Aortoenteric Fistula 'Herald Bleed' me te nui o te whakaheke toto o runga GI i muri i te pokanga Aortic Graft¶

Ko te aortoenteric fistula (AEF) he hononga kino i waenga i te aorta puku o te puku me te waahanga whekau e tata ana, ko te nuinga o te wahanga tuatoru, tuawha ranei o te duodenum ka whiti tika atu i te tuara. Neke atu i te 90 ōrau o ngā take he aortoenteric fistula tuarua ka whanake marama ki te 15 tau i muri mai i te whakatuwheratanga o te pokanga o Dacron graft whakatikatika, endovascular stent-graft repair (EVAR) ranei o te abdominal aortic aneurysm (AAA), i te wa e paopao ana te miihini me te mate o te karaehe iti ka pakaru te poka ki roto i te pakitara aodenal. I te mea he 100 paiheneti te mate o te fistula aortoenteric kare i rongoatia, ka whakawhirinaki katoa te oranga ki te mohio ki tana tohu whakatupato haumanu: te "Heald bleed" (sentinel bleed). Tae atu ki te 60 ki te 80 paiheneti o nga turoro, ko te whakamaaramatanga kino ka puta i mua i te ahua iti, ka whakaiti i a ia ano te ruaki i te iti o te toto whero kanapa ranei, i nga mea whenua kawhe ranei (hematemesis), ka pahemo te maroon pouri, te kuetere pango ranei (melena, hematochezia), ka mate ranei i te wa poto (ka mutu te mate o te toto) i te wa poto (**) ka kuhu te toka i te wahi fistula iti ka heke te pehanga toto. I roto i nga haora ki etahi ra, ka memeha, ka puhipuhi ranei te toto toto ka pakaru, ka puta mai te toto toto e kore e taea te aukati ki roto i te whekau. Mena kua **kua ** kua pa ki te mate aortic aneurysm abdominal aortic aneurysm, aortic bypass graft, abdominal aortic aneurysm ranei e mohiotia ana ka pa ** te rere toto gastrointestinal, te kutae pango, te ngenge kore ranei, waea atu ki to rohe. tau ohorere tonu. I a koe e tatari ana ki te kawe waka tūroro, arotakehia nga aratohu ohorere e pa ana te wehenga aortic me te ruptured abdominal aortic aneurysm, te toto gastrointestinal, te ruaki toto, me te melena, a te pakaru o te esophageal (Boerhaave syndrome) me nga roimata Mallory-Weiss.

Na te mea ka tae noa ki nga waahanga tuatahi me te tuarua o te duodenum (e ngaro ana te kapiti i roto i te tuatoru o nga wahanga o te duodenum) na te mea ka taea e te pupuhi wai whakaroto te whakanui ake i te pehanga toto ki te pupuhi atu i te mono thrombus whakamarumaru i roto i te kaikawe korero, ko te mahi tino nui i mua i te hōhipera he kii atu ki te 9. rata te kupu tika: "Ko tenei turoro he abdominal aortic graft a he GI bleed; whakatauhia he aortoenteric fistula herald bleed."

Mahia tenei inaianei¶

1. Waea wawe ki to nama whawhati tata ka panuitia he Aortoenteric Fistula Herald Bleed e whakapaetia ana. Waea 911 i te United States me Canada, 112 puta noa i te Kotahitanga o Europi, 999 i te United Kingdom, 000 i Ahitereiria, tirohia to maatau rarangi ingoa tau ohorere. Kia marama te korero: *"Te rongoa ohorere: te toto gastrointestinal i roto i te turoro me te hitori o te whakatikatika o te aortic aneurysm abdominal.
2. Ahakoa kua tino mutu te ruaki o te toto, te rere toto ranei, a kua 100 paiheneti te hokinga o te tangata ki tona ahua, me rongoa hei mahi ohorere tonu. Kaua rawa e whakaaro he whewhe puku, he hemorrhoid, he gastritis ranei te wahanga kotahi o te kuetu pouri, he kapu iti o te toto ruaki, he whewhe puku, he hemorrhoid, he gastritis ranei kua mutu noa iho. Ko taua wa marino tinihanga ko te whakamaarama haumanu tika o te Heald bleed (kei reira te vasospasm me te iti o te toka toto iti e kore e mau te pehanga katoa o te aorta puku).
3. Whakatakotohia te turoro ki runga i te tuara (ka hurihia ranei ki te taha maui ki te waahi whakaora mena ka kaha te nausea, ka ruaki ranei) ka aukati i te tu katoa, te noho ki runga, te hikoi ranei. Ma te tu ki runga ka heke te hau o te roro me te whakanui ake i te uaua o te pakitara o roto o te puku, ka taea te whakararu i te syncope, ka whakararu ranei i te maru o te thrombus i waenga i te aortic graft.
4. Whakahauhia te NPO tino (kaore he mea ma te waha: kore wai, kore kai, kore antacids-waha, me te kore he whakaheke toto, rongoa mamae ranei). Ma te horomia te wai, te kai ranei, ka whakaihiihi i te waikawa pekitia, te papa, me te pancreatic proteolytic enzymes (trypsin me te chymotrypsin) ki te ringihia ki te tuatoru o nga wahanga o te duodenum, ka kemu ki te wahangu, ka kemu ki roto i te wahanga o te duodenum. whakaohohia te whakakorenga tonu.
5. Kaua e pehia, te paopao, te mirimiri ranei i te puku. Ka pehi hohonu te tangata e noho ana, te rata haumanu ranei ki waenganui-kopu ki te tirotiro mo te ngawari, he papatipu pahekeheke ranei ka taea e te tinana te kopiri i te duodenum ki te taha o raro o te porosthetic aortic graft me te whakakore i te kopa.
6. Kimihia te kaari whakahiato a te turoro, te whakarāpopototanga ranei o te tukunga o te hōhipera e whakaatu ana i te ra me te momo o te pokanga aortic, ka tuku tika atu ki nga kaiparapara. Ma te mohio mena kei te manawanui he aortobifemoral Dacron bypass graft, he interposition tube graft, he **endovascular aortic stent-graft ranei ki te matohi o te VAR)**i te matohi (EVAR)i te hohipera whakahohooho (EVAR) Ko te roopu pokanga me te CT Angiography scanner i mua i te hurihanga o te manawanui ki nga kuaha.

Rakau whakatau: hematemesis whakapeka, melena, he whakamatautau toto i muri i te ruaki¶

flowchart TD
    Start["Te Ruaki Toto (Hematemesis), Te Kawhe-Papa Emesis, Te Tarry Stool Pango (Melena), te Maroon Stool ranei"] --> CheckAorta{"Hipanga 1: Kei te Turoro tetahi hitori mo te Whakatikatika Aortic Aneurysm (AAA) (Tuwhera Graft, EVAR Stent ranei), Aortoiliac Bypass, AAA e mohiotia ana, me te Pukuhi Puhi Puke?"}

    CheckAorta -->|"ĀE (Ahakoa he 5 ki te 15 tau ki muri te pokanga ka iti te toto, ka mutu ranei)"| HeraldAEF["TE WHAKAMAHI AORTOENTERIC FISTULA (AEF) HERALD BLEED: Waea wawetia 911 / 112 / 999; Matohi Takotoranga Vascular + Tonoa Kia Tatauhia te Multiphasic CT Angiogram (CTA) I mua i tetahi Whakamutunga"]

    CheckAorta -->|"KORE e mohiotia ana he aortic graft, aneurysm ranei"| CheckVomitContext{"Hipanga 2: I timata tonu te whakaheke toto i muri tonu i te tuku kaha, te ruaki ranei?"}

    CheckVomitContext -->|"Ae: Ko te pupuhi kaha, te ruaki ranei i mua i nga tohu"| CheckMackler{"Hipanga 3: Tirohia Boerhaave Rupture vs. Mallory-Weiss Tear: Kei te mamae 10/10 te mamae o te uma, te mamae tuara ranei, te poto o te manawa, te hau pupuhi ranei i raro i te kiri kaki (crepitus)?"}

    CheckMackler -->|"ĀE: Te mamae nui o te uma, te mamae o te tuara, te pupuhi, te ngongo kaki ranei"| Boerhaave["TE WHAKAMAHI I TE BOERHAAVE SYNDROME (TRANSMURAL ESOPHAGEAL RUPTURE): Waea wawetia nga ratonga ohorere; NPO tino (Karekau i te 1 topa wai), noho i te taha-tika 30 ki te 45 nga nekehanga."]

    CheckMackler -->|"KORE te mamae o te uma me te mate aporo: Ka rere te toto whero kanapa i muri i te maha o nga ruaki"| MalloryWeiss["E whakapaetia ana Mallory-Weiss Mucosal Tear: Kia mau ki te NPO; Kawea ki te Tari Ohotata mo te Tirohanga Hemoglobin, IV Proton Pump Inhibitor, me te Aromātai Endoscopic"]

    CheckVomitContext -->|"KORE he reanga i mua: Te ruaki kore mamae o te toto, te papa kawhe, te kutae pango ranei"| CheckCirrhosis{"Hipanga 4: Kei te mate te mate ate Cirrhosis, te mate toto toto, me te hitori NSAID/Ulcer taumaha ranei?"}

    CheckCirrhosis -->|"Cirrhosis / Jaundice / Ascites RĀNEI Toto Toto Nui"| VaricesUlcer["TE WHAKAMAHI I TE WHAKAMAHI I TE WHAKAMAHI I TE WHAKAMAHI I TE WHAKAMAHI I TE KAUPAPA KAUPAPA KAUPAPA KAUPAPA KAUPAPA (DIEULAFOY): Waea wawetia nga ratonga ohorere; Te Turanga Whakaora, NPO Tino"]

    HeraldAEF --> AEFProtocol["Kawa Whakaora AEF Inamata: Ko te okiokinga mo te moenga, ko te kore o te puku o te puku, te NPO tino, te mate whakaahuru (Target Systolic BP 80 ki te 100 mmHg kia kore ai e pupuhi te Clot Plug), Emergent Endovascular Stent-Graft Relining (EVAR Bridge) or Open Aortic Control"]

Anatomy me te pathophysiology: he aha te take i pakaru ai te aortic graft ki te wahanga tuatoru o te duodenum¶

Kia mohio ai koe me pehea te hono tika o tetahi arai nui i roto i te retroperitoneum ki roto i te ara kena, me te aha i puta ai te toto i roto i nga wahanga motuhake e rua (ko te heald bleed ka whai muri i te catastrophic exsanguination), he pai ki te tirotiro i te ahua o te puku o te puku:

1. Ko nga whitinga tinana i te wahanga tuatoru o te duodenum (D3)¶

I roto i te tinana o te tangata, ka rere poutū te aorta puku ki mua o te tuara lumbar i roto i te waahi retroperitoneal. Kei raro noa iho i te takenga mai o nga uaua renal (kei te 95 paiheneti o nga aortic aneurysms abdominal abdominal aneurysms, ka tuia nga grafts prosthetic surgical), ko te tuatoru (whakapae) o te duodenum (D3) ka whiti whakapae mai i te taha matau ki te maui ** tika puta noa i mua o te aorta abdominal me te taha taha o te kopu (**) he pepa angiangi o te ngako retroperitoneal me te peritoneum.

• Aortoenteric Fistula Tuatahi (Onge, <10% o nga keehi): Ka tupu i roto i te turoro me te kaore i rongoatia, kare ano i whakahaeretia te aortic aneurysm abdominal (i te nuinga o te wa ka pangia te aneurysm "mycotic", te aortitis tuberculous, syphilitic ranei, te whara iraruraru, te puku pancreatic/duodenal ranei) kei reira te pukoro aneurysm whakawhänui ki te pakitara e rua ka pakaru tika atu ki te pakitara e rua.
• Aortoenteric Fistula Tuarua (Mahi, >90% o nga keehi): Ka tupu marama ki te 15+ tau (tauwaenga 3 ki te 5 tau) i muri i te pokanga tuwhera o te aortic aneurysm puku me te raranga, te raranga ranei Dacron or PTFE prosthetic graft, i muri ranei endovascular aneurysm repair (EVAR) me te stent-graft whakarewa. E rua nga mahi whakakotahi i kawe mai i te aorta ki roto i te kopu:
• Te Necrosis Pehenga Ahu Ahu Miihini: Ki te mea te takai kiko angiangi i tuuhia i waenga i te kopa prosthetic me te duodenum i te wa o te pokanga taketake ka memeha haere, ka 100,000 nga wa ia ra ka pao te raina tuitui tata o te raima hangai ki te pakitara o muri o te duodenum tuatoru. I roto i nga tau, ka puta mai tenei jackhammering mihini ki te ischemia pehanga me te whewhe o te pakitara duodenal tae noa ki te wa e kitea ana nga muka o te raima hangai ki roto i te lumen intestinal.
• Waihanga Mate Huakita Perigraft-Koeke Iti: Kia huri te huakita whekau mokitokito (Escherichia coli, Enterococcus, Staphylococcus epidermidis, Streptococcus, Bacteroides, me Candida momo) ka whakawhiti puta noa i te angiangi o te duodenal mucosa o te kirikiri koiora huri noa i te duodenal mucosa. te anastomosis, te tuku i nga huakita huakita ka whakakore i nga tuitui pakitara aortic ope ka hanga he hongere fistula tika (paraprosthetic-enteric ranei aorto-duodenal fistula).

2. Ko nga waahi tinana e pa ana ki te Aortoenteric Fistula¶

Ahakoa ka taea te whakakore i tetahi waahanga o te kopa gastrointestinal e pa ana ki te aorta, ko te tohatoha tinana ka tino kaha ki roto i te duodenum hohonu:

1. Tuatoru me te Tuawha nga wahanga o te Duodenum (D3 / D4): 75 ki te 80 paiheneti o nga keehi katoa (na te mea ka herea te D3 ki te taha o te aortic graft anastomosis tata e te taura o Treitz).
2. Jejunum and Ileum (Intestine Iti): 10 ki te 15 paiheneti o nga keehi.
3. Sigmoid Colon or Cecum: 3 ki te 5 paihēneti (ina koa ka pahemo te peka aortobifemoral ki roto i te koroni sigmoid i te pelvis maui).
4. Te puku, te Esophagus ranei: 2 ki te 5 paiheneti (ka pakaru nga stent-grafts thoracic aortic ki roto i te waenganui-esophagus, e mohiotia ana he aortoesophageal fistula, e whakaatu ana me Chiari's triad: te mamae o waenganui-thoracic, he hematemesis arterial sentinel ka mutu te nguina, me te mate mate i muri mai).

3. Ko nga mahi koiora o te "Herald Bleed" (Sentinel Bleed) me te aha i mutu ai i a ia ano¶

Ko nga turoro, ko nga whanau, tae noa ki nga taote kore mohio, he maha nga wa e pohehe ana te kaikawe korero: *"Me pehea e taea ai e te kohao i roto i te aorta puku nui te toto i tetahi kapu toto ka mutu ka mutu?"

1. Microscopic initial mucosal pinhole: I te wa tuatahi ka pakaru te raina aortic suture aortic or pseudoaneurysm i roto i te uaua me te mucosa o te tuatoru duodenum, he maha noa te whakatuwheratanga 1 ki te 3 mirimita te whanui kaua ki te roimata whanui.
2. Ko te mokowhiti o te toto me te whakaheke tere: Ko te rerenga ohorere o te 200 ki te 500 milliliters (7 ki te 17 hekere) o te toto toto e rere ana ki roto i te duodenum ka whakaheke i te pehanga toto (he maha nga wa poto ka ngenge, ka whanoke ranei) me te whakaoho i te kaha o te reflex smooth-muscle **vasodenal wall a huri noa i te uaua.
3. Te hanga o te pereti-fibrin thrombus plug mo te wa poto: I te mea ka heke te pehanga toto me te whaiti o te fistula, ka tere te whakakotahitanga o nga platelets me te fibrin ki roto i te riipene i waenga i te raima waihanga me te mucosa duodenal, ka purua te kohao kia rite ki te tutakina i roto i te pounamu.
4. Te keri me te pupuhitanga o te plug thrombus (Te Matapihi Latent): Ka mutu te rere o te toto, ka hoki ano te pehanga toto o te manawanui (ka neke ake ranei ki te kaha ake mena ka tukuna e te roopu o te hohipera he boluse whakaheke toto, ka whakaheke toto ranei hei "whakatika" i nga tohu tino nui). I te wa ano, ka horoi tonu te wai o te kopu waikawa, te papa, me nga enzyme pancreatic kaha (trypsin, elastase, me te lipase) ki runga i te taha duodenal e kitea ana o te toto, ka memeha matū te mono fibrin. I muri i te matapihi huna mai i haora torutoru ki etahi ra (i roto i te 50 paiheneti o nga keehi i roto i te 6 ki te 24 haora, me te 90 paiheneti i roto i te 1 ki te 2 wiki), ka pupuhi katoa te kopa, ka whakatuwhera i te paipa tika, te pehanga teitei mai i te aorta ki roto i te whekau ka rere te toto 1 ki te 2 rita ia meneti.

Te Wehenga i te 4 Nga Tirohanga Nui o runga o te GI Toto me te Waea i muri i te Ruaki¶

Na te mea ko te toto o te kopu o runga me te oho o te uma i muri i te ruaki/kopu e hiahia ana kia rereke te rereke o nga wawaotanga tonu (mai i te hypotension whakaae me te CT angiography mo te fistula aortoenteric ki te whakahekenga o te uma mo te mate o Boerhaave), whakamahia tenei ripanga whakataurite haumanu:

Nga haki whero haumanu: te Tawhito Tauhira me nga tohu whakatupato "Graft Sepsis".¶

Ahakoa e whakaahuahia ana e nga pukapuka pukapuka he Tawhito Tawhito o te Aortoenteric Fistula kei roto **(1) Te toto o te kopu, (2) Te mamae o te puku, te tuara ranei, me te (3) He papatipu puku e pupuhi ana **, e whakaatu ana nga rangahau ka puta tahi nga tohu e toru i roto i ** 11 ki te 25 paiheneti noa o nga turoro ka taea te aukati i te kopa i muri i te mahi ** papatipu mai i te whawha). Engari, kia ata titiro ki enei tauira haumanu o te ao:

1. Te Tauira "Herald Bleed + Syncope" (Ka kitea i te 60% ki te 80% o nga keehi)¶

• Ka rongo te manawanui i te mahana, te nausea, te ngongo, te mahunga ranei, a ka ** ka ngenge noa (syncope)** i runga i te papa kaukau.
• Ka ruakina e ratou he toto whero iti, he "papa kawhe" pouri ranei, ka haere ranei i te whekau kotahi o te toto maroon pouri, te kumete pango ranei, te koroke (melena).
• I roto i te 15 ki te 30 meneti, ka hoki mai to ratou tae, ka mutu te toto, ka tohe ratou kei te pai to ratou ahua me te kore e pirangi ki te haere ki te hohipera. Koinei te wa tika e ora ai nga waka ohorere.

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

I roto i te maha o nga turoro he fistula aortoenteric tuarua, wiki, marama ranei i mua i te putanga o te topata tuatahi o te toto e kitea ana, ka tuku te duodenum kua pakaru i te huakita ki runga i te aortic graft prosthetic, ka puta te chronic perigraft sepsis: - Ko te kirika kore e whakamaramatia, te werawera o te po, te uaua ranei (he maha nga wiki ka pohehehia he mate viral, he mate mimi, he kirikaa kaore i te mohiotia te takenga mai). - He hou, he hohonu, he hoha te mamae tuara o waenganui-lumbar, he mamae puku periumbilical ranei (na te mumura retroperitoneal me te roha pseudoaneurysm e pehi ana ki te tuara lumbar). - Septic emboli ki nga waewae, maihao ranei ("Blue Toe Syndrome"): Ko nga koka iti kua pangia e pakaru ana i te aortic graft ka heke ki roto i nga waewae, ka puta he wahi papura mamae ki nga matimati, ki te osteomyelitis waewae kotahi ranei. - Bacteremia me nga rauropi whekau: Ko nga ahurea toto e tipu ana Escherichia coli, Enterococcus, Streptococcus bovis/anginosus, Bacteroides, Candida ranei i roto i nga turoro me te aortic graft he pathognomonic mo te aortoenteric fistula, te mate graft ranei.

E rua nga mahanga hōhipera whakamate: ko te "Standard Endoscopy Trap" me te "Over-Resuscitation Trap"¶

Ina haere koe i te taha o te hoa aroha ki te tari whawhati tata ki te tari whawhati tata, ma te mohio e rua nga mahanga haumanu nui e tautokohia ana e te Society for Vascular Surgery (SVS) me European Society for Vascular Surgery (ESVS) ka taea te whakarite kia tere, kia rurukuhia te tiaki:

Mahanga 1: He aha te take ka ngaro i te Whakamutunga Upper Endoscopy (EGD) he Aortoenteric Fistula¶

I roto i te rere toto o te whekau o runga, ka karangahia e nga taote ohorere tetahi tohunga mo te gastroenterologist ki te mahi esophagogastroduodenoscopy (EGD). Heoi, ko te gastroscope paerewa he mea hanga noa kia tae ki te tuatahi me te wahanga tuarua o te duodenum (D1 me D2), ka tu tika i te taha o te ampulla o Vater. Na te mea ** 75 ki te 80 ōrau o te aortoenteric fistula kei te hohonu ake i te tuatoru me te wha o nga wahanga o te duodenum (D3 me D4)**, he ahua noa te ahua o te EGD i roto i te haurua o nga keehi fistula aortoenteric katoa.

E rua atu nga raru ka puta i te wa o te endoscopy: - Ko te Mahanga "Ko te Maamaa": Ka kai nga turoro mate pukupuku i ia ra, i nga wa katoa he ahipirini, he whakaheke toto ranei, a, he maha nga wa ka pa mai te gastritis ngawari, te hakihaki puku iti, he whewhe peptic iti kua ora i roto i te puku. Mena ka kitea e te endoskopi he maareti ngawari i roto i te puku, ka mutu te whakamatautau me te kore e tirotirohia tae noa ki te wha o nga wahanga o te duodenum (me te kore ranei e tono he CT angiogram), ka whakapae teka te kaikawe korero ki te gastritis i te wa e noho ana te aortic fistula he inihi te hohonu kua rite ki te pakaru. - Te whakakore i te Herald Clot i roto i te GI Lab: Ki te panaia e te endoscopist he colonoscope pediatric roa, pana-enteroscope ranei ki roto i te tuatoru o nga wahanga o te duodenum, ka kite ratou i te pupuhi toto pouri e mau ana ki te pakitara duodenal, a ka ** ka ngana ki te horoi, ki te biopsy, ki te tope ranei ki roto i te huinga endoscopy paerewa, ka taea e ratou te tango i te waahanga o te aototopia, ka taea e ratou te tarai i roto i te waahanga endoscopy o te aorta. exsanguination tawhiti atu i te ruma mahi. No reira, ki te mahia te endoscopy ki te tirotiro i te D3/D4, ka whakahauhia e nga aratohu pokanga ngongo me mahi ** i roto i te rūma mahi me te roopu pokai toto kua rukuhia ki roto, kua rite mo te awhi aortic tonu**.

Mahanga 2: He aha te "Whakaaetanga Whakaaetanga" ka ora i mua i te hiri o te aorta¶

I te wa o te matapihi huna i muri i te toto o te kaikawe korero, ko te kopa pereti-fibrin pakarukaru te arai e wehe ana i te toto aortic pehanga teitei mai i te lumen tuwhera o te whekau. Mena ka tukuna e nga paramedic, nga kaimahi o te hohipera ranei nga rita o nga bolus saline tere ki roto i te toto, ka whakaheke ranei i nga waeine maha o nga pūtau toto whero kua kikii hei peia te pehanga toto systolic o te manawanui ki runga. 130 to 150 mmHg, ma taua paheketanga o te pehanga wai ka ** ka puta mai te parai totoka ki waho tonu o te ara fistula** (penei i te pakaru o te puku aortic aneurysm).

• Te Ture Whakaaetanga Whakaaetanga: I te mea e oho ana te manawanui, e mataara ana, e korero ana (e tohu ana i te pai o te rere o te toto ki te roro me te ngakau), ka whaaia e nga aratohu whaanui me nga aratohu whakaoranga ** ka whakahaeretia te mate whakaheke (he pehanga toto systolic o te tata 80 to 100 mmHg)** te whakamahi i nga wē kua whakatairitehia kia oti ra ano te hiri e te taote taatai ​​i te aorta na roto i te stent-graft endovascular ortic cross-clamp ranei.

Te whakamaaramatanga o te hōhipera tino me te whakaora pokanga: CTA, EVAR piriti, me te hanga ano¶

Ina tae atu te manawanui ki te aortoenteric fistula ki te tari whawhati tata, ka whakahohehia e te hōhipera he ara pokanga vascular tere:

1. Whakamātautau Tuatahi Paerewa-Gold: Multiphasic CT Angiography (CTA) o te Pupu me te Pelvis: Ka mahia kare he pai te rereke o te waha (e huna ana i te toto kaha i roto i te duodenum), ka roa te CTA i raro i te 5 meneti, he 85 ki te 95 paiheneti te tairongo, ka kitea nga tohu pathognomonic:
2. Ectopic perigraft hau: He mirumiru hau huri noa i te aortic graft (he rerekee i nga wa katoa neke atu i te 4 ki te 6 wiki i muri i te pokanga).
3. Te ngaronga o te rererangi ngako aorto-duodenal: Te herenga tika o te tuatoru duodenum ki roto i te pakitara o mua, he anastomotic pseudoaneurysm.
4. Te whakahiatotanga whakahiatotanga: Ka rere te rereke o roto mai i te aorta ki roto i te pukoro duodenal.
5. Wāhanga 1 Whakaoranga: Endovascular Stent-Graft Relining ("EVAR Bridge to Surgery"): I raro i SVS me nga aratohu ESVS, hei utu mo te laparotomy tuwhera tonu (e kawe ana i te 50 ki te 70 paiheneti te mate i te wa e kaha ana te whakaheke toto), ka werohia e nga kaitoro poka-a-whare** te arai uwha me te whawha** i roto i te whaowhaowhao i roto i te whaowhao. i roto i te raakau tawhito puta noa i te fistula (whakanuia ranei he REBOA poihau aortic i te hopukina). I roto i te 20 meneti, ka mutu te toto, ka tau te pehanga toto. Ko nga patu paturopi whaanui IV (piperacillin-tazobactam, meropenem + vancomycin) me te IV antifungal (fluconazole me te micafungin) ka timata tonu.
6. Wāhanga 2 Whakatika Tino: Kia ora ake, ka wetekina, ka whakatikahia e nga taote te tuatoru o te duodenum, ka kuhu he papa matotoru o te nui ake i waenganui i te whekau me te aorta, ka tango i te rapa waihanga kua pangia, ka whakahoki ano i te rere toto ma te extra-anatomic axillobifemoral bypass or in-situgen femoral bypass or in-situgen femoral bypass or (NAIS), homograft cryopreserved, rifampin/hiriwa-impregnated Dacron ranei.

Nga nama ohorere a rohe me nga tikanga umanga¶

Ko te whakapae aortoenteric fistula me tere tere te kawe waka tūroro ki te whare wānanga Vascular Surgery Center me te 24-haora CT Angiography, Hybrid Endovascular Operating Rooms, Massive Transfusion Protocol, and Surgical Intensive Care:

• Te Hononga o Amerika me Kanata: Waea 911. Korero atu ki nga kaiparapara kua mate te manawanui i te abdominal aortic aneurysm aneurysm me te hiahia ki tetahi hohipera nui me te 24/7 Vascular Surgery (kaore rawa he ER, he whare haumanu hapori ranei). Whakahaerehia i raro i Society for Vascular Surgery (SVS) Practice Guidelines on the Care of Patient with a Abdominal Aortic Aneurysm and American Heart Association (AHA) Vascular Graft Infection Scientific Statements.
• United Kingdom: Waea 999 mo te waka tūroro Kāwai ½ ki te rohe Arterial Vascular Hub. Ka whakahaerehia i raro i te National Institute for Health and Care Excellence (NICE NG156) me Vascular Society of Great Britain and Ireland (VSGBI) nga tikanga.
• Uniana Pakeha: Waea 112. Ka whakahaeretia i raro i te Hapori Pakeha mo te Takuranga Vascular (ESVS) 2020 Nga Aratohu Mahi Hauora mo te Whakahaerenga o nga Waahanga Ake me nga Mate Endograft.
• Ahitereiria me Aotearoa: Waea 000 i Ahitereiria, 111 ranei i Aotearoa. Ka whakahaerehia i raro i nga tikanga Australian and New Zealand Society for Vascular Surgery (ANZSVS).
• India me Ahia-Kiwa: Waea 112 (ranei 108 i Inia), 995 i Singapore, 119 i Hapani me Korea ki te Tonga, 999 ranei i Malaysia me Hong Kong. Tonoa he whare wananga whai mana endovascular me te cardiothoracic/vascular pokanga.

Pātai auau¶

He aha te "Heald bleed" (sentinel bleed) i roto i te aortoenteric fistula?¶

Ko te herald bleed he wahanga tinihanga, he whakaiti i a ia ano o te toto gastrointestinal (pēnei i te ruaki i te iti o te toto, i te papanga kawhe ranei, ka pahemo i tetahi tuu pango pango, pouri maroon ranei, he poto poto ranei te ngenge) ka puta i te 60 ki te 80 paiheneti o nga turoro he fistula aortoenteric i mua i te paheketanga o te toto. I te wa tuatahi ka tuwhera te kohao aortic ki roto i te duodenum, na te hekenga o te pehanga toto me te vasospasm arterial ka taea e te toto iti ki te puru te poka, ka mutu te toto mo etahi haora ki etahi ra. I te wa ka rewa, ka pupuhi ranei te waikawa o te kopu, nga whaahaki pancreatic, me te pikinga o te toto toto, ka pakaru te toto toto, ka timata te whakaheke toto. Ko te waea atu ki nga ratonga ohorere i te wa o te matapihi herald bleed te matapae tino nui mo te oranga.

Ka taea te tupu mai i te aortoenteric fistula i te 10 ki te 15 tau i muri i te pokanga aortic aneurysm abdominal?¶

Ae. Ahakoa ka tupu etahi fistula aortoenteric tuarua i roto i nga marama torutoru i muri i te pokanga aortic graft tuwhera, i te whakatikatika stent-graft endovascular ranei (EVAR), ko te wa toharite mai i te pokanga aortic taketake ki te hanganga fistula ko te 3 ki te 5 tau, a ko nga keehi kua tuhia he rite tonu ki te 10, 15, tae atu ki te 20 tau i muri i te whakatikatika aneurysm. Mo te toenga o te oranga o te manawanui i muri mai i nga mahi aortic abdominal graft, stent stent ranei, ko nga wahanga o te ruaki toto, nga kutae pango pango, te toto totika maroon, te kirikaa kore e whakamaramatia me te mamae o waenganui o muri me waiho hei fistula aortoenteric pea kia whakakorehia e te CT angiogram.

He aha te mea he pai ake te CT Angiogram (CTA) i te paerewa Upper Endoscopy (EGD) hei whakamatautau tuatahi mo te whakapae aortoenteric fistula?¶

Kua hoahoatia te whānuitanga o te endoscopy o runga ki te tirotiro i te esophagus, te puku, me nga wahanga tuatahi me te tuarua o te duodenum, ka mutu i te taha o te hohonu whakapae tuatoru me te wha o nga wahanga o te duodenum kei reira te 75 ki te 80 ōrau o te katoa o te aortoenteric fistula. Ko te hua o tenei, ka ngaro atu i te haurua o nga fistula aortoenteric nga tikanga o runga o te waa, ka pohehe pea te toto i runga i te kopu ngawari. Engari, he iti iho i te 5 meneti te CT Angiogram (CTA) o te puku me te pelvis, ka tiro i te aorta katoa me te duodenum i te wa kotahi, ka kitea te 85 ki te 95 paiheneti o nga fistula ma te whakaatu i nga mirumiru hau e mau ana i te taha o te aortic graft, te ngaronga o te rererangi ngako i waenga i te graft me te whekau, he rereke ranei.

He aha te take ka karohia e nga kaiparapara me nga taote ohorere te whakanui ake i te pehanga toto ("whakaaetanga hypotension") i muri i te toto o te kaikawe korero?¶

I muri tonu i te whakamutua o te toto o te kaikawe korero, ko te mea anake e arai ana i te aorta puku pehanga teitei kia kore e pupuhi rita o te toto ki roto i te whekau iti, ko te putunga pereti-fibrin iti, he pakarukaru e piri ana i te waahanga fistula. Mena ka tukuna e nga roopu rongoa nga bolus wai whakaroto, he whakaheke toto tere ranei ki te turaki i te pehanga toto systolic o te manawanui ki runga ki nga taumata noa, teitei ranei (penei i te 130 ki te 150 mmHg) i mua i te hiri a te taote taatai ​​i te aorta, ka puta ohorere mai te pehanga toto o te manawanui ki waho o te kohao ka puta te mate. Ki te kore e kaha te roro o te manawanui, ka mau tonu te "whakaaetanga hypotension" ngawari (he pehanga toto systolic o te 80 ki te 100 mmHg, he nui noa kia oho te manawanui me te korero) tae noa ki te hiri o te stent-graft me te rawhi pokanga i te aorta.

He aha te take e kore ai te tangata e whakapaetia ana he kaikawe korero kia whakaheke toto ki te inu wai, ki te tango ranei i te rongoa whewhe waha i te kainga?¶

Tuatahi, ko te inu wai, te kai kai, te tango rongoa-a-waha ranei e whakaihiihi ana i te puku, te gallbladder, me te pancreas ki te huna i te waikawa waikawa, te ate, me te kaha o nga whaamu (trypsin me te chymotrypsin) ki roto tika ki te wahanga tuatoru o te duodenum, i reira ka wetewete matū i te toka toto whakamarumaru e piri ana i te fistula aortic. Tuarua, ka hiahia te manawanui ki te karapa CT rereke me te mate whaanui whawhati tata mo te pokanga aortic endovascular, tuwhera aortic ranei, i te mea he wai, he kai ranei i roto i te kopu ka nui te mate o te ruaki me te aspirating ki roto i nga ngongo i te wa e werohia ana.

He aha te "piriti EVAR" me te pehea i pai ake ai te oranga i roto i te aortoenteric fistula?¶

I nga wa o mua, ko te huarahi anake hei aukati i te pupuhi toto nui ko te laparotomy tuwhera ohorere (te tapahi i te kopu katoa, te wehe i roto i te kiko nawe mato, me te awhi i te aorta), na te 50 ki te 70 paiheneti te mate i te mate toto me te ohorere. I tenei ra, ka whakamahia e nga taote pukupuku he "EVAR piriti": na roto i te werohanga ngira iti ki roto i te uaua o te whao, ka paopaohia he stent endovascular stent-graft ki runga ki roto i te raima aortic tawhito, ka horahia ki roto i te rua i raro i te 20 meneti. Ma tenei ka whakamutua te toto o roto me te whakapumau i te manawanui kia taea ai te whakatikatika tino o te duodenum me te taarua kua pangia i te wa e ora ana te manawanui.

Nga puna me nga aratohu whai mana¶

• Sotaiete Pakeha mo te Taapiri Vascular (ESVS, Europe): ESVS 2020 Nga Aratohu Mahi Hauora mo te Whakahaerenga o te Whakaaetanga Vascular Graft me te Endograft Infections (Chakfe et al., European Journal of Vascular and Endovascular Surgery, Section on Secondary Aortoenteric Fistula, recorald C. endovascular EVAR piriti i roto i te tūroro iu, me te in-situ vs. extra-anatomic reconstruction).
• Society for Vascular Surgery (SVS, United States): Te Society for Vascular Surgery Practice Guidelines on the Care of Patients with a Abdominal Aortic Aneurysm (Chaikof et al., Journal of Vascular Surgery, tātaritanga me te whakahaere puta o te horonga aortoenteric tuatahi me te tuarua me te fistula).
• ** American Heart Association (AHA, United States):** Vascular Graft Infections, Mycotic Aneurysms, and Endovascular Infections: He Korero Putaiao mai i te American Heart Association (Circulation, microbiology, biofilm pathogenesis, antimicrobial and antifungal coverage, and surgical management of aortoenteric fistulae).
• American College of Gastroenterology (ACG) & European Society of Gastrointestinal Endoscopy (ESGE): He Aratohu Hauora mo te Whakahaere o te Acute Gastrointestinal Bleeding Acute Upper Gastrointestinal Bleeding (te mohiotanga o te aortoenteric fistula i roto i nga turoro me nga grafts aortic prosthetic, nga herenga o te EGD mua / mua ki te tae atu ki te D3).
• National Institute for Health and Care Excellence (NICE, United Kingdom): Abdominal Aortic Aneurysm: Diagnosis and Management (NICE Guideline NG156).

Nga kaiarahi e pa ana¶

• Te wehenga aortic me te ruptured aneurysm aortic abdominal
• Te toto gastrointestinal, te ruaki toto (hematemesis), me te melena
• Te pakaru o te esophageal (Boerhaave syndrome), nga roimata Mallory-Weiss, me te ruaki te mamae o te uma
• Ka pakaru nga momo esophageal, te toto cirrhosis, me te encephalopathy ate
• Ko te awhina tuatahi ohorere me te tohu whakaheke toto