I-Aortoenteric Fistula 'i-Herald Bleed' kunye ne-Massive Upper GI Hemorrhage Emva koLwando lwe-Aortic Graft¶

I-aortoenteric fistula (AEF) yintlekele, ngokukhawuleza ukudibanisa ubomi obungaqhelekanga phakathi kwe-aorta ye-abdominal ye-high-pressure kunye ne-gastrointestinal tract, ngokuqhelekileyo inxalenye yesithathu okanye yesine ye-duodenum apho iwela ngokuthe ngqo phezu komqolo. Ngaphezulu kweepesenti ze-90 zamatyala ** i-fistula yesibini ye-aortoenteric ** ephuhlisa iinyanga ukuya kwiminyaka eyi-15 emva kokuhlinzwa okuvulekileyo kwe-Dacron ukulungiswa kwe-graft okanye ukulungiswa kwe-endovascular stent-graft (EVAR) ye-aneurysm ye-aortic yesisu (AAA), xa i-pulsation ye-mechanical kunye ne-low-grade graft infections igubungula kwi-aodenal edongeni ngqo kwi-aorta ye-aortic. Ngenxa yokuba i-aortoenteric fistula enganyangwayo ibulala i-100 ekhulwini, ukusinda kuxhomekeke ngokupheleleyo ekuqondeni uphawu lwayo lwesilumkiso lwekliniki: ** "i-herald bleed" (i-sentinel bleed) **. Ukuya kuthi ga kwi- ** 60 ukuya kwi-80 ekhulwini yezigulane **, ukutshatyalaliswa kwentlekele kulandelwa yinto ebonakala incinci, i-self-limiting episode of vomiting encinci yegazi elibomvu elikhanyayo okanye i-coffee-ground material (**hematemesis **), ukudlula i-maroon emnyama okanye i-black tarry stool (*melena ** okanye ** i-hematocheziope * i-spell emfutshane) leyo iyazimisa yodwa xa ihlwili legazi lethutyana livala i-fistula tract encinci kunye noxinzelelo lwegazi lwehla. Ngaphakathi iiyure ukuya kwiintsuku ezimbalwa, ii-enzymes zokwetyisa kunye nokunyuka koxinzelelo lwegazi zinyibilika okanye zivuthele iplagi ye-thrombus eethe-ethe, ekhokelela kwinkanyamba, i-arterial hemorrhage engayekiyo emathunjini. Ukuba nabani na wake wanokungiswa kwe-aortic aneurysm yesisu, i-aortic bypass graft, okanye amava aziwayo e-aortic aneurysm yesisu nakuphi na ukopha kwesisu, isitulo esimnyama, okanye ukutyhafa okungachazwanga, fowunela indawo yakho. amanani kaxakeka ngoko nangoko. Ngelixa ulindele ukuthuthwa kwe-ambulensi, jonga kwakhona izikhokelo ezinxulumene nonxunguphalo ukuchithwa kwe-aorta kunye nokuqhekeka kwe-aortic aneurysm yesisu, ukopha emathunjini, ukugabha igazi, kunye ne-melena, kwaye ukuqhawuka kommizo (Boerhaave syndrome) kunye neenyembezi zeMallory-Weiss.

Ngenxa yokuba i-endoscopy ephezulu (EGD) ifikelela kuphela kwindawo yokuqala neyesibini ye-duodenum (ehlala ilahlekile i-fistula efihlwe nzulu kwinxalenye yesithathu ye-duodenum) kwaye ngenxa yokuba ukumpompa ulwelo olunobundlongondlongo kunokunyusa uxinzelelo lwegazi ngokwaneleyo ukuvuthela iplagi ye-thrombus ekhuselayo ngaphakathi kwe-herald ukopha, eyona nto ibalulekileyo yakho ibaluleke kakhulu ukukhupha i-pre-hospital1 i-paramedics, kunye nogqirha ongxamisekileyo amagama achanekileyo: "Esi sigulana sixhunywe kwi-aorta yesisu kwaye wopha nge-GI; makukhutshwe i-aortoenteric fistula herald bleed."**

Yenza oku ngoku¶

1. Fowunela inombolo yakho kaxakeka ngokukhawuleza kwaye ubhengeze iAortoenteric Fistula Herald Bleed. Cofa u-911 eUnited States naseKhanada, 112 kulo lonke elase-European Union, 999 eUnited Kingdom, 000 e-Australia, okanye ujonge uluhlu lwethu lwe amanani kaxakeka. Yitsho ngokucacileyo: * "Imeko engxamisekileyo yonyango: ukopha kwesisu kwisigulane esinembali yokulungiswa kwe-graft ye-aortic aneurysm yesisu. I-aortoenteric fistula ekrokrelwayo iphuma igazi."*
2. Kwanokuba ukugabha kwegazi okanye ukopha okuphuma embotsheni kuyekile ngokupheleleyo yaye umntu uziva ebuyele kwisiqhelo i-100 ekhulwini, kuphathe njengemeko yotyando olungxamisekileyo olukhawulezileyo. Ungaze ucinge ukuba isiqendu esinye selili elimnyama okanye ikomityi encinane yegazi eligatyiweyo yayisisilonda nje sesisu, i-hemorrhoid, okanye isisu esizicombululela ngokwaso. Elo xesha lokuzola elikhohlisayo yinkcazo yeklinikhi echanekileyo ye-herald bleed (apho i-vasospasm kunye nehlwili legazi elincinci lexeshana alibambeli ngokupheleleyo uxinzelelo olupheleleyo lwe-aorta yesisu).
3. Lalisa isigulane emhlane wabo (okanye uqengqele kwicala labo lasekhohlo kwindawo yokubuyisela ukuba unesicaphucaphu okanye ugabha) kwaye uthintele konke ukuma, ukuhlala, okanye ukuhamba. Ukuma kuwisa i-cerebral perfusion kunye nokwandisa ukuxinzelela kodonga lwangaphakathi kwesisu, okunokubangela i-syncope okanye ukuphazamisa ngomatshini i-fragile thrombus iplagi ye-apula phakathi kwe-firebral fibre.
4. Nyanzelisa i-NPO engqongqo (akukho nto ngomlomo: amanzi anothi, ukutya okuziro, i-zero oral antacids, kunye ne-zero blood thinners okanye amayeza eentlungu). Ukuginya ulwelo okanye ukutya kuvuselela i-gastric acid, i-bile, kunye ne-pancreatic proteolytic enzymes (trypsin kunye nechymotrypsin) ukugalela kwinxalenye yesithathu yekhemikhali ye-clogenesis Ukuxhuma i-aortic fistula kwaye kubangele ukukhutshwa ngokukhawuleza.
5. USUKUcinezela, ucofe, okanye uphulule isisu. Umntu obukeleyo okanye ugqirha ocinezela ngokunzulu embindini wesisu ukujonga ukuthamba okanye ubunzima bokuphefumla unokucinezela i-duodenum ngokuchasene ne-prosthetic graft ye-aorta engaphantsi kwaye ikhuphe ihlwili le-sentinel.
6. ** Fumana ikhadi lokufakela utyando lwesigulane okanye isishwankathelo sokukhutshwa kwesibhedlele esibonisa umhla kunye nohlobo lotyando lwe-aortic, kwaye ulunike ngokuthe ngqo kwi-paramedics.** Ukwazi ukuba isigulane sivulekile ** i-aortobifemoral ye-Dacron bypass graft **, i- **interposition tube graft , okanye ** i-endovascular aortic stent-graft * ifumana zombini i-Varste yesibhedlele i-Varste i-Varste i-Activar Iqela lotyando kunye ne-CT Angiography scanner phambi kokuba isigulane sigqithe neengcango.

Umthi wesigqibo: i-hematemesis ebukhali, i-melena, okanye i-triage yokopha emva kokugabha¶

flowchart TD
    Start["Ukugabha okukrakra kweGazi (iHematemesis), i-Emesis yeKofu-Ground, i-Black Tarry Stool (iMelena), okanye iSitulo seMaroon"] --> CheckAorta{"Inyathelo 1: Ngaba isigulane sineMbali ye-Abdominal Aortic Aneurysm (AAA) yokulungiswa (i-Graft evulekileyo okanye i-EVAR Stent), i-Aortoiliac Bypass, i-AAA eyaziwayo, okanye i-Pulsating Abdominal Mass?"}

    CheckAorta -->|"EWE (Nokuba utyando lwaluneminyaka emi-5 ukuya kweli-15 eyadlulayo kwaye ukopha kwakuncinci okanye kuyekile)"| HeraldAEF["I-AORTOENTERIC FISTULA (AEF) ESELELWEYO I-HERALD BLEED: Tsalela umnxeba 911 / 112 / 999 Ngoko nangoko; Yazisa ngoTyando lweVascular + Oda ngoko nangoko Multiphasic CT Angiogram (CTA) phambi kwayo nayiphi na i-Endoscopy"]

    CheckAorta -->|"AKUKHO uxhulumaniso lwe-aorta lwaziwayo okanye i-aneurysm"| CheckVomitContext{"Inyathelo lesi-2: Ngaba ukopha kuqale kwangoko emva kokuBuya ngenkani okanye ukugabha?"}

    CheckVomitContext -->|"EWE: Ukurhoxa ngamandla okanye ukugabha kwandulela iimpawu"| CheckMackler{"iNyathelo 3: Jonga iBoerhaave Rapture vs. Mallory-Weiss Tear: Ingaba kukho intlungu ebuhlungu 10/10 yesifuba okanye umqolo obuhlungu, ukuphelelwa ngumphefumlo, okanye ukuqhekeka komoya phantsi kwesikhumba sentamo (crepitus)?"}

    CheckMackler -->|"EWE: Isifuba esibuhlungu / intlungu ebuhlungu, i-dyspnea, okanye i-neck crepitus"| Boerhaave["I-BOERHAAVE SYNDROME ESESIKHANJWAYO (UKUQHUKA KWEEMSOPHAGAGEAL OKUPHILAYO): Tsalela umnxeba iiNkonzo eziNgxamisekileyo ngoko nangoko; I-NPO engqongqo (Nokuba iSiphuphu esinye saManzi), Hlala uSemi-Uthe tye 30 ukuya kuma-45 iDigri"]

    CheckMackler -->|"AKUKHO zintlungu zesifuba okanye i-dyspnea: Igazi elibomvu eliqaqambileyo emva kokugabha okuqhelekileyo"| MalloryWeiss["Umrhanelwa weMallory-Weiss Mucosal Tear: Gcina ngokungqongqo iNPO; UThutho oluya kwiSebe likaNgxamiseko lokuHlola iHemoglobin, i-IV Proton Pump Inhibitor, kunye noVavanyo lwe-Endoscopic"]

    CheckVomitContext -->|"AKUKHO ukuphindaphinda kwangaphambili: Ukugabha igazi okuzenzekelayo, indawo yekofu, okanye ilindle elimnyama."| CheckCirrhosis{"Inyathelo lesi-4: Ngaba iSigulana sine-Cirrhosis yesibindi, i-Portal Hypertension, okanye i-NSAID enzima/iMbali yesilonda?"}

    CheckCirrhosis -->|"Isifo sokuqhawuka kwesibindi / iNjandisi / Ukuqaqanjelwa OKANYE Igazi eliKhulu eliKhulu"| VaricesUlcer["IZINDABA EZINGQINELWAYO ZOKUQHUKA OKANYE KWEZINDUNA ZOKUKHUPHA KWE-PEPTIC (DIEULAFOY): Tsalela umnxeba weeNkonzo zikaNgxamiseko ngoko nangoko; Isikhundla soBuyiselo, iNPO engqongqo"]

    HeraldAEF --> AEFProtocol["I-Protocol yokuvuselela i-AEF ngokukhawuleza: I-Strict Bed Rest, i-Zero Abdominal Palpation, i-NPO engqongqo, i-Permissive Hypotension (Ithagethi ye-Systolic BP 80 ukuya kwi-100 mmHg ngoko i-Clot Plug Ayiphuli), Emergent Endovascular Stent-Graft Relining (EVARtic Control Bridge) okanye i-Open Aor Bridge"]

I-Anatomy kunye ne-pathophysiology: kutheni i-aorta graft iguguleka kwinxalenye yesithathu ye-duodenum¶

Ukuqonda indlela i-artery enkulu kwi-retroperitoneum idibanisa ngokuthe ngqo kwi-digestive tract, kwaye kutheni ukuphuma kwegazi kwenzeka kwizigaba ezibini ezihlukeneyo (i-ezolile ** i-herald bleed ** ilandelwa ngu ** i-catastrophic exsanguination **), kunceda ukuhlolisisa i-anatomy yesisu esiphakathi:

1. Ukunqumla kwe-anatomical kwisahlulo sesithathu se-duodenum (D3)¶

Kwi-anatomy yomntu, i-aorta yesisu ihamba ngokuthe nkqo phambi kwe-lumbar spine ngaphakathi kwendawo ye-retroperitoneal. Ngaphantsi nje kwemvelaphi yemithambo yezintso (apho i-95 yepesenti ye-aortic aneurysms yesisu yenzeke kwaye apho uqhaqho loqhaqho lweprosthetic luthungelwa endaweni), inxalenye yesithathu (ethe tye) ye-duodenum (D3)** iwela ngokuthe tye ukusuka ekunene ukuya ekhohlo ** ngokuthe ngqo ngaphaya komphambili we-prosthetic ye-prosthetic ye-prosthetic yahlulwe kuphela kwiphepha-elincinci lamafutha e-retroperitoneal kunye ne-peritoneum.

• I-Fistula yokuqala ye-Aortoenteric (Enqabileyo, <10% yamatyala): Yenzeka kwisigulane esine engaphathwanga, engasetyenziswanga isisu esine-aortic aneurysm (idla ngokuba yintsholongwane ye-"mycotic" aneurysm, i-tuberculous okanye i-syphilitic aortitis, ukwenzakala okubangelwa yi-radiation, okanye i-pancreatic/duodenal tumor) apho i-aneurysm sac ekhulayo ikhuhla ngokuthe ngqo kwiindonga ezimbini ze-duode kunye ne-duode.
• I-Fistula ye-Aortoenteric yesibini (Eqhelekileyo, >90% yamatyala): Yenzeka iinyanga ukuya kwi-15+ iminyaka (i-median 3 ukuya kwi-5 iminyaka) emva kokulungiswa kotyando oluvulekileyo lwe-aorta yesisu ene-aorta ene-knitted okanye ephothiweyo **I-Dacron okanye i-PTFE prosthetic graft **, okanye emva ukulungiswa kwe-aneurysm ye-endovascular (EVAR) intente ene-metallic. Iindlela ezimbini ze-synergistic zithwele itonela ukusuka kwi-aorta ukuya emathunjini:
• I-Relentless Mechanical Pulsation Pressure Necrosis: Ukuba i-tissue ebhityileyo esongelayo ebekwe phakathi kwe-prosthetic graft kunye ne-duodenum ngexesha lotyando lwangaphambili iyancipha, umgca oqinileyo, oshukumisayo we-suture wokwenziwa ubetha kudonga olungasemva lwe-duodenum yesithathu esisigxina amaxesha angama-100,000 ngosuku. Ngokuhamba kweminyaka, le jackhammering yomatshini ibangela uxinzelelo lwe-ischemia kunye nezilonda kudonga lwe-duodenal de imicu ye-synthetic graft ibonakale ngqo ngaphakathi kwilumen yamathumbu.
• Ukosuleleka kweBhaktiriya yoHlelo oluPhantsi lwePerigrafti: Xa ibhaktiriya ebonakele emathunjini (Escherichia coli, Enterococcus, Staphylococcus epidermidis, Streptococcus, Bacteroides, kunye ne-Candida) idlulela kuhlobo lwe-datocrode ye-datocrotic ethe kratya kwi-Datocrodenal i-biofilm engapheliyo ejikeleze i-graft anastomosis, ikhupha i-proteases ye-bacterial echitha i-host stitches eludongeni lwe-aortic kwaye idale umjelo othe ngqo we-fistula (** paraprosthetic-enteric ** okanye ** i-aorto-duodenal fistula **).

2. Iziza ze-anatomical ezichaphazelekayo kwi-Aortoenteric Fistula¶

Ngelixa naliphi na icandelo lomzila wesisu ochukumisa i-aorta inokutshatyalaliswa, ukusabalalisa kwe-anatomical kugxininiswe ngokugqithiseleyo kwi-duodenum enzulu:

1. Izahlulo zeSithathu nezeSine zeDuodenum (D3 / D4): 75 ukuya kwi-80 ipesenti yazo zonke iimeko (kuba i-D3 ibopheleleke ngokungashukumiyo kwi-proximal aortic graft anastomosis yi-ligament ye-Treitz).
2. ** I-Jejunum kunye ne-Ileum (I-Intestine encinci): ** ** i-10 ukuya kwi-15 ipesenti ** yamatyala.
3. ** I-Sigmoid Colon okanye i-Cecum: ** ** i-3 ukuya kwi-5 ipesenti ** (ngokukodwa xa i-aortobifemoral bypass i-aortobifemoral ikhupha kwi-colon ye-sigmoid kwi-pelvis yasekhohlo).
4. **Isisu okanye i-Esophagus: ** ** i-2 ukuya kwi-5 ekhulwini ** (i-thoracic aortic stent-grafts iguguleka phakathi kwe-esophagus, eyaziwa ngokuba yi-**aortoesophageal fistula **, ebonisa nge- ** Chiari's triad **: intlungu ephakathi kwe-thoracic, i-sentinel fassination emva kweeyure ze-extension ye-arterial, i-sentinel fassasngume kunye ne-artial arterial).

3. I-biomechanics ye "Herald Bleed" (i-Sentinel Bleed) kwaye kutheni iyazimisa ngokwayo.¶

Izigulana, iintsapho, kwanabezonyango abangenamava basoloko bebhideka ngokuphuma kwegazi iherald: *“Inokwenzeka njani into yokuba umngxuma okwi-aorta yesisu wophe ikomityi yegazi ize iyeke yodwa?”

1. I-Microscopic initial mucosal pinhole: Xa umgca we-aorta we-aortic suture okanye i-pseudoaneurysm uqala ugqobhoze kwi-muscularis kunye ne-mucosa ye-duodenum yesithathu, ukuvuleka kudla ngokuba yi-1 ukuya kwi-3 yeemilimitha ububanzi* kunokukrazuka okuvulekileyo.
2. I-Arterial vasospasm kunye ne-hypotension edlulayo: Ijethi ngequbuliso ye-200 ukuya kwi-500 milliliters (7 ukuya kwi-17 ounces) yegazi le-arterial elitsibela kwi-duodenum yehlisa uxinzelelo lwegazi lwenkqubo (ehlala ibangela ukupela okuncinci okanye isiyezi) kwaye ibangela i-reflex ebukhali ye-smooth-muscle** i-vasodemosis ejikeleze udonga
3. Ukwenziwa kweplagi yethutyana yeplagi yeplatelet-fibrin thrombus: Njengoko uxinzelelo lwegazi lutsiba kunye nefistula incipha, iiplatelets kunye nefibrin zijiya ngokukhawuleza ngaphakathi kwendlela yokugruzuka phakathi kwe-synthetic graft kunye ne-duodenal mucosa, ivala umngxuma njengesithinteli ebhotileni.
4. Ukwetyisa kunye nokuvuthela kweplagi ye-thrombus (Ifestile eLatent): Emva kokuba ukopha kunqumama, uxinzelelo lwegazi lwesigulana lubuyela kwisiqhelo (okanye luqhutywe ngakumbi ukuba iqela lasesibhedlele likhupha ngokukhawuleza ulwelo lwe-intravenous boluses okanye litofelwe igazi ukuze "lilungele" iimpawu ezibalulekileyo). Ngaxeshanye, ijusi yesisu esine-asidi, i-bile, kunye ne-pancreatic enzymes enamandla (**trypsin, elastase, kunye ne-lipase **) ihlamba ngokuqhubekayo phezu kwecala elivezwe le-duodenal yehlwili legazi, ukunyibilika kweekhemikhali iplagi ye-fibrin. Emva kwefestile efihliweyo ukusuka ** kwiiyure ezimbalwa ukuya kwiintsuku ezininzi ** (kwiipesenti ezingama-50 zamatyala ngaphakathi ** 6 ukuya kwiiyure ze-24 **, kunye neepesenti ezingama-90 ngaphakathi kwe- ** 1 ukuya kwiiveki ezi-2 ** ), iplagi yehlwili ivuthela ngokupheleleyo, ivule umbhobho othe ngqo, ophakamileyo woxinzelelo olusuka kwi-aorta ukuya emathunjini angakwazi ukopha ** 1 ukuya kwi-2 iilitha * ngomzuzu *

Ukwahlula i-4 ye-High-Stakes ephezulu ye-GI yokopha kunye ne-Post-Vomiting Emergency¶

Ngenxa yokuba ukopha kwesisu esingasentla kunye neemeko ezingxamisekileyo zesifuba / zesisu emva kokugabha zifuna ungenelelo olukhawulezileyo olwahlukileyo (ukususela kwi-permissive hypotension kunye ne-CT angiography ye-aortoenteric fistula ukuya kwimijelo yesifuba ngokukhawuleza ye-Boerhaave syndrome), sebenzisa le theyibhile yothelekiso lweklinikhi:

Iiflegi ezibomvu zeklinikhi: I-Classic Triad kunye ne-subacute "Graft Sepsis" iimpawu zokulumkisa¶

Ngelixa iincwadi zezifundo zichaza **I-Classic Triad ye-Aortoenteric Fistula ** equka **(1) ukopha kweGastrointestinal, (2) Ubuhlungu besisu okanye umqolo, kunye (3) Ubunzima besisu obuchukumisayo **, izifundo zibonisa ukuba zontathu iimpawu zivela kunye ** kuphela kwi-11 ukuya kwi-25 ipesenti yezigulane ** (i-scars scaruse) ikhusela i-scars-post ubunzima obuphathekayo ekubeni buve). Endaweni yoko, jonga kakhulu ezi patheni zeklinikhi zokwenyani:

1. Ipateni ethi "Herald Bleed + Syncope" (Ibonwe kwi-60% ukuya kwi-80% yamatyala)¶

• Isigulana ngesiquphe siziva sishushu, sicaphukile, sinesiyezi, okanye sinentloko encinci, kwaye sinokuthi sife isiqaqa ngokufutshane (syncope) kumgangatho wokuhlambela.
• Bagabha igazi elincinane elibomvu okanye "iindawo zekofu" ezimnyama, OKANYE bakhuphe ithumbu elinye legazi* elimaroon elimnyama okanye i-jet-black, i-tarry stool enuka kakubi (melena)**.
• Kwimizuzu nje eli-15 ukusa kwengama-30, umbala wabo uyabuya, ukopha kuyayeka, yaye bazingisa ukuba baziva bephilile yaye abafuni ukuya esibhedlele. Eli lixesha kanye apho isithuthi sikaxakeka sisindisa ubomi babo.

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

Kwizigulane ezininzi ezine-aortoenteric fistula yesibini, iiveki okanye iinyanga ngaphambi kokuba kuvele ithontsi lokuqala legazi elibonakalayo, i-duodenum eroding ivuza ibhaktheriya kwi-prosthetic aortic graft, ebangela ** i-perigraft engapheliyo sepsis **: - **Imikhuhlane engachazwanga, ukubila ebusuku, okanye ukuqina ** (idla ngokuchazwa kakubi kangangeeveki njengesigulo sentsholongwane, usulelo lomchamo, okanye umkhuhlane ongaziwayo). - *Intlungu entsha, enzulu, ekruqulayo phakathi kwe-lumbar okanye iintlungu zesisu esiswini ** (ezibangelwa kukuvuvukala kwe-retroperitoneal kunye nokwandiswa kwe-pseudoaneurysm ecinezela i-lumbar spine). - I-septic emboli ukuya emilenzeni okanye ezinzwaneni ("Blue Toe Syndrome"): Amahlwili amancinci awosulelwe yi-aorta aqhawuka kwi-colonized aorta graft aze awele ezinyaweni, abangele amabala amfusa abuhlungu kwiinzwane okanye i-unilateral leg osteomyelitis. - ** -Bacteremia nezilwanyana zamathumbu: * Iinkcubeko zegazi ezikhulay Escherichi coli , *Enteococcus, Streptococcus bovis/anginosus, Bacteroides, okanye Candida kuso nasiphi na isigulane esine-aortic graft yi-pathognomonic ye-aortoenteric fistula okanye i-graft.

Imigibe emibini yezibhedlele ebulalayo: "I-Standard Endoscopy Trap" kunye ne "Over-Resuscitation Trap"¶

Xa uhamba nomntu othandekayo kunye ne-aortic graft yangaphambili kwisebe likaxakeka, ukwazi imigibe emibini ebalulekileyo yeklinikhi ekhuthazwa yi ** I-Society for Vascular Surgery (SVS) ** kunye ** Umbutho waseYurophu we-Vascular Surgery (ESVS) ** unokunceda ukuqinisekisa ukuba ukhathalelo olukhawulezayo, olulungelelanisiweyo lwenzeka:

Umgibe woku-1: Kutheni i-Endoscopy ePhakamileyo (EGD) ihlala iphoswa yi-Aortoenteric Fistula¶

Kwinkqubo yesiqhelo yokuphuma kwegazi emathunjini, oogqirha bexakeka babiza i-gastroenterologist ukwenza i-*esophagogastroduodenoscopy (EGD)**. Nangona kunjalo, i-gastroscope esemgangathweni yenzelwe kuphela ukufikelela ** isahlulo sokuqala kunye nesesibini se-duodenum (D1 kunye ne-D2) **, ukuma ngqo malunga ne-ampulla yeVater. Ngenxa yokuba ** i-75 ukuya kwi-80 ipesenti ye-fistula ye-aortoenteric ifumaneka ngokunzulu kwisahlulo sesithathu nesine se-duodenum (D3 kunye ne-D4) **, i-EGD yesiqhelo ibonakala iqhelekile ngokupheleleyo ngaphezu kwesiqingatha sazo zonke iimeko ze-aortoenteric fistula.

Kukho iingozi ezimbini ezongezelelweyo ngexesha le-endoscopy: - I-"Ilcer Ulcer" Trap: Izigulana ezisele zikhulile ezinemithambo zihlala zithatha yonke imihla i-aspirin okanye i-blood thiners kwaye zihlala zinegastritis engephi, ukhukuliseko lwesisu oluncinci, okanye isilonda esincinci esiphilisiweyo esiswini. Ukuba i-endoscopist ibona i-gastritis ethambileyo esiswini kwaye imise uviwo ngaphandle kokuhlola yonke indlela ukuya kwinxalenye yesine ye-duodenum (okanye ngaphandle kokuyalela i-CT angiogram), banokuthi ngobuxoki i-herald bleed kwi-gastritis ngelixa i-aortic fistula ihlala i-intshi enzulu ilungele ukuphuka. - Ukukhupha iHerald Clot ngaphakathi kwe-GI Lab: Ukuba ugqirha we-endoscopist utyhala ikholonoskopu ende yabantwana okanye i-push-enteroscope nzulu kwisiqingatha sesithathu se-duodenum, ibone ihlwili legazi elintywilayo elincanyatheliswe kudonga lwe-duodenal, kwaye *izame ukuyihlamba, i-biopsy yayo, okanye iyikhuphele iplagi yesuti ngaphakathi kwiplagi I-aorta yesisu kwaye ibangele ukukhutshwa ngokukhawuleza, okubulalayo kude negumbi lotyando. Ngoko ke, ukuba i-endoscopy yenziwa ukuhlola i-D3 / D4, izikhokelo zotyando lwe-vascular ziyalela ukuba zenziwe ** kwigumbi lokusebenza kunye neqela lotyando lwe-vascular scrubbed kwaye lulungele ukukhawuleza kwe-aortic clamping **.

Umgibe 2: Kutheni "i-Permissive Hypotension" isindisa ubomi ngaphambi kokuba i-aorta itywinwe¶

Ngexesha lefestile efihlakeleyo emva kokuba i-herald iphuma igazi, ihlwili eethe-ethe ye-platelet-fibrin kuphela komqobo owahlula igazi elinoxinzelelo oluphezulu lwe-aorta kwilumen evulekileyo yamathumbu. Ukuba i-paramedics okanye abasebenzi basesibhedlele balawula iilitha ze-saline boluses ngokukhawuleza okanye batofe iiyunithi ezininzi zeeseli ezibomvu zegazi ezipakishweyo ukuqhuba uxinzelelo lwegazi lwe-systolic ukuya kuthi ga. 130 to 150 mmHg, loo spike ye-hydrostatic pressure spike iya kukhupha iplagi yehlwili ngqo kwi-fistula tract ** (kanye njengokuba i-aneurysm ye-aorta yesisu eqhekekileyo).

• Umgaqo we-Permissive Hypotension Rule: Logama nje isigulane siphaphile, sithe qwa, kwaye sithetha (esibonisa ukuhamba kwegazi okwaneleyo kwingqondo nentliziyo), ukuxhwaleka kwemithambo kunye nezikhokelo zokuvuselela okujoliswe kuko okulawulwa yi-hypotension evumayo (uxinzelelo lwegazi lwe-systolic ngokurhabaxa). 80 to 100 mmHg) usebenzisa ulwelo olunenyameko, olunetitrated de ugqirha wotyando womthambo uvale i-aorta nge-endovascular stent-graft okanye i-aortic cross-clamp.

Ukuxilongwa kwesibhedlele esicacileyo kunye nokusindiswa kotyando: CTA, EVAR ibhuloho, kunye nokwakhiwa kwakhona¶

Xa isigulana esikrokreleka ukuba yi-aortoenteric fistula sifika kwisebe likaxakeka, isibhedlele sivula indlela yotyando olukhawulezayo:

1. Uvavanyo lokuQala lweGold-Standard: Multiphasic CT Angiography (CTA) yeSisu kunye nePelvis: Yenziwe ** ngaphandle ** ngaphandle kokuchasana kakuhle komlomo (okuya kufihla ukopha okusebenzayo ngaphakathi kwe-duodenum), i-CTA ithatha ngaphantsi kwemizuzu ye-5, ine- ** 85 ukuya kwi-95 yeepesenti uvakalelo **, kwaye ityhila iimpawu ze-pathognomonic:
2. Irhasi ye-Ectopic perigraft: Amaqamza omoya ajikeleze i-aorta graft (ihlala ingaqhelekanga ngaphezu kweeveki ezi-4 ukuya kwezi-6 emva kotyando).
3. Ukulahleka kwenqwelomoya yamafutha e-aorto-duodenal: Ukubotshelelwa ngokuthe ngqo kwe-duodenum yesithathu kudonga lwangaphambili lwegrafti okanye i-anastomotic pseudoaneurysm.
4. Uchasaniso olusebenzayo lwe-extravasation: Uchasaniso lwe-intravenous ukusuka kwi-aorta ukuya kwi-lumen ye-duodenal.
5. Inqanaba loku-1 lokuhlangula: I-Endovascular Stent-Graft Relining ("i-EVAR Bridge ukuya kuTyando"): Ngaphantsi kwe **SVS kunye nezikhokelo ze-ESVS , endaweni ye-laparotomy evulekileyo ngokukhawuleza (ethwala i-50 ukuya kwi-70 yeepesenti yokufa ngexesha lokuphuma kwegazi elisebenzayo), oogqirha botyando be-vascular bahlaba i-femoral artery and deplovascular artery i-stent-graft ngaphakathi kwi-graft endala ngapha kwe-fistula (okanye faka i- **REBOA ** ibhaluni ye-aorta ekubanjweni). Kwimizuzu engama-20, ukopha kuyayeka kwaye noxinzelelo lwegazi luyazinza. I-Broad-spectrum IV antibiotics (piperacillin-tazobactam okanye i-meropenem + vancomycin) kunye ne-IV antifungal (**fluconazole okanye i-micafungin **) ziqaliswa ngokukhawuleza.
6. Inqanaba lesi-2 Ulungiso oluQinisekayo: Emva kokuba bevusiwe, oogqirha botyando baqhawula kwaye balungise i-duodenum yesithathu, bafake i-flap eshinyeneyo ye-i-omentum enkulu phakathi kwamathumbu kunye ne-aorta, bacofe igrafti yokwenziwa eyosulelekileyo, kwaye babuyisele ukuhamba kwegazi ngokusebenzisa i-axillobifemoral bypassion eyongezelelweyo ye-anatomic axillobifemoral bypassion** okanye ngokusebenzisa i-femoral-popliteal vein (NAIS), i-cryopreserved homograft, okanye i-rifampin / i-silver-impregnated Dacron.

Iinombolo zengingqi zikaxakeka kunye neeprothokholi ze-arhente¶

I-fistula ye-aortoenteric ekrokrelwayo ifuna ukuthuthwa kwe-ambulensi ngokukhawuleza ukuya kwindawo ephakamileyo Iziko loTyando lweVascular elixhotyiswe nge-24-hour CT Angiography, Hybrid Endovascular Operating Rooms, Massive Transfusion Protocol, kunye ne-Surgery Intensive Care:

• I-United States neKhanada: Cofa 911. Xelela abagadi be-paramedics ukuba isigulane sinokulungiswa kwe-aortic aneurysm yesisu kwaye sidinga isibhedlele esikhulu nge- ** 24/7 i-Vascular Surgery ** (akuzange kube yi-ER ekhululekile okanye ikliniki yoluntu). Ukulawulwa phantsi kwe- ** I-Society for Vascular Surgery (SVS) Izikhokelo zokuSebenza malunga noNyango lweZigulana ezine-Abdominal Aortic Aneurysm ** kunye ne ** I-American Heart Association (AHA) i-Vascular Graft Infection Scientific Statements **.
• EUnited Kingdom: Cofa 999 ukuze ufumane i-ambulensi ye-½ ngokukhawuleza ukuya kwindawo ekhethiweyo **I-Arterial Vascular Hub **. Ukulawulwa phantsi kwe-*Iziko leSizwe lezeMpilo kunye nokuGqwesa ngokuGqwesileyo (NICE NG156) kunye ne Vascular Society of Great Britain and Ireland (VSGBI) protocol.
• I-European Union: Cofa 112. Ukulawulwa phantsi ** Umbutho waseYurophu we-Vascular Surgery (ESVS) 2020 Izikhokelo zokuSebenza kweKlinikhi kuLawulo lwe-Vascular Graft kunye ne-Endograft Infections **.
• Ostreliya neNew Zealand: Cofa 000 e-Australia okanye 111 eNew Zealand. Ilawulwa phantsi kwe-*Australia kunye neNew Zealand Society for Vascular Surgery (ANZSVS) protocol.
• ** I-Indiya kunye ne-Asia-Pacific: ** Ukudayela ** 112 ** (okanye ** 108 ** eIndiya), ** 995 ** eSingapore, ** 119 ** eJapan naseMzantsi Korea, okanye ** 999 ** eMalaysia naseHong Kong. Cela iziko lemfundo ephakamileyo elineendovascular and cardiothoracic/vascular surgical capabilities.

Imibuzo edla ngokubuzwa¶

Yintoni i-"herald bleed" (i-sentinel bleed) kwi-aortoenteric fistula?¶

I-herald bleed yinto ekhohlisayo, eyazikhawulelayo yokopha kwesisu (njengokugabha umlinganiselo omncinci wegazi okanye i-coffee-ground material, ukugqithisa i-tarry enye emnyama okanye i-maroon stool emnyama, okanye ukuphelelwa amandla ngokufutshane) okwenzeka kwi-60 ukuya kwi-80 yeepesenti yezigulane ezine-aortoenteric fistula ngaphambi kokuhlaselwa yintlekele. Xa i-aortic graft iqala ukuvula umngxuma kwi-duodenum, ukuhla okwethutyana koxinzelelo lwegazi kunye ne-vasospasm ye-arterial kuvumela ihlwili legazi elincinci ukuba livale umngxuma, linqande ukopha ngokupheleleyo kangangeeyure ezimbalwa ukuya kwiintsuku ezimbalwa. Nje ukuba i-asidi yesisu, ii-enzymes ze-pancreatic, kunye nokunyuka koxinzelelo lwegazi zinyibilike okanye zivuthulule iplagi yehlwili eethe-ethe, iqala ukopha okukhulu okusongela ubomi. Ukufowunela iinkonzo ezingxamisekileyo ngexesha lefestile ethe cwaka ye-herald bleed yeyona nto iphambili yokusinda.

Ngaba i-aortoenteric fistula inokwenzeka kwi-10 okanye i-15 iminyaka emva kotyando lwe-aortic aneurysm yesisu?¶

Ewe. Nangona ezinye iifistula zesibini ze-aortoenteric zikhula kwiinyanga ezimbalwa zokuvula utyando lwe-aortic graft okanye ukulungiswa kwe-endovascular stent-graft (EVAR), ixesha eliphakathi ukusuka kwi-aorta yasekuqaleni ukuya kwi-fistula formation yi-3 ukuya kwi-5 iminyaka, kwaye iimeko ezibhalwe kakuhle zenzeka rhoqo kwi-10, i-15, okanye iminyaka engama-20 emva kokulungiswa kwe-aneurysm. Ubomi besigulane emva kwayo nayiphi na i-aorta yesisu ye-graft okanye inkqubo ye-stent, nayiphi na isiqendu segazi lokuhlanza, i-black tarry stools, i-maroon rectal blood, okanye umkhuhlane ongachazwanga kunye nentlungu ephakathi kwe-back-back kufuneka iphathwe njenge-aortoenteric fistula enokubakho de ikhutshwe yi-CT angiogram.

Kutheni i-CT Angiogram (CTA) ingcono kune-Endoscopy yoMgangatho ePhezulu (EGD) njengovavanyo lokuqala lwe-aortoenteric fistula ekrokrelekayo?¶

Umda we-endoscopy osemgangathweni ophezulu wenzelwe ukuhlola ummizo, isisu, kunye nenxalenye yokuqala neyesibini ye-duodenum, umise mfutshane kwindawo enzulu yesithathu kunye neyesine ye-duodenum apho i-75 ukuya kwi-80 yeepesenti yazo zonke i-aortoenteric fistula zikhoyo. Ngenxa yoko, i-endoscopy ephezulu yesiqhelo ilahlekelwa ngaphezu kwesiqingatha sayo yonke i-aortoenteric fistula kwaye inokugxeka ngephutha ukopha kwi-gastritis yesisu. Ngokwahlukileyo koko, i-multiphasic CT Angiogram (CTA) yesisu kunye ne-pelvis ithatha ngaphantsi kwemizuzu emi-5, ibona yonke i-aorta kunye ne-duodenum ngaxeshanye, kwaye ifumanisa i-85 ukuya kwi-95 yeepesenti ye-fistula ngokubonisa amaqamza omoya abanjwe malunga ne-aortic graft, ukulahlekelwa kwendiza ye-fat phakathi kwe-graft okanye i-jetineta kwi-bowel.

Kutheni i-paramedics kunye noogqirha bexesha likaxakeka kufuneka bakuphephe ukunyusa uxinzelelo lwegazi oluphezulu kakhulu ("permissive hypotension") emva kokuba i-herald iphuma?¶

Kanye emva kokuba i-herald bleed iye yazimisa ngokwayo, ekuphela kwento ethintela i-aorta yesisu enoxinzelelo oluphezulu ekumpompeni iilitha zegazi kumathumbu amancinci lihlwili elincinci, elibuthathaka leplatelet-fibrin eliplaga iphecana le-fistula. Ukuba amaqela ezonyango anika i-aggressive intravenous fluid boluses okanye utofelo-gazi olukhawulezileyo ukutyhala uxinzelelo lwegazi lwe-systolic lunyuke luye kumanqanaba aqhelekileyo okanye aphezulu (afana ne-130 ukuya kwi-150 mmHg) phambi kokuba ugqirha wotyando avale i-aorta, eso spike ngequbuliso kuxinzelelo lwe-arterial sinokukhupha ihlwili kunye ne-hole hemorrhage ngaphandle komatshini. Ngaphandle kokuba isigulane sine-ischemia ebuchosheni obukhulu, amaqela e-vascular agcina i-"permissive hypotension" ethambileyo (uxinzelelo lwegazi lwe-systolic lwe-80 ukuya kwi-100 mmHg, ngokwaneleyo ukugcina isigulane siphapheme kwaye sithetha) de i-endovascular stent-graft okanye i-clamp yotyando itywine i-aorta.

Kutheni le nto umntu okrokrelwa ukuba wopha angasela amanzi okanye athathe iyeza lomlomo lezilonda ekhaya?¶

Okokuqala, amanzi okusela, ukutya ukutya, okanye ukuthatha amayeza omlomo kuvuselela isisu, i-gallbladder, kunye ne-pancreas ukuba ikhuphe i-hydrochloric acid, i-bile, kunye ne-protein-digesting enzymes enamandla (i-trypsin kunye ne-chymotrypsin) ngokuthe ngqo kwisahlulo sesithathu se-duodenum, apho bachitha i-blood clot ekhuselayo iplagi i-aortic fistula. Okwesibini, isigulane siya kufuna ukuchasana ngokukhawuleza kwe-CT scan kunye ne-anesthesia jikelele engxamisekileyo ye-endovascular okanye utyando oluvulekileyo lwe-aortic, apho ukuba nolwelo okanye ukutya esiswini kudala umngcipheko omkhulu wokuhlanza kunye nokunqwenela kwimiphunga ngexesha lokungena.

Yintoni "ibhuloho ye-EVAR" kwaye iphucule njani ukusinda kwi-aortoenteric fistula?¶

Ngaphambili, ekuphela kwendlela yokunqanda ukopha kwe-aortoenteric fistula yayiyi-laparotomy evulekileyo kaxakeka (ukusika isisu sivuleke, ukuhlanjululwa kwezicubu ezixineneyo, kunye nokubamba i-aorta), eyayithwala i-50 ukuya kwi-70 yepesenti yokufa ngenxa yokulahleka kwegazi kunye nokothuka. Namhlanje, oogqirha botyando lwemithambo basebenzisa "ibhulorho ye-EVAR": ngokuhlatywa kwenaliti encinci kwi-groin artery, batyibilika i-endovascular stent-graft egqunyiweyo ngaphakathi kwegrafti endala ye-aorta kwaye bayisasaze kumngxuma ongaphantsi kwemizuzu engama-20. Oku kuyeka ngokukhawuleza ukopha kwangaphakathi kwaye kuzinzise isigulane ukuze ukulungiswa okuqinisekileyo kwe-duodenum kunye ne-graft echaphazelekayo kunokwenziwa ngokukhuselekileyo xa isigulane sivuselelwe ngokupheleleyo.

Imithombo kunye nezikhokelo ezisemthethweni¶

• ** Umbutho waseYurophu we-Vascular Surgery (ESVS, iYurophu): ** *ESVS 2020 Izikhokelo zokuSebenza kweKliniki kuLawulo lwe-Vascular Graft kunye ne-Endograft Infections * (Chakfe et al., * I-European Journal ye-Vascular and Endovascular Surgery *, iCandelo kwiSekondari ye-Aortoenteric ye-Aortoenteric, i-fistula ye-fistula ye-multi-diagnostic yokuqala, i-herald-diagnostic yokuqala indlela, i-endovascular EVAR bridging kwizigulana ezingazinzanga, kunye ne-in-situ vs. extra-anatomic reconstruction).
• ** Umbutho we-Vascular Surgery (SVS, eUnited States): ** * UMbutho weZikhokelo zoCwangciso lwe-Vascular Surgery kwi-Capital of Patients nge-Abdominal Aortic Aneurysm * (Chaikof et al., * I-Journal ye-Vascular Surgery *, ukuxilongwa kunye nolawulo oluvelayo lwe-primary and secondary aortoenteric ero).
• ** I-American Heart Association (AHA, eUnited States): ** * I-Vascular Graft Infections, i-Mycotic Aneurysms, kunye ne-Endovascular Infections: INkcazo yeNzululwazi evela kwi-American Heart Association * (* Ukujikeleza *, i-microbiology, i-biofilm pathogenesis, i-antimicrobial and antifungal coverage, kunye nolawulo lotyando lwe-aortoenteric).
• ** I-American College ye-Gastroenterology (ACG) kunye ne-European Society of Gastrointestinal Endoscopy (ESGE): ** *Izikhokelo zeKlinikhi kuLawulo lwe-Acute Upper Gastrointestinal Bleeding * (ukuqatshelwa kwe-aortoenteric fistula kwizigulane ezine-prosthetic aortic grafts, ukulinganiselwa kwe-EG3D esemgangathweni kunye nokufikelela kuqala kwi-D3D4 kunye nokufikelela kuqala kwi-DTA).
• Iziko leSizwe lezeMpilo kunye neNkathalelo eGqwesileyo (NICE, eUnited Kingdom): I-Abdominal Aortic Aneurysm: Ukuxilongwa kunye noLawulo (iSikhokelo se-NICE NG156).

Izikhokelo ezinxulumeneyo¶

• I-aortic dissection kunye ne-aortic aneurysm yesisu esiqhekezayo
• Ukopha emathunjini, ukuhlanza igazi (hematemesis), kunye ne-melena
• Ukuqhawuka komqala (Boerhaave syndrome), iinyembezi zikaMallory-Weiss, kunye nokugabha iintlungu zesifuba
• Ukuqhawuka komqala wommizo, ukopha kwe-cirrhosis, kunye ne-hepatic encephalopathy
• Uncedo lokuqala lokothuka kunye nokuqondwa kokuwa kokujikeleza kwegazi