụlọ ọgwụ. ** Nke a bụ oge ụgbọ njem mberede na-azọpụta ndụ ha.

2. "Occult Graft Infection + Back Pain" Prodrome¶

N'ọtụtụ ndị ọrịa nwere fistula nke abụọ nke aortoenteric fistula, izu ma ọ bụ ọnwa tupu ọdịda mbụ nke ọbara a na-ahụ anya apụta, duodenum na-emebi emebi na-agbapụta nje bacteria n'ime oghere aortic prosthetic, na-akpata ** perigraft sepsis na-adịghị ala ala : - ** Ahụ ọkụ na-adịte aka na-enweghị nkọwa, ọsụsọ abalị, ma ọ bụ ihe mgbagwoju anya *** (a na-achọpụtakarị ya ruo izu ole na ole dị ka ọrịa nje, ọrịa urinary tract, ma ọ bụ ahụ ọkụ nke amaghị ebe ọ si malite). - ** Ọhụrụ, miri emi, na-agwụ ike n'etiti mgbu azụ azụ ma ọ bụ mgbu abdominal periumbilical ** (nke sitere na mbufụt retroperitoneal na mgbasawanye pseudoaneurysm na-agbanye megide ọkpụkpụ azụ lumbar). - ** Septic emboli ruo n'ụkwụ ma ọ bụ mkpịsị ụkwụ ("Blue Toe Syndrome"): Obere mkịrịkọ nwere ọrịa na-agbajisị n'oghere aortic a na-achịkwa ma na-adaba n'ụkwụ, na-ebute ntụpọ odo odo na-egbu mgbu na mkpịsị ụkwụ ma ọ bụ osteomyelitis ụkwụ. - ** Bacteremia nwere akụkụ eriri afọ:* Omenala ọbara na-eto eto Escherichia coli, Enterococcus, Streptococcus bovis/anginosus, Bacteroides, ma ọ bụ Candida n'ime onye ọrịa ọ bụla nwere eriri afọ bụ pathognomonic maka ọrịa fistula aortoenteric ma ọ bụ graft.

Ọnyà ụlọ ọgwụ abụọ na-egbu egbu: "Ọnyà Endoscopy Standard" na "Ọnyà Resuscitation karịrị"¶

Mgbe ị na-eso onye ị hụrụ n'anya na-aga n'ihu na ngalaba mberede, ịmara ọnyà abụọ dị oke egwu nke Society for Vascular Surgery (SVS) na ** European Society for Vascular Surgery (ESVS) nwere ike inyere aka hụ na nlekọta ngwa ngwa na-eme:

Ọnyà 1: Gịnị kpatara ọkọlọtọ Upper Endoscopy (EGD) na-atụkarịkarị fistula Aortoenteric¶

N'ime ọbara ọgbụgba dị elu nke eriri afọ, ndị dọkịta mberede na-akpọ onye gastroenterologist ka ọ mee esophagogastroduodenoscopy (EGD). Agbanyeghị, naanị gastroscope ọkọlọtọ ka emebere iji rute ** akụkụ mbụ na nke abụọ nke duodenum (D1 na D2)**, na-akwụsị ozugbo na ampulla Vater. N'ihi na ** 75 ruo 80 pasent nke fistulas aortoenteric dị omimi na akụkụ nke atọ na nke anọ nke duodenum (D3 na D4) **, EGD na-emekarị na-ele anya nke ọma na ihe karịrị ọkara nke ikpe fistula aortoenteric.

Enwere ihe ize ndụ abụọ ọzọ n'oge endoscopy: - ** Ọnyà ''coincidental ọnya'':** Ndị agadi na-arịa ọrịa akwara na-ejikarị aspirin kwa ụbọchị ma ọ bụ ihe na-ebelata ọbara ma na-enwekarị gastritis dị nro, obere ihe nke afọ, ma ọ bụ obere ọnya peptic a gwọọla n'afọ. Ọ bụrụ na endoscopy na-ahụ gastritis dị nro n'ime afọ ma kwụsị nyocha ahụ n'enweghị nyochaa ruo n'akụkụ anọ nke duodenum (ma ọ bụ na-enyeghị iwu CT angiogram), ha nwere ike ikwu na onye na-anụ ọkụ n'obi na-agbapụta na gastritis mgbe fistula aortic na-anọdụ ala na sentimita miri emi dị njikere ịgbawa. - ** Ọ bụrụ na onye na-ahụ maka endoscopist na-akwali ogologo colonoscope ụmụaka ma ọ bụ push-enteroscope n'ime akụkụ nke atọ nke duodenum, na-ahụ mkpụkọ ọbara gbara ọchịchịrị na-arapara na mgbidi duodenal, na ** na-agbalị ịsacha ya, biopsy ya, ma ọ bụ kechie ya n'ime ọkọlọtọ endoscopy ma ọ bụ tinye ya n'ime eriri afọ. exsanguination na-egbu egbu tere aka n'ọnụ ụlọ ịwa ahụ. Ya mere, ọ bụrụ na a na-eme endoscopy iji nyochaa D3/D4, ntụziaka ịwa ahụ vaskụla na-ekwu na a ga-eme ya ** n'ime ụlọ ịwa ahụ na ndị otu ịwa ahụ vaskụla na-ehichapụ ma dị njikere maka mgbachi aortic ozugbo.

Ọnyà 2: Gịnị kpatara na "Permissive Hypotension" bụ ịzọpụta ndụ tupu e mechie aorta.¶

N'ime windo a na-adịghị ahụ anya mgbe onye mgbasa ozi gbasịrị ọbara, mkpụkọ platelet-fibrin na-esighi ike bụ naanị ihe mgbochi na-ekewa ọbara aortic dị elu na lumen nke eriri afọ. Ọ bụrụ na ndị na-ahụ maka ahụike ma ọ bụ ndị ọrụ ụlọ ọgwụ na-enye lita lita nke saline boluses ngwa ngwa ma ọ bụ na-amịnye ọtụtụ nkeji nke mkpụrụ ndụ ọbara uhie juru eju iji mee ka ọbara mgbali systolic onye ọrịa ahụ ruo. 130 to 150 mmHg, na hydrostatic mgbali spike ga ** gbapụta klọt ozugbo na traktị fistula ** (dị ka ọ na-agbaji agbaji aortic aneurysm abdominal).

• ** Iwu Hypotension na-ekwe ka onye ọrịa na-amụ anya, na-amụ anya ma na-ekwu okwu (na-egosi oke ọbara na-eruba n'ụbụrụ na obi), trauma vaskụla na ntughari ụkpụrụ ntụzịaka ** hypotension na-achịkwa (ọbara mgbali elu systolic nke siri ike). 80 to 100 mmHg)** na-eji nlezianya eme ihe na mmiri titrated ruo mgbe dọkịta na-awa vaskụla kpuchiri aorta site na endovascular stent-graft ma ọ bụ aortic cross-mchie.

Nchọpụta ụlọ ọgwụ akọwapụtara na ịwa ahụ: CTA, EVAR bridging, na mwughachi¶

Mgbe onye ọrịa nwere fistula aortoenteric a na-enyo enyo rutere na ngalaba mberede, ụlọ ọgwụ na-eme ka ụzọ ịwa ahụ vaskụla ngwa ngwa:

1. ** Nnwale mbụ nke ọla edo: Multiphasic CT Angiography (CTA) nke Abdomen na Pelvis: ** Emere ** na-enweghị *** ọdịiche ọnụ ọnụ (nke ga-ezochi ọbara ọgbụgba na-arụ ọrụ n'ime duodenum), CTA na-ewe n'okpuru nkeji 5, nwere ** 85 ruo 95 percent uche **, ma na-ekpughe ihe ịrịba ama pathognomonic:
2. Ectopic perigraft gas: Ikuku na-afụ gburugburu aortic graft (na-adịkarịghị ihe karịrị izu 4 ruo 6 mgbe a wachara ya ahụ).
3. ** Mfu nke ụgbọ elu aorto-duodenal abụba: ** Direct tethering nke duodenum nke atọ n'ime mgbidi aka ochie ma ọ bụ anastomotic ** pseudoaneurysm ***.
4. ** Mgbakwunye ọdịiche dị n'ọrụ:** Ntugharị dị iche iche nke eriri afọ si na aorta banye lumen duodenal.
5. ** Nzọpụta nke 1: Endovascular Stent-Graft Relining ("EVAR Bridge to Surgery"):** N'okpuru ** SVS na ESVS ụkpụrụ , kama ịmeghe laparotomy ozugbo (nke na-ebu pasent 50 ruo 70 na-anwụ n'oge ọbara ọgbụgba), ndị dọkịta na-awa vaskụla na-akụtu akwara femoral na-arụ ọrụ n'ime akwara femoral. stent-graft *** n'ime aka ochie gafere fistula (ma ọ bụ tinye balloon aortic ** REBOA na njide). N'ime nkeji iri abụọ, ọbara ọgbụgba na-akwụsị, ọ̀tụ̀tụ̀ ọbara ji erugharịkwa na-eguzosi ike. A na-amalite ngwa ngwa ọgwụ nje dị iche iche IV (*piperacillin-tazobactam ma ọ bụ meropenem + vancomycin) gbakwunyere IV antifungal (fluconazole ma ọ bụ micafungin).
6. ** Ndozi nke 2 nke ọma: *** Ozugbo agbakechara, ndị dọkịta na-awa ahụ na-ewepụ ma rụkwaa duodenum nke atọ, tinye nnukwu flap nke ** nnukwu omentum n'etiti eriri afọ na aorta, wepụ ihe ntinye aka na-ebute ọrịa, ma weghachite ọbara na-erugharị site na ** extra-anatomic axillobifemoral bypassigen ma ọ bụ ** iji regharịa axillobifemoral autoinpass vein femoral-popliteal (NAIS), homograft nke a na-echekwa, ma ọ bụ rifampin/ọlaọcha nke impregnated Dacron.

Nọmba mberede mpaghara na ụkpụrụ ụlọ ọrụ¶

Fistula aortoenteric a na-enyo enyo chọrọ ibuga ụgbọ ihe mberede ngwa ngwa gaa na ụlọ akwụkwọ sekọndrị ** Vascular Surgery Center ** nwere ** CT Angiography nke awa 24, ọnụ ụlọ arụ ọrụ endovascular vaskụla, Usoro mbufe mbufe, na nlekọta ịwa ahụ **:

• United States na Canada: Kpọọ 911. Gwa ndị dọkịta na-ahụ maka ahụike onye ọrịa ahụ enweela nrụzi aortic aneurysm nke afọ ma chọọ nnukwu ụlọ ọgwụ nwere 24/7 Vascular Surgery (ọ dịghị mgbe ER ma ọ bụ ụlọ ọgwụ obodo). Ejiri ya n'okpuru Society for Vascular Surgery (SVS) Ntuziaka omume na nlekọta nke ndị ọrịa nwere Abdominal Aortic Aneurysm ** na ** American Heart Association (AHA) Nkwupụta Sayensị Na-ahụ Maka Ọrịa Vascular Graft.
• United Kingdom: Kpọọ 999 maka ụgbọ ihe mberede Atiya ½ ozugbo gaa na mpaghara akpọrọ Arterial Vascular Hub. Ejiri ya n'okpuru ** National Institute for Health and Care Excellence (NICE NG156)** na Vascular Society of Great Britain and Ireland (VSGBI) ụkpụrụ.
• European Union: Kpọọ 112. Ejiri ya n'okpuru **European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on Management of Vascular Graft and Endograft Infection ***.
• Australia na New Zealand: Kpọọ 000 na Australia ma ọ bụ 111 na New Zealand. Ejikwara n'okpuru usoro ** Australian na New Zealand Society for Vascular Surgery (ANZSVS) ***.
• India na Asia-Pacific: Kpọọ 112 (ma ọ bụ 108 na India),995 na Singapore,119 na Japan na South Korea, ma ọ bụ 999 na Malaysia na Hong Kong. Rịọ ụlọ akwụkwọ sekọndrị nwere ike ịwa ahụ endovascular na cardiothoracic/vaskụla.

Ajụjụ a na-ajụkarị¶

Kedu ihe bụ "ọbara ọgbụgba na-ekwusa" (ọbara ọbara sentinel) na fistula aortoenteric?¶

Ọbara onye na-ekwusa ozi ọma bụ ihe omume aghụghọ, na-egbochi onwe ya nke ọbara ọgbụgba eriri afọ (dị ka ịgbanye ntakịrị ọbara ma ọ bụ ihe ala kọfị, na-agafe otu tarry ojii ma ọ bụ stool ojii gbara ọchịchịrị, ma ọ bụ ịda mbà n'obi nkenke) nke na-eme na pasent 60 ruo 80 nke ndị ọrịa nwere fistula aortoenteric tupu ọbara ọgbụgba apụta. Mgbe aortic graft mbụ na-eme ka oghere pinhole banye n'ime duodenum, mbelata ọbara mgbali nwa oge na akwara akwara na-ekwe ka obere mkpụkọ ọbara gbanye oghere ahụ, na-akwụsị ọbara ọgbụgba ahụ kpamkpam ruo awa ole na ole ruo ụbọchị ole na ole. Ozugbo acid afo, pancreatic enzymes, na ịrị elu ọbara mgbali gbazee ma ọ bụ fesa plọg ahụ na-emebi emebi, nnukwu ọbara ọgbụgba akwara na-eyi ndụ na-amalite. Ịkpọ ndị ọrụ mberede na windo ọbara ọgbụgba dị jụụ bụ otu nnukwu amụma maka nlanarị.

Enwere ike ime fistula aortoenteric afọ 10 ma ọ bụ 15 mgbe ịwa ahụ aortic anerysm abdominal?¶

Ee. Ọ bụ ezie na ụfọdụ fistulas aortoenteric nke abụọ na-etolite n'ime ọnwa ole na ole nke ịwa ahụ aortic graft ma ọ bụ endovascular stent-graft mmezi (EVAR), nkezi oge site na ịwa ahụ aortic mbụ na-emepụta fistula bụ afọ 3 ruo 5, na akwụkwọ ndekọ nke ọma na-emekarị 10, 15, ma ọ bụ ọbụna afọ 20 mgbe nrụzi aneurysm gasịrị. N'ime ndụ ndị ọzọ nke onye ọrịa mgbe ọ bụla aortic graft ma ọ bụ usoro stent ọ bụla, ihe omume ọ bụla nke vomiting ọbara, black tarry stools, maroon rectal blood blood, ma ọ bụ ahụ ọkụ na-enweghị nkọwa na n'etiti mgbu mgbu ga-emeso dị ka ihe nwere ike aortoenteric fistula ruo mgbe CT angiogram ga-ekpebi ya.

Kedu ihe kpatara CT Angiogram (CTA) ji dị mma karịa ọkọlọtọ Upper Endoscopy (EGD) dịka ule mbụ maka fistula aortoenteric a na-enyo enyo?¶

A na-eme usoro endoscopy elu ọkọlọtọ iji nyochaa esophagus, afo, na akụkụ nke mbụ na nke abụọ nke duodenum, na-akwụsị mkpụmkpụ nke akụkụ nke atọ na nke anọ nke duodenum ebe 75 ruo 80 pasent nke fistulas aortoenteric niile dị. N'ihi nke a, endoscopy nke elu na-emekarị na-atụfu ihe karịrị ọkara nke fistulas aortoenteric ma nwee ike ịta ụta na-agba ọbara ahụ na gastritis dị nro. N'ụzọ dị iche, a multiphasic CT Angiogram (CTA) nke afọ na pelvis na-ewe ihe na-erughị 5 nkeji, na-ahụ anya dum aorta na duodenum n'out oge, na-achọpụta 85 ka 95 pasent nke fistulas site n'igosi ikuku egosipụta tọrọ n'akụkụ aortic graft, ọnwụ nke abụba ụgbọelu n'etiti aka aka na bowel, ma ọ bụ dị iche na jetting n'ime ihe.

Kedu ihe kpatara ndị na-ahụ maka ahụike na ndị dọkịta na-ahụ maka ihe mberede ga-ezere iwelite ọbara mgbali elu nke ukwuu (" hypotension na-ekwe ka ọ dị") ka ọbara gbasasịrị?¶

Ozugbo ọbara nke onye mgbasa ozi kwụsịrị n'onwe ya, naanị ihe na-egbochi aorta afọ nke nwere nrụgide ịgbanye lita ọbara n'ime obere eriri afọ bụ obere mkpụkọ platelet-fibrin na-esighi ike na-agbanye traktị fistula. Ọ bụrụ na ndị otu ahụike na-enye boluses mmịnye ọbara na-eme ihe ike ma ọ bụ mmịnye ọbara ngwa ngwa iji mee ka ọ̀tụ̀tụ̀ ọbara ji erugharị systolic nke onye ọrịa ahụ ruo n'ọkwa dị elu ma ọ bụ dị elu (dị ka 130 ruo 150 mmHg) tupu dọkịta na-awa vaskụla agbachie aorta, mmụba mberede na akwara akwara nwere ike jiri ụzọ gbapụ mkpụkọ ahụ n'ime oghere ahụ wee kpalite ọnwụ. Ọ gwụla ma onye ọrịa ahụ nwere ọrịa ischemia nke ụbụrụ siri ike, ndị otu vaskụla ahụ na-eji nwayọ “na-anabata hypotension” (ọbara mgbali systolic nke 80 ruo 100 mmHg, naanị iji mee ka onye ọrịa na-amụ anya ma na-ekwu okwu) ruo mgbe endovascular stent-graft ma ọ bụ ịwa ahụ mechiri aorta.

Gịnị kpatara na onye a na-enyo enyo na ọ na-agba ọbara na-agaghị aṅụ mmiri ma ọ bụ na-aṅụ ọgwụ ọnya ọnya n'ụlọ?¶

Nke mbụ, ịṅụ mmiri, iri nri, ma ọ bụ ịṅụ ọgwụ ọnụ na-akpali afọ, gallbladder, na pancreas iji zoo hydrochloric acid, bile, na enzymes dị ike na-agbari protein (trypsin na chymotrypsin) kpọmkwem n'ime akụkụ nke atọ nke duodenum, bụ ebe ha na-eji ọgwụ na-agbaze mkpụkọ ọbara na-echebe na-ejikọta fistula aortic. Nke abụọ, onye ọrịa ahụ ga-achọ nyocha CT dị iche ozugbo na mgbakasị izugbe mberede maka ịwa ahụ endovascular ma ọ bụ nke mepere emepe, ebe inwe mmiri mmiri ma ọ bụ nri n'ime afọ na-emepụta nnukwu ihe egwu nke ịgba agbọ na ịchọ n'ime ngụgụ n'oge intubation.

Kedu ihe bụ "àkwà mmiri EVAR" na kedu ka o si mee ka ndụ dị mma na fistula aortoenteric?¶

N'oge gara aga, naanị otu ụzọ isi kwụsị ọbara ọgbụgba aortoenteric fistula na-arụsi ọrụ ike bụ laparotomy mepere emepe nke mberede (ịchacha imeghe afọ dum, na-ekesa anụ ahụ dị oke mkpa, na ịpịkọta aorta), nke na-ebute ọnwụ pasent 50 ruo 70 site na mfu ọbara na ujo. Taa, ndị dọkịta na-awa vaskụla na-eji "àkwà mmiri EVAR": site na obere mkpịsị agịga dị n'ime akwara ukwu, ha na-amali ekpuchi ekpuchi endovascular stent-graft n'ime ochie aortic graft na-ebuga ya gafee oghere n'ime ihe na-erughị nkeji iri abụọ. Nke a na-akwụsị ozugbo ọbara ọgbụgba dị n'ime ma mee ka onye ọrịa kwụsie ike ka e wee nwee ike ịrụzi nrụzi zuru oke nke duodenum na aka nke butere ọrịa ahụ ozugbo emechara onye ọrịa ahụ n'ụzọ zuru oke.

Isi mmalite na nduzi ọchịchị¶

• ** European Society for Vascular Surgery (ESVS, Europe): *** ESVS 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections* (Chakfe et al., * European Journal of Vascular and Endovascular Surgery*, Nkebi na Secondary Aortoenteric Fistulaed, Centre) usoro nchọpụta nchọpụta, endovascular EVAR na-ejikọta na ndị ọrịa na-adịghị akwụsi ike, na in-situ vs. extra-anatomic reconstruction).
• Society for Vascular Surgery (SVS, United States):* Society for Vascular Surgery Practice Practice Guidelines on the Care of Patients with an Abdominal Aortic Aneurysm* (Chaikof et al., Journal of Vascular Surgery, nchoputa na emergent management nke isi na nke abụọ aortoenteric erosion na fistula).
• ** American Heart Association (AHA, United States): *** Ọrịa akwara, Mycotic Aneurysms, na Ọrịa Endovaskụla: Nkwupụta Sayensị sitere na American Heart Association * (* Circulation *, microbiology, biofilm pathogenesis, antimicrobial and antifungal mkpuchi, na ịwa ahụ nke aortoenteric fistulae).
• ** American College of Gastroenterology (ACG) & European Society of Gastrointestinal Endoscopy (ESGE): ** * Ntuziaka nlekọta ahụike na njikwa ọbara ọgbụgba dị elu nke gastrointestinal siri ike * (nghọta nke fistula aortoenteric na ndị ọrịa nwere prosthetic aortic grafts, njedebe nke ọkọlọtọ EGD na-erute D3/D4).
• ** National Institute for Health and Care Excellence (NICE, United Kingdom):** Abdominal Aortic Aneurysm: Diagnosis and Management (NICE Guideline NG156).

Ntuziaka emetụtara¶

• Mgbasa aortic na mgbawa nke eriri afọ aortic aneurysm
• Ọbara ọgbụgba nke eriri afọ, ọbara ọgbụgba (hematemesis), na melena
• Esophageal rupture (Boerhaave syndrome), Mallory-Weiss anya mmiri, na vomiting mgbu obi.
• Esophageal varices mgbawa, ọbara ọgbụgba cirrhosis, na imeju encephalopathy
• Enyemaka mbụ na-awụ akpata oyi n'ahụ na njirimara ọdịda ọbara