Aortoenteric Fistula 'Herald Bleed' uye Massive Upper GI Hemorrhage Mushure mekuvhiyiwa kweAortic Graft¶

Aortoenteric fistula (AEF) injodzi, pakarepo inotyisidzira hupenyu husina kujairika kubatana pakati pe-high-pressure abdominal aorta uye iri pedo nemudumbu, kazhinji chikamu chechitatu kana chechina cheduodenum painoyambuka yakananga pamusoro pemusana. Inopfuura 90 muzana yezviitiko ndeye ** yechipiri aortoenteric fistula ** inokura mwedzi kusvika kumakore gumi nemashanu mushure mekuvhiyiwa kwakavhurika kweDacron graft kugadzirisa kana endovascular stent-graft repair (EVAR) yeabdominal aortic aneurysm (AAA), apo mechanical pulsation uye yakaderera-giredhi graft infection inopinda mugomba reaortic. Nekuti iyo aortoenteric fistula isina kurapwa inouraya zana muzana, kupona kunoenderana zvachose nekuziva chiratidzo chayo chekiriniki yambiro: **"herald bleed" (sentinel kubuda ropa) **. Kusvika ku ** 60 kusvika ku80 muzana yevarwere **, kuputika kwenjodzi kunotungamirirwa nechiitiko chinoratidzika sechiduku, chinozvidzivirira chekurutsa zvishoma ropa rakatsvuka rakajeka kana kofi-pasi zvinhu (**hematemesis **), kupfuura maroon yakasviba kana dema tarry stool (melena kana hematocheziope pfupi) iyo inomira zvachose pachayo apo ropa reropa rechinguva rinovhara turakiti duku refistula uye ropa rinodonha. Mukati maawa kusvika kumazuva mashoma, maenzayimu ekugaya uye kukwira kweBP zvinonyungudika kana kuburitsa plug iyo isina kusimba yethrombus, zvichikonzera kubuda kweropa kusinga mire muura. Kana paine chero akamboita ** akambova neabdominal aortic aneurysm kugadziriswa, aortic bypass graft, kana anozivikanwa abdominal aortic aneurysm aneurysm ** chero ** kubuda ropa remudumbu, tsvina dema, kana kupera simba kusingatsananguriki, fonera munharaunda yako. nhamba dze emergency pakarepo. Paunenge wakamirira kutakurwa kweamburenzi, ongorora zvine hukama madhairekitori pa aortic dissection uye kuputika abdominal aortic aneurysm, kubuda ropa mudumbu, kurutsa ropa, uye melena,uye esophageal rupture (Boerhaave syndrome) uye Mallory-Weiss misodzi.

Nekuti mwero wepamusoro endoscopy (EGD) inongosvika kune yekutanga neyechipiri zvikamu zve duodenum (inowanzo kushayikwa fistula yakavanzwa zvakadzika muchikamu chechitatu cheduodenum) uye nekuti hasha inopinza mvura inopomba inogona kusimudza BP inokwana kuburitsa inodzivirira thrombus plug mukati meherald kubuda ropa, chako chakakosha pre-chipatara kuudza displital. vanachiremba, uye chiremba wechimbichimbi mashoko chaiwo: "Murwere uyu ane abdominal aortic graft uye ari kubuda ropa reGI; bvisa aortoenteric fistula herald kubuda ropa."**

Ita izvi ikozvino¶

1. Fonera nhamba yako yechimbichimbi nekukasika uye zivisa munhu anofungidzirwa kuti ane Aortoenteric Fistula Herald Bleed. Dhonza 911 muUnited States neCanada, 112 mhiri kweEuropean Union, 999 muUnited Kingdom, 000 kuAustralia, kana kutarisa mazita edu nhamba dze emergency. Taura zvakajeka: "Chimbichimbi chekurapa: kubuda ropa kwegastrointestinal mumurwere ane nhoroondo yeabdominal aortic aneurysm graft kugadziriswa. Anofungidzirwa aortoenteric fistula herald bleed."
2. **Kunyange kana kurutsa kweropa kana kubuda ropa romudumbu kwamira zvachose uye munhu wacho onzwa adzokera kunguva yake ne100 muzana, zvibate sechimbichimbi chokuvhiyiwa chapakarepo. Iyo inonyengera nguva yekudzikama ndiyo chaiyo yekiriniki tsananguro ye herald bleed (apo vasospasm uye diki diki reropa clot zvisingadzore kudzoreredza kuzere kweabdominal aorta).
3. ** Radzikai murwere kumusana wavo (kana kuti akakungurutsira kudivi ravo rekuruboshwe munzvimbo yekupora kana achikurumidza kusvotwa kana kurutsa) uye rambidza kumira, kugara, kana kufamba.** Kusimuka kunodonhedza cerebral perfusion uye kunowedzera intra-abdominal madziro tension, izvo zvinogona kukonzeresa syncope kana mechanically kuvhiringidza iyo isina kusimba thrombus plug the thrombus plug uye fifitula
4. Simbisai NPO yakasimba (hapana chinhu nemuromo: zero mvura, zero chikafu, zero oral antacids, uye zero blood thinner kana mishonga yemarwadzo). Kumedza zvinwiwa kana chikafu kunokurudzira gastric acid, bile, uye pancreatic proteolytic enzymes (trypsin nechymotrypsin) kuti idire muchikamu chechitatu chechikamu chetatu chemushonga wenguva pfupi kuvhara iyo aortic fistula uye kukonzeresa kudzima nekukurumidza.
5. USATI kudzvanya, kupuruzira, kana kukwiza dumbu. Munhu akamira pedyo kana murapi achidzvanya mukati-kati medumbu kuti atarise kana kupfava kana kuti kupuruzira muviri anogona kutsimbirira duodenum paari pasi peprosthetic aortic graft uye kuburitsa clot.
6. Tsvaga kadhi rekuvhiyiwa kwemurwere kana chidimbu chekubuda muchipatara chinoratidza zuva uye rudzi rwekuvhiyiwa kweaortic, uye uipe zvakananga kune varapi vehutano. Kuziva kana murwere ane yakazaruka ** aortobifemoral Dacron bypass graft **, ** interposition tube graft **, kana ** endovascular aortic stent-graft * inogamuchira VARA stent-graft yechipatara (Vateti yeVateti yeVate). Chikwata chekuvhiya ** uye ** CT Angiography scanner ** murwere asati atomboumburuka nepamusuwo.

Muti wesarudzo: acute hematemesis, melena, kana post-kurutsa kubuda ropa triage¶

flowchart TD
    Start["Kurutsa kweRopa kwakanyanya (Hematemesis), Kofi-Ground Emesis, Black Tarry Stool (Melena), kana Maroon Stool"] --> CheckAorta{"Nhanho 1: Ko Murwere Ane Nhoroondo yeAbdominal Aortic Aneurysm (AAA) Repair (Open Graft kana EVAR Stent), Aortoiliac Bypass, Inozivikanwa AAA, kana Pulsating Abdominal Mass?"}

    CheckAorta -->|"EHE (Kunyangwe dai kuvhiyiwa kwaive makore mashanu kusvika gumi nemashanu apfuura uye kubuda ropa kwaive kudiki kana kumiswa)"| HeraldAEF["SUSPECTED AORTOENTERIC FISTULA (AEF) HERALD BLEED: Dana 911 / 112 / 999 Pakarepo; Yambiro Vascular Surgery + Raira Pakarepo Multiphasic CT Angiogram (CTA) Pamberi Chero Endoscopy"]

    CheckAorta -->|"HAPANA inozivikanwa aortic graft kana aneurysm"| CheckVomitContext{"Nhanho 2: Ko Kubuda Kweropa Kwakatanga Pakarepo Mushure mekumanikidza Kudzokorodza kana Kurutsa?"}

    CheckVomitContext -->|"EHE: Kudzora nesimba kana kurutsa kwakatangira zviratidzo"| CheckMackler{"Nhanho 3: Tarisa Boerhaave Rupture vs. Mallory-Weiss Tear: Pane marwadzo 10/10 kubvarura chipfuva kana musana, kutadza kufema, kana kuputika kwemhepo pasi peganda remutsipa (crepitus)?"}

    CheckMackler -->|"EHE: Chifuva chakanyanya / kurwadziwa shure, dyspnea, kana mutsipa crepitus"| Boerhaave["SUSPECTED BOERHAAVE SYNDROME (TRANSMURAL ESOPHAGEAL RUPTURE): Dana Emergency Services Pakarepo; Yakasimba NPO (Kwete kana Kamwe Sip yeMvura), Gara Semi-Upright 30 kusvika 45 Degrees"]

    CheckMackler -->|"HAPANA marwadzo emuchipfuva kana dyspnea: Ropa rakatsvuka rakajeka mushure mekurutsa kwakati wandei"| MalloryWeiss["Anofungidzirwa Mallory-Weiss Mucosal Tear: Ramba Wakasimba NPO; Kutakura kuenda kuDhipatimendi reEmergency yeHemoglobin Check, IV Proton Pump Inhibitor, uye Endoscopic Evaluation."]

    CheckVomitContext -->|"HAPANA kudzokorora kusati kwatanga: Kurutsa kweropa kusingarwadzi, nzvimbo dzekofi, kana tsvina nhema."| CheckCirrhosis{"Nhanho 4: Ko Murwere Ane Chiropa Cirrhosis, Portal Hypertension, kana Heavy NSAID/Ulcer History?"}

    CheckCirrhosis -->|"Cirrhosis / Jaundice / Ascites KANA Ropa Rakawanda Ropa"| VaricesUlcer["ZVINOFUNGWA ESOPHAGEAL VARICES KUKUKA KANA ARTERIAL PEPTIC ULCER BLEED (DIEULAFOY): Dana Emergency Services Pakarepo; Recovery Position, Strict NPO"]

    HeraldAEF --> AEFProtocol["Pakarepo AEF Resuscitation Protocol: Strict Bed Rest, Zero Abdominal Palpation, Strict NPO, Permissive Hypotension (Target Systolic BP 80 kusvika 100 mmHg saka Clot Plug Haiputi), Emergent Endovascular Stent-Graft Relining (EVARtic Control Bridge)"]

Anatomy uye pathophysiology: nei iyo aortic graft ichipinda muchikamu chetatu che duodenum.¶

Kuti unzwisise kuti tsinga huru iri mu retroperitoneum inobatanidza sei zvakananga mukati megumbo, uye nei kubuda ropa kunoitika muzvikamu zviviri zvakasiyana (yakanyarara ** herald bleed ** inoteverwa ne ** catastrophic exsanguination ** ), zvinobatsira kuongorora anatomy yepakati pedumbu:

1. Mharadzano dzeanatomical pachikamu chechitatu cheduodenum (D3)¶

Muchimiro chemunhu, aorta yedumbu inomhanya ichidzika kumberi kwe lumbar spine mukati me retroperitoneal space. Pazasi pekwakabva tsinga dzetsvo (apo 95 muzana yeabdominal aortic aneurysms inoitika uye panosonwerwa masimbi ekuvhiya), chikamu chechitatu (chakatwasuka) cheduodenum (D3)** chinoyambuka chakatwasuka kubva kurudyi kuenda kuruboshwe ** chakananga kumberi kwe abdominal mutsara we abdominal aorta, abdominal aorta, abdominal line yakaparadzaniswa chete nepepa-yakaonda mutsara we retroperitoneal mafuta uye peritoneum.

• ** Yekutanga Aortoenteric Fistula (Kashoma, <10% of kesi):** Inoitika mumurwere ane isina kurapwa, isingashandiswi abdominal aortic aneurysm (kazhinji ane utachiona "mycotic" aneurysm, tuberculous kana syphilitic aortitis, kukuvara kwemwaranzi, kana pancreatic/duodenal bundu) uko kuwedzera aneurysm sac inokwesha kune imwe madziro maviri ega ega uye kuputika.
• Secondary Aortoenteric Fistula (Yakajairika, >90% yezviitiko): Inoitika ** mwedzi kusvika kumakore gumi nemashanu (yepakati 3 kusvika kumakore mashanu)** mushure mekuvhiyiwa kwakazaruka kugadziriswa kweabdominal aortic aneurysm ine yakarukwa kana yakarukwa **Dacron kana PTFE prosthetic graft **, kana mushure me endovascular aneurysm kugadzirisa (EVAR) ne-metallic tende. Maitiro maviri e synergistic akatakura mugero kubva kune aorta kupinda mudumbu:
• Relentless Mechanical Pulsation Pressure Necrosis: Kana jira rakatetepa rakaiswa pakati peprosthetic graft neduodenum panguva yekuvhiyiwa kwekutanga rikatetepa, mutsara wakaoma, unopuruzira suture weiyo synthetic graft unorovera kumadziro kumashure kweiyo yakatarwa yechitatu duodenum ka100,000 pazuva. Kwemakore, iyi mechanic jackhammering inokonzeresa ischemia uye maronda emudhuri weduodenal kudzamara isina kugadzirwa mafibhi egraft aburitswa mukati memukati me lumen.
• Low-Giredhi Perigraft Bacterial Infection: Kamwe kamwe microscopic intestinal bacteria (Escherichia coli, Enterococcus, Staphylococcus epidermidis, Streptococcus, Bacteroides, uye Candida) vanofamba vachipfuura nepakati peiyo thinned mudumbu reDatocrosa chronic biofilm yakatenderedza graft anastomosis, ichiburitsa mabhakitiriya maprotease anonyungudutsa aortic wall stitches uye kugadzira yakananga fistula chiteshi (** paraprosthetic-enteric ** kana ** aorto-duodenal fistula **).

2. Nzvimbo dzeAnatomical dzakabatwa muAortoenteric Fistula¶

Nepo chero chikamu chedumbu chedumbu chinobata aorta chinogona kunyungudika, kupararira kweanatomical kwakanyanyisa kunyura mukati meduodenum yakadzika:

1. ** Yechitatu uye Yechina Zvikamu zveDuodenum (D3 / D4): ** ** 75 kusvika 80 muzana ** yezvese zviitiko (nekuti D3 inosungirirwa isingazungunuke kuyambuka proximal aortic graft anastomosis ne ligament yeTreitz).
2. ** Jejunum uye Ileum (Small Intestine): ** ** 10 kusvika 15 muzana ** yemhosva.
3. Sigmoid Colon kana Cecum: 3 kusvika 5 muzana (kunyanya kana aortobifemoral bypass nhengo inopinda mu sigmoid colon iri kuruboshwe pelvis).
4. ** Dumbu kana Esophagus: ** ** 2 kusvika ku5 muzana ** ( thoracic aortic stent-grafts inopinda mukati mesophagus, inozivikanwa se ** aortoesophageal fistula **, iyo inopa ne ** Chiari's triad **: pakati-muthoracic kurwadziwa, sentinel fakisisis inomira shure kwemaawa ekupedzisira, sentinel fassasngume .

3. Iyo biomechanics ye "Herald Bleed" (Sentinel Bleed) uye nei ichimira yega.¶

Varwere, mhuri, uye kunyange varapi vasina ruzivo rwokuzviwanira vanowanzovhiringidzika neherald kubuda ropa: *“Gomba riri mutsinga huru yedumbu ringabuda sei kapu yeropa robva ramira roga roga?”

1. Microscopic initial mucosal pinhole: Kana iyo aortic suture line kana kuti pseudoaneurysm inotanga kupaza nemuscularis uye mucosa yechitatu duodenum, kuvhura kunowanzova 1 kusvika 3 millimeters yakafara kwete kubvarura-yakavhurika.
2. Arterial vasospasm uye transient hypotension: Kamwe kamwe jeti ye200 kusvika 500 milliliters (7 kusvika 17 ounces) yeropa retsinga richikwira muduodenum rinodonhedza systemic blood pressure (kazhinji ichikonzera kupera kwechinguva kufenda kana dzungu) uye inokonzeresa intense reflex smooth-muscle* muscle* muscle.
3. Kugadzirwa kweplatelet-fibrin thrombus plug yechinguvana: Kunyura kweropa uye fistula painodzikira, maplatelet nefibrin zvinokurumidza kubatirana mukati megwara rinorwadza riri pakati pechigadzirwa chegraft neduodenal mucosa, chichivhara buri sechivharo chiri mubhodhoro.
4. Kugaya uye kuputika kweplagi yethrombus (Hwindi Rakavharika): Kana kubuda ropa kwangomira, BP yomurwere inodzokera kune yakajairika (kana kuti inofambiswa zvakanyanya kana boka rechipatara rikaisa mabhomba emvura inopinza nekukurumidza kana kumuisira ropa kuti "aite" zviratidzo zvakakosha). Panguva imwe cheteyo, acidic yemudumbu muto, bile, uye ane simba pancreatic enzymes (trypsin, elastase, uye lipase) achigeza nguva dzose pamusoro peduodenal yakafumuka yeropa, ichinyungudutsa plug yefibrin nemakemikari. Mushure mehwindo rakavanda rinobva ku ** maawa mashomanana kusvika kumazuva akawanda ** (mu 50 muzana yezviitiko mukati me ** 6 kusvika kumaawa 24 **, uye mu 90 muzana mukati me ** 1 kusvika kumavhiki maviri **), clot plug inoputika zvachose, ichizarura pombi yakananga, yepamusoro-soro kubva paaorta ichipinda muura inogona kubuda ropa ** 1 kusvika 2 malita paminiti *

Kusiyanisa iyo 4 Yakakwira-Stakes Upper GI Kubuda ropa & Post-Kurutsa Emergency¶

Nekuti kubuda kweropa kwepamusoro uye mushure mekurutsa kwechipfuva / dumbu rekukurumidzira kunoda kupindira kwakasiyana kwakasiyana (kubva pakubvumidza hypotension uye CT angiography yeaortoenteric fistula kusvika nekuvhiyiwa kwechipfuva kuyerera kweBoerhaave syndrome), shandisa iyi tafura yekuenzanisa yekiriniki:

Clinical mireza mitsvuku: iyo Classic Triad uye subacute "Graft Sepsis" zviratidzo zvekunyevera¶

Kunyange zvazvo mabhuku ezvinyorwa achitsanangura ** Classic Triad yeAortoenteric Fistula ** inosanganisira ** (1) Kubuda ropa kwemudumbu, (2) Kurwadziwa kwepamuviri kana musana, uye (3) Chirwere chinoputika chinoputika mudumbu **, zvidzidzo zvinoratidza kuti zviratidzo zvose zvitatu zvinoonekwa pamwe chete mu ** 11 chete kusvika ku25 muzana yevarwere ** ( vascular scaruse anowanzodzivirira mushure mekuvhara maronda kana kuti scargause abdominal. huremu hunonzwisisika kubva pakunzwa). Pane kudaro, nyatsotarisa kune aya chaiwo-epasi rose emakiriniki maitiro:

1. Iyo "Herald Bleed + Syncope" Patani (Inoonekwa mu60% kusvika 80% yezviitiko)¶

• Murwere anongoerekana anzwa kudziya, kusvotwa, dzungu, kana kureruka, uye anogona ** kupera simba kwenguva pfupi (syncope) ** ari pauriri hwekugezera.
• Vanorutsa ropa diki diki kana "nzvimbo dzekofi" dzakasvibira, KANA kubuda ura kamwe chete kwemaroon ropa rakasvibira kana jet-black, tarry stool inonhuwa (melena).
• Mumaminitsi 15 kusvika ku30, ruvara rwavo runodzoka, kubuda ropa kunomira, uye vanosimbirira kuti vanzwe zvakanaka uye havadi kuenda kuchipatara. Iyi ndiyo nguva chaiyo apo kutakurwa kwechimbichimbi kunoponesa hupenyu hwavo.

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

Mune varwere vakawanda vane yechipiri aortoenteric fistula, mavhiki kana mwedzi kusati kwasvika donho rekutanga reropa rinooneka, duodenum inoputika inodonha mabhakitiriya pane prosthetic aortic graft, zvichiita ** chronic perigraft sepsis **: - **Kupisa kusingatsananguriki kusingatsananguriki, kudikitira husiku, kana kuomarara ** (kazhinji kusingazivikanwe kwemavhiki sechirwere chevhairasi, hutachiona hwehutachiwana, kana kupisa kusingazivikanwe kwakabva). - **Itsva, yakadzika, inofinha yepakati pe-lumbar musana kana periumbilical abdominal kurwadziwa ** (kunokonzerwa ne retroperitoneal kuzvimba uye pseudoaneurysm kuwedzera kudzvanya kurwisa lumbar musana). - Septic emboli kusvika kumakumbo kana zvigunwe ("Blue Toe Syndrome"): Magwamba madiki ane utachiona anotsemuka kubva pacolonized aortic graft uye achinaya mutsoka, zvichikonzera marwadzo epepuru pazvigunwe kana unilateral leg osteomyelitis. - Bacteremia ine zvipenyu zvemudumbu: Tsika dzeropa dzinokura Escherichia coli, Enterococcus, Streptococcus bovis/anginosus, Bacteroides, kana Candida mune chero murwere ane aortic graft is pathognomonic for aortoenteric fistula kana utachiona.

Misungo miviri yechipatara inouraya: iyo "Standard Endoscopy Trap" uye "Over-Resuscitation Trap"¶

Paunenge uchiperekedza mudiwa ane preaortic graft kune dhipatimendi rekukurumidzira, kuziva mbiri dzakakomba dzekiriniki dzinotsigirwa ne Society for Vascular Surgery (SVS) uye **European Society for Vascular Surgery (ESVS) ** inogona kubatsira kuve nechokwadi chekukurumidza, kurongeka kwakarongeka kunoitika:

Musungo wekutanga: Sei yakajairwa Upper Endoscopy (EGD) ichiwanzopotsa Aortoenteric Fistula¶

Muchigadziro chepamusoro chekubuda ropa, vanachiremba vekukurumidzira vanoshevedza gastroenterologist kuti vaite ** esophagogastroduodenoscopy (EGD) **. Zvisinei, gastroscope yakajairwa inongogadzirirwa kusvika ** yekutanga uye yechipiri zvikamu zve duodenum (D1 uye D2) **, ichimira pakatarisana neampulla yeVater. Nokuti ** 75 kusvika 80 muzana yeaortoenteric fistulas inowanikwa zvakadzika mukati mechikamu chechitatu nechechina che duodenum (D3 uye D4) **, EGD yenguva dzose inotarisa zvakakwana mune inopfuura hafu yevose aortoenteric fistula kesi.

Dzimwe njodzi mbiri dziripo panguva ye endoscopy: - Musungo we"Coincidental Ulcer": Varwere vakwegura vane tsinga dzetsinga vanowanzotora aspirin zuva nezuva kana mishonga inoderedza ropa uye vanowanzova negastritis isina kusimba, kukukurwa kwemudumbu, kana ronda diki remudumbu rapora. Kana endoscopist akaona gastritis yakapfava mudumbu uye amisa bvunzo pasina kuongorora nzira yose kusvika kune chikamu chechina che duodenum (kana pasina kuraira CT angiogram), vanogona nhema kuti herald inobuda ropa kune gastritis nepo aortic fistula inogara masendimita yakadzika yakagadzirira kuputika. - Kubvisa Herald Clot mukati meGI Lab: Kana endoscopist akasunda colonoscope refu yevana kana kusundira-enteroscope kwakadzika mukati mechikamu chetatu cheduodenum, anoona ropa rakasviba richiyerera rakanamira kumadziro eduodenal, uye *achiedza kurigeza, biopsy iyo, kana kuibvisa mukati meiyo svutugadzike abdominal aorta uye inokonzeresa pakarepo, inouraya exsanguination kure nekamuri yekuvhiya. Nokudaro, kana endoscopy ichiitwa kuti iongorore D3 / D4, mirayiridzo yekuvhiyiwa kwevascular inorayira kuti inofanira kuitwa ** mukamuri yekuvhiya neboka rekuvhiya revascular rakakweshwa mukati uye rakagadzirira pakarepo aortic clamping **.

Musungo wechipiri: Nei "Permissive Hypotension" ichichengetedza hupenyu iyo aorta isati yavharwa¶

Mukati mefafitera rakavanda mushure mekubuda ropa kweherald, jira replatelet-fibrin ndiro chete chipingamupinyi chinopatsanura ropa remutsinga wepamusoro kubva muvhu rakavhurika reura. Kana vanobatsira varwere vechipatara kana vashandi vepachipatara vakapa marita ekukurumidza intravenous saline boluses kana kuisa mayunitsi akawanda emasero matsvuku eropa kufambisa systolic yeropa remurwere kusvika. 130 to 150 mmHg, iyo hydrostatic pressure spike ichaita ** pop the clot plug kubva kunze kwefistula tract ** (sezvakangoita mukutsemuka kweabdominal aortic aneurysm).

• The Permissive Hypotension Rule: Chero bedzi murwere akamuka, akasvinura, uye achitaura (zvichiratidza kuyerera kweropa rakakwana kuuropi nemoyo), vascular trauma uye resuscitation guidelines target ** controlled permissive hypotension (systolic blood pressure of roughly 80 to 100 mmHg)** kushandisa zvinwiwa zvakangwarira, zvine titrated kusvikira chiremba wevascular avhara aorta kuburikidza ne endovascular stent-graft kana aortic cross-clamp.

Definitive hospital diagnosis uye kuvhiyiwa salvage: CTA, EVAR bhiriji, uye kuvakazve¶

Kana murwere anofungidzirwa kuti aortoenteric fistula asvika kudhipatimendi rekukurumidzira, chipatara chinomutsa nzira yekuvhiya yevascular nekukurumidza:

1. Gold-Standard First Test: Multiphasic CT Angiography (CTA) yeAbdomen nePelvis: Inoitwa pasina musiyano wakanaka wemuromo (uyo waizovanza kubuda ropa mukati me duodenum), CTA inotora pasi pemaminetsi mashanu, ine **85 kusvika 95 muzana yekunzwa **, uye inoratidza zviratidzo zvepathognomonic:
2. Ectopic perigraft gasi: Mhepo inoputika yakatenderedza aortic graft (yagara isingawanzoitiki kwemavhiki mana kusvika matanhatu mushure mekuvhiyiwa).
3. Kurasika kweaorto-duodenal mafuta ndege: Kusungirirwa kwakananga kweyechitatu duodenum mumadziro egraft anterior kana anastomotic pseudoaneurysm.
4. Active mutsauko extravasation: Mutsinga jetting kubva patsinga uchipinda muduodenal lumen.
5. ** Nhanho 1 Rescue: Endovascular Stent-Graft Relining ("EVAR Bridge kusvika Kuvhiyiwa"):** Pasi pe **SVS uye ESVS nhungamiro **, panzvimbo yekukurumidza kuvhurika laparotomy (inotakura 50 kusvika 70 muzana yekufa panguva yekubuda ropa), vanachiremba vevascular vanobaya femoral artery uye deploma stent-graft ** mukati meiyo yekare graft mhiri kwefistula (kana inflate a **REBOA ** aortic balloon mukusungwa). Mumaminitsi makumi maviri, kubuda ropa kunomira uye BP inodzikama. Broad-spectrum IV antibiotics (piperacillin-tazobactam kana meropenem + vancomycin) pamwe neIV antifungal (fluconazole kana micafungin) zvinotangwa pakarepo.
6. ** Danho rechipiri Definitive Repair:** Kana vamutswa, vanachiremba vanovhiya uye vogadzirisa duodenum yechitatu, vopinza mutsindo wakakora we greater omentum pakati pebowel neaorta, vobvisa iyo ine utachiona, uye kudzoreredza kuyerera kweropa kuburikidza ne extra-anatomic axillobifemoral bypassion kana kushandisa automoral bypassion** femoral-popliteal vein (NAIS), cryopreserved homograft, kana rifampin/silver-impregnated Dacron.

Nhamba dzenharaunda dzechimbichimbi uye zvirongwa zveagency¶

Inofungidzirwa kuti aortoenteric fistula inoda kukurumidza kutakurwa neamburenzi kuenda kuchikoro chepamusoro Vascular Surgery Center ine 24-hour CT Angiography, Hybrid Endovascular Operating Rooms, Massive Transfusion Protocol, uye Surgical Intensive Care:

• United States neCanada: Dial 911. Udza vanobatsira varwere kuti murwere ave neabdominal aortic aneurysm kugadziriswa uye anoda chipatara chikuru ne ** 24/7 Vascular Surgery ** (isina kumbobvira yakasununguka ER kana kiriniki yemunharaunda). Inotungamirirwa pasi pe **Society for Vascular Surgery (SVS) Practice Guidelines paKuchengeta Varwere vane Abdominal Aortic Aneurysm ** uye ** American Heart Association (AHA) Vascular Graft Infection Scientific Statements **.
• United Kingdom: Dhonza 999 yeChikamu ½ ambulensi kuenda kunzvimbo yakatarwa Arterial Vascular Hub. Inotungamirirwa pasi pe National Institute for Health and Care Excellence (NICE NG156) uye Vascular Society yeGreat Britain neIreland (VSGBI) mitemo.
• European Union: Dial 112. Inotungamirirwa pasi pe **European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines pamusoro peKutungamirirwa kweVascular Graft uye Endograft Infections **.
• Australia neNew Zealand: Dial 000 muAustralia kana 111 muNew Zealand. Inotungamirirwa pasi pe Australian neNew Zealand Society for Vascular Surgery (ANZSVS) maprotocol.
• India neAsia-Pacific: Dial 112 (kana 108 muIndia), 995 muSingapore, 119 muJapan neSouth Korea, kana 999 muMalaysia neHong Kong. Kumbira nzvimbo yepamusoro ine endovascular uye cardiothoracic/vascular surgical capability.

Mibvunzo inowanzo bvunzwa¶

Chii chinonzi "herald bleed" (sentinel kubuda ropa) mune aortoenteric fistula?¶

Kubuda ropa kweherald chiitiko chinonyengera, chinozvimisa chekubuda ropa mudumbu (zvakadai sokurutsa ropa shoma kana kuti kofi-pasi zvinhu, kupfuura imwe dema dema kana rima maroon stool, kana kufenda kwenguva pfupi) kunoitika mu60 kusvika 80 muzana yevarwere vane aortoenteric fistula kubuda ropa risati rarova njodzi. Kana iyo aortic graft ikatanga kuvhurika muduodenum, kudonha kweropa kwenguva pfupi uye arterial vasospasm inobvumira kuti ropa diki rivhare buri, kumisa kubuda ropa zvachose kwemaawa mashoma kusvika kumazuva mashoma. Kamwe asidhi yemudumbu, pancreatic enzymes, uye kukwira kweBP inonyungudika kana kuburitsa iyo isina kusimba clot plug, hombe, inotyisidzira upenyu arterial hemorrhage inotanga. Kufonera masevhisi ekukurumidzira panguva yakanyarara herald kubuda ropa hwindo ndiyo imwe hombe kufanotaura kwekupona.

Ko aortoenteric fistula inogona kuitika makore gumi kana gumi nemashanu mushure mekuvhiyiwa kweabdominal aortic aneurysm?¶

Ehe. Kunyange zvazvo imwe yechipiri aortoenteric fistulas inokura mukati memwedzi mishomanana yekuvhura aortic graft kuvhiyiwa kana endovascular stent-graft repair (EVAR), nguva yepakati kubva pakuvhiyiwa kwekutanga kweaortic kusvika pakugadzirwa kwefistula ndeyemakore matatu kusvika ku5, uye nyaya dzakanyatsonyorwa dzinogara dzichiitika 10, 15, kana kunyange makore makumi maviri mushure mekugadzirisa aneurysm. Kwehupenyu hwese hwemurwere mushure mehupi hweabdominal aortic graft kana stent process, chero chiitiko chekurutsa ropa, black tarry stools, maroon rectal kubuda ropa, kana fivha isina kutsanangurwa ine marwadzo epakati-mushure inofanira kurapwa sechinhu chinogona kuitika aortoenteric fistula kusvikira yabviswa neCT angiogram.

Sei CT Angiogram (CTA) iri nani pane yakajairwa Upper Endoscopy (EGD) seyekutanga bvunzo yeanofungidzirwa aortoenteric fistula?¶

Muyero wepamusoro we endoscopy scope wakagadzirirwa kuongorora gurokuro, dumbu, uye yekutanga neyechipiri zvikamu zve duodenum, ichimira kupfupi nedzakadzika yakachinjika yechitatu nechina zvikamu zve duodenum uko 75 kusvika 80 muzana yeaortoenteric fistulas iripo. Nekuda kweizvozvo, muitiro wepamusoro endoscopy inopotsa inopfuura hafu yeaortoenteric fistulas uye inogona kukanganisa kukanganisa kubuda kweropa pane gastritis yemudumbu. Kusiyana neizvi, multiphasic CT Angiogram (CTA) yedumbu uye pelvis inotora zvishoma kudarika 5 maminitsi, inotarisa aorta yose uye duodenum panguva imwe chete, uye inoona 85 kusvika ku95 muzana yefistulas nekuratidza mabhubhu emhepo akavharirwa kumativi eaortic graft, kurasikirwa kwemafuta ndege pakati pegrafti mukati mejeti kana kuputika mudumbu.

Sei vanobatsira varwere uye vanachiremba vekukurumidzira vachifanira kudzivirira kukwidza BP yakakwira zvakanyanya ("permissive hypotension") mushure mekubuda ropa kweherald?¶

Mushure mekunge mushambadzi angomira kubuda ropa ari ega, chinhu chega chinodzivirira aorta yemudumbu ine simba guru kubva pakupomba marita eropa muura hudiki igwamba diki, risina kusimba replatelet-fibrin rinovhara turakiti refistula. Kana zvikwata zvekurapa zvikapa hukasha hwemvura mutsinga kana kuisirwa ropa nekukurumidza kusunda systolic yeropa kusvika kune yakajairwa kana yakakwirira mwero (senge 130 kusvika 150 mmHg) chiremba anovhiya wevascular asati avhara aorta, iyo kamwe kamwe spike mu arterial pressure inogona kubuditsa buri rehele uye kuburitsa buri kubva muropa. Kunze kwekunge murwere ane uropi hwakanyanya ischemia, zvikwata zvevascular zvinochengetedza zvinyoro "permissive hypotension" (systolic blood pressure ye80 kusvika 100 mmHg, inongokwana kuchengetedza murwere uye kutaura) kusvikira endovascular stent-graft kana surgical clamp yakavhara aorta.

Sei munhu ane anofungidzirwa kuti anobuda ropa asinganwe mvura kana kunwa mushonga wemaronda emumuromo kumba?¶

Kutanga, kunwa mvura, kudya zvokudya, kana kunwa mishonga inonwiwa kunokurudzira dumbu, gallbladder, uye pancreas kuti ibudise hydrochloric acid, bile, uye simba reprotein-digesting enzymes (trypsin uye chymotrypsin) zvakananga muchikamu chetatu che duodenum, apo ivo vanonyungudutsa nekemikari yekudzivirira ropa clot plugging the aortic fistula. Chechipiri, murwere achada pakarepo musiyano CT scan uye emergency general anesthesia ye endovascular kana kuvhura aortic kuvhiyiwa, uko kuve nemvura kana chikafu mudumbu kunogadzira njodzi huru yekurutsa uye kushuvira mumapapu panguva yekupinda.

Chii chinonzi "EVAR zambuko" uye yakavandudza sei kurarama muaortoenteric fistula?¶

Kare, nzira chete yekumisa kubuda ropa kweaortoenteric fistula yaive yekukurumidzira yakavhurika laparotomy (kucheka dumbu rose, kuvhiya nepakati pemavanga mavanga, uye kuvhara aorta), iyo yakatakura kufa kwe50 kusvika 70 muzana kubva pakurasikirwa neropa uye kuvhunduka. Nhasi, vavhiyi vevascular vanoshandisa "EVAR zambuko": kuburikidza nekaburi ketsono mutsinga yezvidya, vanotsveta stent-graft yakavharwa mukati meiyo aortic graft yekare uye voiisa paburi mukati memaminitsi asingasviki makumi maviri. Izvi zvinokurumidza kumisa kubuda ropa kwemukati uye kudzikamisa murwere kuitira kuti kugadziriswa kwechokwadi kwe duodenum uye utachiona hwegraft hunogona kuitwa zvakachengeteka kana murwere anyatsogadziriswa.

Nzvimbo uye nhungamiro yepamutemo¶

• European Society for Vascular Surgery (ESVS, Europe): ESVS 2020 Clinical Practice Guidelines pamusoro peKutungamirirwa kweVascular Graft uye Endograft Infections (Chakfe et al., European Journal of Vascular and Endovascular Surgery, Chikamu cheSecondary Aortoenteric Fistula, yekutanga recognignication yeChstulable, herald diagnostics modality, endovascular EVAR bridging muvarwere vasina kugadzikana, uye in-situ vs. extra-anatomic reconstruction).
• Society for Vascular Surgery (SVS, United States): The Society for Vascular Surgery Practice Guidelines pamusoro peKuchengeta Varwere vane Abdominal Aortic Aneurysm (Chaikof et al., Journal of Vascular Surgery, kuongororwa uye hutungamiri huripo hwepuraimari nesekondari aortoenteric ero).
• American Heart Association (AHA, United States): Vascular Graft Infections, Mycotic Aneurysms, uye Endovascular Infections: A Scientific Statement kubva kuAmerican Heart Association (* Circulation*, microbiology, biofilm pathogenesis, antimicrobial and antifungal coverage, uye surgical management of aortoenteric).
• American College of Gastroenterology (ACG) & European Society of Gastrointestinal Endoscopy (ESGE): Clinical Guidelines pamusoro peKutungamirirwa kweAcute Upper Gastrointestinal Bleeding (kuzivikanwa kweaortoenteric fistula muvarwere vane prosthetic aortic grafts, zvisingakwanisi zvekutanga EG3zing / DTA mukusvika, kusvika kuD3D4).
• National Institute for Health and Care Excellence (NICE, United Kingdom): Abdominal Aortic Aneurysm: Diagnosis and Management (NICE Guideline NG156).

Mazano anoenderana¶

• Aortic dissection uye kuputika abdominal aortic aneurysm
• Kubuda ropa mudumbu, kurutsa ropa (hematemesis), uye melena
• Esophageal rupture (Boerhaave syndrome), Mallory-Weiss misodzi, uye kurutsa kurwadziwa kwechipfuva.
• Esophageal varices kuputika, cirrhosis kubuda ropa, uye hepatic encephalopathy
• Kuvhunduka kwekutanga rubatsiro uye kutenderera kweropa kudonha kuzivikanwa