I-Aortoenteric Fistula 'Herald Bleed' kanye Nokopha Okukhulu Kwe-GI Ephezulu Ngemva Kokuhlinzwa Kwe-Aortic Graft¶

I-aortoenteric fistula (AEF) iyinhlekelele, ukuxhumana okungavamile okusongela ukuphila ngokushesha phakathi kwe-aorta yesisu enomfutho ophezulu kanye nomgudu wamathumbu oseduze, ngokuvamile ingxenye yesithathu noma yesine ye-duodenum lapho iwela khona ngokuqondile phezu komgogodla. Ngaphezulu kwamaphesenti angu-90 wezigameko ama-fistula esibili e-aortoenteric akhula izinyanga kuya eminyakeni engu-15 ngemva kokuhlinzwa okuvulekile ukulungiswa kwegraft ye-Dacron noma ukulungiswa kwe-stent-graft ye-endovascular (EVAR) ye-aortic aneurysm yesisu (AAA), lapho ukushaya kwemishini kanye ne-low-grade graft infection kuguguleka imbobo ye-aodenal ngqo. Ngenxa yokuthi i-aortoenteric fistula engelashiwe ibulala ngamaphesenti angu-100, ukusinda kuncike ngokuphelele ekuqapheleni uphawu lwayo lwesixwayiso somtholampilo: the "herald bleed" (sentinel bleed). Ku-60 kuya kumaphesenti angu-80 eziguli, ukukhishwa kwenhlekelele kwandulelwa isiqephu esibonakala sincane, esizibekela umkhawulo sokuhlanza inani elincane legazi elibomvu elikhanyayo noma i-coffe-ground material (hematemesis), ukudlula i-maroon emnyama noma i-tarry stool (melena noma i-hematocheziaint) i-spell emfushane* lokho kuzima kukodwa lapho ihlule lesikhashana legazi lixhuma umgudu omncane we-fistula futhi umfutho wegazi wehla. Phakathi kwamahora kuya ezinsukwini ezimbalwa, ama-enzyme okugaya ukudla kanye nomfutho wegazi okhuphukayo kuncibilika noma kukhiphe lelo pulaki le-thrombus elintekenteke, okuholela ekopheni kwe-arterial okuguquguqukayo okungavimbeki emathunjini. Uma noma ubani wake waba nokulungiswa kwe-aortic aneurysm yesisu, i-aorta bypass graft, noma i-aortic aneurysm eyaziwayo yesisu noma yikuphi ukopha emathunjini, indle emnyama, noma ukuquleka okungachazwanga, shayela indawo yangakini izinombolo eziphuthumayo ngokushesha. Ngenkathi usalinde ukuthuthwa kwe-ambulensi, buyekeza imihlahlandlela yezimo eziphuthumayo ehlobene i-aortic dissection kanye ne-aortic aneurysm yesisu ephukile, ukopha emathunjini, igazi lokuhlanza, kanye ne-melena, futhi ukuqhuma kommizo (i-Boerhaave syndrome) kanye nezinyembezi zikaMallory-Weiss.

Ngenxa yokuthi i-endoscopy yangenhla evamile (EGD) ifinyelela kuphela ezingxenyeni zokuqala nezesibili ze-duodenum (evame ukushoda nge-fistula efihlwe ekujuleni kwengxenye yesithathu ye-duodenum) nangenxa yokuthi ukumpompa uketshezi olungena emthanjeni kungakhuphula umfutho wegazi ngokwanele ukuze kuqhunyiswe ipulaki ye-thrombus evikelayo ngaphakathi kwe-herald ukopha, isenzo sakho esibaluleke kakhulu ukutshela ngaphambi kokuya esibhedlela1 abezimo eziphuthumayo, nodokotela wezimo eziphuthumayo amagama aqondile: "Lesi siguli sixhunywe kwi-aorta yesisu futhi sopha nge-GI; khipha i-aortoenteric fistula ememezela ukopha."**

Yenza lokhu manje¶

1. Shayela inombolo yakho yasendaweni yezimo eziphuthumayo ngokushesha futhi umemezele i-Aortoenteric Fistula Herald Bleed. Shayela u-911 e-United States nase-Canada, 112 yonkana i-European Union, 999 e-United Kingdom, 000 e-Australia, noma uhlole uhlu lwethu izinombolo eziphuthumayo. Yisho ngokucacile: "Izimo eziphuthumayo zezokwelapha: ukopha emathunjini esigulini esinomlando wokulungiswa kwe-graft ye-aorta yesisu. I-aortoenteric fistula herald yopha."
2. Ngisho noma ukuhlanza kwegazi noma ukopha komgudu kunqanyulwe ngokuphelele futhi umuntu ezizwa ebuyele esimweni esivamile ngamaphesenti angu-100, kuphathe njengesimo esiphuthumayo esiphuthumayo sokuhlinzwa. Ungalokothi ucabange ukuthi isiqephu esisodwa sendle emnyama noma inkomishi encane yegazi elihlanziwe kwakuyizilonda zesisu, ukopha, noma isifo sofuba esizixazululela sona sodwa. Leso sikhathi sokuzola esikhohlisayo siyincazelo eqondile yomtholampilo ye-herald bleed (lapho i-vasospasm nehlule legazi lesikhashana libambezela kancane ukucindezela okugcwele kwe-aorta yesisu).
3. Lalisa isiguli emhlane waso (noma usigingqe ohlangothini lwaso lwesobunxele lapho sisesimweni sokululama uma sicanuzela inhliziyo noma sihlanza) futhi wenqabele ukuma, ukuhlala, noma ukuhamba. Ukusukuma kwehlisa ukugcwala kobuchopho futhi kwenyuse ukungezwani kodonga lwangaphakathi kwesisu, okungase kuqalise i-syncope noma kuphazamise ngokuzenzakalelayo i-thrombus ephukile phakathi kwe-thrombus nepulagi ye-athomu.
4. Phoqelela i-NPO eqinile (akukho lutho oluphuma emlonyeni: amanzi anguziro, ukudla okuyiziro, ama-antacid omlomo angenawo, kanye nemithi enciphisa igazi noma yezinhlungu). Ukugwinya uketshezi noma ukudla kuvuselela i-gastric acid, i-bile, kanye nama-enzyme e-pancreatic proteolytic (trypsin ne-chymotrypsin) ukuze athululele engxenyeni yesithathu ye-clortlyde ye-duogenesis yekhemikhali ukuxhuma i-aortic fistula futhi kubangele ukukhishwa ngokushesha.
5. Ungacindezeli, uphephethe, noma usihlikihle isisu. Obukele noma udokotela ocindezela ajule phakathi nesisu ukuze ahlole ukuthamba noma ukushaya kwenhliziyo angakwazi ukuyicindezela ngokomzimba i-duodenum ngokumelene ne-aortic graft engaphansi futhi akhiphe ihlule legazi.
6. Thola ikhadi lesiguli lokufakelwa ngokuhlinzwa noma isifinyezo sokukhishwa esibhedlela esibonisa idethi nohlobo lokuhlinzwa kwe-aortic, futhi ulunikeze ngqo abezimo eziphuthumayo. Ukwazi ukuthi isiguli sine-aortobifemoral Dacron bypass graft** evulekile , i-interposition tube graft, noma i-endovascular aortic stent-graft ethola i-VARcular ethola kokubili esibhedlela) Ithimba labahlinzayo** kanye ne-CT Angiography scanner ngaphambi kokuba isiguli size sigingqike naseminyango.

Isihlahla sesinqumo: i-hematemesis ebabazekayo, i-melena, noma i-triage yokopha ngemva kokuhlanza¶

flowchart TD
    Start["Ukuphalaza Kakhulu Kwegazi (i-Hematemesis), i-Coffee-Ground Emesis, i-Black Tarry Stool (i-Melena), noma i-Maroon Stool"] --> CheckAorta{"Isinyathelo 1: Ingabe Isiguli Sinomlando We-Abdominal Aortic Aneurysm (AAA) Repair (Open Graft noma EVAR Stent), Aortoiliac Bypass, AAA eyaziwayo, noma i-Pulsating Abdominal Mass?"}

    CheckAorta -->|"YEBO (Ngisho noma ukuhlinzwa kwakuneminyaka emi-5 kuya kweyi-15 edlule futhi ukopha kwakukuncane noma kumisiwe)"| HeraldAEF["OKUSOLWA I-AORTOENTERIC FISTULA (AEF) HERALD BLEED: Shayela ku-911 / 112 / 999 Ngokushesha; Yazisa Ukuhlinzwa Kwemithambo + Oda Ngokushesha I-Multiphasic CT Angiogram (CTA) Ngaphambi Kwanoma Iyiphi I-Endoscopy"]

    CheckAorta -->|"AKUKHO ukuxhunyelelwa kwe-aortic okwaziwayo noma i-aneurysm"| CheckVomitContext{"Isinyathelo sesi-2: Ingabe Ukopha Kwaqala Ngokushesha Ngemva Kokuphinda Ngenkani Noma Ukuhlanza?"}

    CheckVomitContext -->|"YEBO: Ukuhlehla okunamandla noma ukuhlanza kwandulela izimpawu"| CheckMackler{"Isinyathelo sesi-3: Hlola i-Boerhaave Rapture vs. Mallory-Weiss Tear: Ingabe kukhona isifuba esidabukile esingu-10/10 noma iqolo, ukuphelelwa umoya, noma ukuklayeka komoya ngaphansi kwesikhumba sentamo (crepitus)?"}

    CheckMackler -->|"YEBO: Ubuhlungu obukhulu besifuba/iqolo, i-dyspnea, noma i-neck crepitus"| Boerhaave["OKUSOLWA I-BOERHAAVE SYNDROME (UKUKHIPHA KOMQOKA WE-TRANSMURAL): Shayela Izinkonzo Eziphuthumayo Ngokushesha; I-NPO Eqinile (Hhayi Ngisho Nokumpompoza Okukodwa Kwamanzi), Hlala Uqondile Ngokuqondile 30 kuya ku-45 Degrees"]

    CheckMackler -->|"AKUKHO ubuhlungu besifuba noma i-dyspnea: Igazi elibomvu ngokugqamile ngemva kokuhlanzwa okujwayelekile okuningana"| MalloryWeiss["I-Mallory-Weiss Mucosal Tear esolwayo: Gcina i-Strictly NPO; Ezokuthutha eziya eMnyangweni Wezimo Eziphuthumayo ukuze Uhlole I-Hemoglobin, i-IV Proton Pump Inhibitor, kanye nokuhlolwa kwe-Endoscopic"]

    CheckVomitContext -->|"AKUKHO ukubuyiswa kabusha: Ukuphalaza kwegazi okuzenzakalelayo, indawo yekhofi, noma indle emnyama"| CheckCirrhosis{"Isinyathelo sesi-4: Ingabe Isiguli Sine-Liver Cirrhosis, Portal Hypertension, noma I-NSAID Enzima/Umlando Wezilonda?"}

    CheckCirrhosis -->|"I-Cirrhosis / Jaundice / Ascites NOMA Igazi Eligelezayo Elikhulu"| VaricesUlcer["OKUSOLWA UKUQHUKA KWEMIHLANGANO YOMTHETHO NOMA ISISUNDA SE-PEPTIC ESEMTHETHWENI (DIEULAFOY): Shayela Izinkonzo Eziphuthumayo Ngokushesha; Isikhundla Sokubuyisela, I-NPO Eqinile"]

    HeraldAEF --> AEFProtocol["Iphrothokholi Esheshayo Yokuvuselela I-AEF: I-Strict Bed Rest, I-Zero Abdominal Palpation, I-Strict NPO, I-Permissive Hypotension (Target Systolic BP 80 kuya ku-100 mmHg ukuze I-Clot Plug Ingaphumi), I-Emergent Endovascular Stent-Graft Relining (EVARtic Control Bridge) noma i-Open Aortic Bridge)"]

I-Anatomy kanye ne-pathophysiology: kungani i-aorta graft iguguleka engxenyeni yesithathu ye-duodenum¶

Ukuze uqonde ukuthi umthambo omkhulu we-retroperitoneum uxhumeka kanjani ngqo emgudwini wokugaya ukudla, nokuthi kungani ukopha kwenzeka ngezigaba ezimbili ezihlukene (ethule herald bleed elandelwa i-catastrophic exsanguination), kuyasiza ukuhlola i-anatomy yesisu esimaphakathi:

1. Isiphambano se-anatomical engxenyeni yesithathu ye-duodenum (D3)¶

Ku-anatomy yomuntu, i-aorta yesisu igijima iqonde phansi ngaphambili kwe-lumbar spine ngaphakathi kwendawo ye-retroperitoneal. Ngaphansi nje kancane komsuka wemithambo yezinso (lapho amaphesenti angu-95 e-aortic aneurysms yesisu eyenzeka khona nalapho ukuxhunyelelwa kokwenziwa kokuhlinzwa kuthungelwa khona), ingxenye yesithathu (evundlile) ye-duodenum (D3)** iwela ngokuvundlile isuka kwesokudla iye kwesobunxele *ngokuqondile inqamule ngaphambili komugqa wesisu (i-abdominal aorta) kanye ne-aorta yesisu ihlukaniswe kuphela ungqimba oluncane lwephepha lwamafutha e-retroperitoneal kanye ne-peritoneum.

• I-Primary Aortoenteric Fistula (Okuvamile, <10% kwezimo): Kuvela esigulini esine engelashiwe, engasebenzi ye-aorta aneurysm (ngokuvamile i-aneurysm ethi "mycotic" enegciwane, i-tuberculous noma i-syphilitic aortitis, ukulimala okubangwa yi-radiation, noma isimila se-pancreatic/duodenal) lapho isaka le-aneurysm elikhulayo ligudla i-aneurysm eyodwa kuze kube izindonga ezimbili ze-duode ephukile.
• I-Fistula yesibili ye-Aortoenteric (Ejwayelekile, >90% yezimo): Kuvela izinyanga kuya eminyakeni engu-15+ (iminyaka eyi-midian engu-3 kuye kwengu-5) ngemva kokuhlinzwa okuvulekile kwe-aorta aneurysm yesisu ngokulukiwe noma okulukiwe I-Dacron noma i-PTFE prosthetic graft, noma ngemva ukulungiswa kwe-endovascular aneurysm (EVAR) ene-metallic-graft. Izindlela ezimbili ze-synergistic zathwala umhubhe osuka ku-aorta uye emathunjini:
• I-Relentless Mechanical Pulsation Pressure Necrosis: Uma ukugoqa kwezicubu ezincanyana ezibekwe phakathi kwe-prosthetic graft ne-duodenum ngesikhathi sokuhlinzwa kwasekuqaleni kuncipha, umugqa oqinile, ophehlayo osondele we-graft yokwenziwa ushaya odongeni olungemuva lwe-duodenum yesithathu egxilile izikhathi ezingu-100,000 ngosuku. Ngokuhamba kweminyaka, le jackhammering eyimishini ibangela i-ischemia yokucindezela kanye nezilonda zodonga lwe-duodenal kuze kube yilapho imicu engenalutho yokwenziwa ivezwa ngokuqondile ngaphakathi kwelumen yamathumbu.
• I-Low-Grade Perigraft Bacterial Infection: Uma amagciwane amathumbu amancane engabonakali (Escherichia coli, Enterococcus, Staphylococcus epidermidis, Streptococcus, Bacteroides, kanye Candida) adlulela ohlotsheni oluncane lwe-mucosa ye-Dantocrodenal i-biofilm engapheli ezungeze i-graft anastomosis, ikhulula ama-bacterial proteases ancibilikisa umthungo wodonga lwe-aorta futhi adale umzila oqondile we-fistula (paraprosthetic-enteric noma aorto-duodenal fistula).

2. Iziza ze-anatomical ezithintekile ku-Aortoenteric Fistula¶

Nakuba noma iyiphi ingxenye yendlela yokugaya ukudla ethinta i-aorta ingaguguleka, ukusatshalaliswa kwe-anatomical kugxile kakhulu ku-duodenum ejulile:

1. Izingxenye Zesithathu Nezine Ze-Duodenum (D3 / D4): 75 kuya kumaphesenti angu-80 azo zonke izimo (ngoba i-D3 iboshelwe ngokunganyakazi kuyo yonke i-proximal aortic graft anastomosis ngomsipha we-Treitz).
2. I-Jejunum ne-Ileum (Amathumbu Amancane): amaphesenti angu-10 kuya kwangu-15 wamacala.
3. I-Sigmoid Colon noma i-Cecum: 3 kuya ku-5 amaphesenti (ikakhulukazi lapho isitho se-aortobifemoral bypass siguguleka kukholoni ye-sigmoid ku-pelvis yangakwesobunxele).
4. Isisu noma umminzo: 2 kuya kumaphesenti angu-5 (ama-thoracic aortic stent-grafts aguguleka phakathi nomgudu, owaziwa ngokuthi i-aortoesophageal fistula, eveza I-Chiari's triad: ubuhlungu obuphakathi kwethoracic, ubuhlungu be-sentinel ngemuva kwesikhathi, i-sentinel fassangumetal hemorrhage).

3. I-biomechanics ye-"Herald Bleed" (Sentinel Bleed) nokuthi kungani iyazimela¶

Iziguli, imindeni, ngisho nabelaphi abangenalwazi bavame ukukhungatheka ngenxa yokopha kwe-herald: *“Ingenzeka kanjani imbobo e-aorta yesisu ikhiphe inkomishi yegazi bese izima yodwa?”

1. Iphinikhodi ye-mucosal yokuqala emincane emincane: Lapho ulayini we-aortic suture ogugulekayo noma i-pseudoaneurysm iqala ngokugqashuka kumisipha kanye ne-mucosa ye-duodenum yesithathu, ukuvuleka kuvame ukuba ngu-1 kuya ku-3 wamamilimitha ububanzi* kunokuba kudabuke okuvuleke kakhulu.
2. I-Arterial vasospasm kanye ne-hypotension yesikhashana: Ijethi engazelelwe engamamililitha angama-200 kuye kwangama-500 (amawunsi angu-7 kuya kwangu-17) egazi le-arterial eliphumela ku-duodenum lehlisa umfutho wegazi wesistimu (okuvame ukubangela ukuquleka okufushane noma isiyezi) futhi ibangele i-reflex ejulile yemisipha ebushelelezi* ne-vasodetula*
3. Ukwakheka kwepulagi ye-platelet-fibrin thrombus yesikhashana: Njengoba umfutho wegazi ucwila futhi i-fistula incipha, ama-platelet ne-fibrin zibophana ngokushesha ngaphakathi kwendlela ehlukunyezwayo phakathi kwe-graft yokwenziwa kanye ne-duodenal mucosa, ivale imbobo njengesivalo ebhodleleni.
4. Ukugaya nokufutheka kwepulaki ye-thrombus (Iwindi Elicashile): Lapho ukopha sekunqamukile, umfutho wegazi wesiguli ubuyela kwesejwayelekile (noma uqhutshwa phezulu nakakhulu uma ithimba lesibhedlela likhipha amabhomu oketshezi olungena emthanjeni ngokushesha noma limpompela igazi ukuze "lijwayele" izimpawu ezibalulekile). Ngesikhathi esifanayo, ijusi yesisu ene-asidi, i-bile, nama-enzyme e-pancreatic anamandla (trypsin, elastase, ne-lipase) ageza ngokuqhubekayo ohlangothini lweduodenal oluveziwe lwehlule legazi, luncibilikisa ipulaki ye-fibrin ngamakhemikhali. Ngemva kwewindi elicashile elisukela ku-emahoreni ambalwa kuya ezinsukwini ezimbalwa (ngamaphesenti angu-50 ezimweni phakathi ** kwamahora angu-6 kuya kwangu-24**, futhi ngamaphesenti angu-90 phakathi ** neviki elingu-1 kuya kwangu-2**), ipulaki yehlule liphephetheka ngokuphelele, livule ipayipi eliqondile, elinomfutho ophezulu osuka ku-aorta uye emathunjini angakwazi ukopha 1 kuya ku-2 amalitha ngomzuzu

Ukuhlukanisa I-4 High-Stakes Upper GI Yopha kanye Nezimo Eziphuthumayo Zangemuva Kokuhlanza¶

Ngenxa yokuthi ukopha kwamathumbu aphezulu kanye nezimo eziphuthumayo zesifuba/zesisu ngemva kokuhlanza zidinga ukungenelela okusheshayo okuhluke kakhulu (kusukela ku-permissive hypotension kanye ne-CT angiography ye-aortoenteric fistula kuya ekuphumeni ngokushesha kwesifuba nge-Boerhaave syndrome), sebenzisa leli thebula lokuqhathanisa lomtholampilo:

Amafulegi abomvu omtholampilo: I-Classic Triad nezimpawu eziyisixwayiso ze-"Graft Sepsis".¶

Nakuba izincwadi zokufunda zichaza I-Classic Triad ye-Aortoenteric Fistula ehlanganisa (1) ukopha emathunjini, (2) ubuhlungu besisu noma iqolo, kanye (3) nesisindo esiphuphumayo sesisu, ucwaningo lubonisa ukuthi zontathu izimpawu zivela ndawonye kumaphesenti angu-11 kuphela kuya kwangu-25 eziguli (i-scariuse evame ukuvimbela izicubu ze-evascular noma i-scarg-raft abscet) isisindo esizwakalayo esizwakalayo). Kunalokho, bhekisisa lawa maphethini omtholampilo omhlaba wangempela:

1. Iphethini ye-"Herald Bleed + Syncope" (Ibonakala ku-60% kuya ku-80% wezigameko)¶

• Isiguli ngokuzumayo sizizwa sifudumele, sicanuzela inhliziyo, sinesiyezi, noma sinekhanda elilula, futhi singase siquleke isikhashana (syncope) phansi endlini yokugezela.
• Bahlanza inani elincane legazi elibomvu noma "indawo yekhofi," emnyama, NOMA bakhiphe ithumbu elilodwa le-igazi elimaroon elimnyama noma indle emnyama, enephunga elibi (melena).
• Phakathi nemizuzu engu-15 kuya kwengu-30, umbala wabo uyabuya, ukopha kuyanqamuka, futhi baphikelele ukuthi bazizwa bephilile futhi abafuni ukuya esibhedlela. Lesi isikhathi esiqondile lapho ezokuthutha eziphuthumayo zisindisa ukuphila kwabo.

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

Ezigulini eziningi ezine-aortoenteric fistula yesibili, amasonto noma izinyanga ngaphambi kokuba kuvele iconsi lokuqala legazi elibonakalayo, i-duodenum egugulekayo ivuza amagciwane ku-graft ye-aortic yokufakelwa, okubangela **i-perigraft sepsis engapheli **: - Imfiva eyenzeka ngezikhathi ezithile engachazeki, ukujuluka ebusuku, noma ukuba namandla (imvamisa akutholwanga kahle amasonto njengesifo esibangelwa amagciwane, ukutheleleka ngomgudu womchamo, noma umkhuhlane ongaziwa umsuka). - **Ubuhlungu obusha, obujulile, obuyisicefe bamaphakathi ne-lumbar noma ubuhlungu besisu be-periumbilical ** (okubangelwa ukuvuvukala kwe-retroperitoneal kanye nokwanda kwe-pseudoaneurysm ukucindezela umgogodla we-lumbar). - I-septic emboli emilenzeni noma ezinzwaneni ("Blue Toe Syndrome"): Amahlule amancane anegciwane aphuka i-colonized aorta graft futhi awele ezinyaweni, abangele izindawo ezibuhlungu ezinsomi ezinzwaneni noma i-unilateral leg osteomyelitis. - I-Bacteremia enezinto eziphilayo zamathumbu: Amasiko egazi akhulayo Escherichia coli, Enterococcus, Streptococcus bovis/anginosus, Bacteroides, noma Candida kunoma isiphi isiguli esixhunywe kwi-aortic yi-pathognomonic ye-aortoenteric fistula noma ukutheleleka.

Izicupho ezimbili zasesibhedlela ezibulalayo: "I-Standard Endoscopy Trap" kanye "Ne-Over-Resuscitation Trap"¶

Lapho uphelezela othandekayo ngokuxhunyelelwa kwe-aorta ngaphambili emnyangweni wezimo eziphuthumayo, ukwazi izingibe ezimbili ezibalulekile zomtholampilo ezigqugquzelwa Society for Vascular Surgery (SVS) kanye I-European Society for Vascular Surgery (ESVS) ingasiza ekuqinisekiseni ukuthi ukunakekelwa okusheshayo, okuhlelekile kwenzeka:

I-Trap 1: Kungani i-Upper Endoscopy (EGD) evamile ivame ukugeja i-Aortoenteric Fistula¶

Esimweni esivamile sokopha emathunjini aphezulu, odokotela bezimo eziphuthumayo babiza i-gastroenterologist ukuze yenze i-esophagogastroduodenoscopy (EGD). Nokho, i-gastroscope evamile iklanyelwe kuphela ukufinyelela ingxenye yokuqala neyesibili ye-duodenum (D1 ne-D2), ime khona kanye eduze kwe-ampulla ye-Vater. Ngenxa yokuthi amaphesenti angu-75 kuya kwangu-80 e-aortoenteric fistula atholakala ekujuleni kwengxenye yesithathu neyesine ye-duodenum (D3 kanye ne-D4), i-EGD evamile ibonakala ijwayelekile ngokuphelele ngaphezu kwengxenye yazo zonke izimo ze-aortoenteric fistula.

Izingozi ezimbili ezengeziwe zikhona ngesikhathi se-endoscopy: - I-"Coincidental Ulcer" Trap: Iziguli esezikhulile ezinemithambo yegazi ngokuvamile ziphuza i-aspirin nsuku zonke noma izinto ezinciphisa igazi futhi ngokuvamile ziba ne-gastritis emaphakathi, ukuguguleka kwesisu esincane, noma isilonda esincane esilapheka esiswini. Uma i-endoscopist ibona i-gastritis ethambile esiswini futhi imisa ukuhlolwa ngaphandle kokuyihlola yonke indlela yehle kuze kufike engxenyeni yesine ye-duodenum (noma ngaphandle koku-oda i-CT angiogram), bangase bathi i-herald iyopha nge-gastritis kuyilapho i-aortic fistula ihlezi ngamasentimitha amasentimitha ukujula ilungele ukuphuka. - Ukukhipha i-Herald Clot ngaphakathi kwe-GI Lab: Uma i-endoscopist iphusha ikholonoscope yezingane ende noma i-push-enteroscope ijule engxenyeni yesithathu ye-duodenum, ibone ihlule legazi elimnyama elishayayo linamathele odongeni lwe-duodenal, futhi klzzwxh:0034 i-aorta yesisu kanye nokucupha ngokushesha, okubulalayo kude negumbi lokuhlinza. Ngakho-ke, uma i-endospy yenziwa ukuze kuhlolwe i-D3/D4, imihlahlandlela yokuhlinzwa kwemithambo ibeka ukuthi kufanele yenziwe egunjini lokuhlinza neqembu labahlinza imithambo yemithambo likhuhlwe futhi lilungele ukucishwa kwe-aorta ngokushesha.

I-Trap 2: Kungani i-"Permissive Hypotension" isindisa impilo ngaphambi kokuba i-aorta ivalwe¶

Phakathi newindi elicashile ngemva kokopha kwe-herald, ihlule le-platelet-fibrin elintekenteke liwukuphela kwesithiyo esihlukanisa igazi elinomfutho ophezulu we-aorta nelume elivulekile lamathumbu. Uma abezimo eziphuthumayo noma abasebenzi basesibhedlela besebenzisa amalitha e-values saline emithanjeni esheshayo noma bempompela amayunithi amaningi amangqamuzana egazi abomvu agcwele ukuze aqhubekisele phambili umfutho wegazi we-systolic wesiguli. 130 to 150 mmHg, lokho kukhuphuka kwe-hydrostatic pressure spike kuzokhipha ipulaki yehlule khona kanye epheshaneni le-fistula** (njengase-aorta aneurysm ephukile yesisu).

• I-Permissive Hypotension Rule: Inqobo nje uma isiguli siphapheme, siqaphile, futhi sikhuluma (okubonisa ukugeleza kwegazi okwanele ukuya ebuchosheni nasenhliziyoni), ukuhlukumezeka kwemithambo kanye neziqondiso zokuvuselela ukuphefumula okuqondiwe ukulawulwa kwe-permissive hypotension (umfutho wegazi we-systolic cishe cishe 80 to 100 mmHg) usebenzisa uketshezi olucophelelayo, olunetitrated kuze kube udokotela ohlinzayo wemithambo esevale i-aorta nge-endovascular stent-graft noma i-aortic cross-clamp.

Ukuxilongwa okuqondile kwesibhedlela nokusindiswa kokuhlinzwa: I-CTA, i-EVAR bridging, nokwakhiwa kabusha¶

Lapho isiguli esisolwa ngokuba ne-aortoenteric fistula sifika emnyangweni wezimo eziphuthumayo, isibhedlela sivula indlela yokuhlinzwa yemithambo esheshayo:

1. Isivivinyo Sokuqala Segolide Esijwayelekile: I-Multiphasic CT Angiography (CTA) Yesisu Nesinqe: Kwenziwe ngaphandle kokuqhathanisa okuhle komlomo (okungafihla ukopha okusebenzayo ngaphakathi kwe-duodenum), i-CTA ithatha ngaphansi kwemizuzu emi-5, iba 85 kuya kumaphesenti angama-95 ukuzwela, futhi yembula izimpawu ze-pathognomonic:
2. Igesi ye-Ectopic perigraft: Amabhamuza omoya azungeze i-aorta graft (ihlala ingavamile ngaphezu kwamaviki angu-4 kuya kwangu-6 ngemva kokuhlinzwa).
3. Ukulahleka kwendiza yamafutha e-aorto-duodenal: Ukusebenzisa ifoni njengemodemu okuqondile kwe-duodenum yesithathu odongeni lwangaphambili lwegraft noma i-anastomotic pseudoaneurysm.
4. I-extravasation esebenzayo yokuqhathanisa: Ukundiza okuhlukile komthambo kusuka ku-aorta kuya kulume lwe-duodenal.
5. I-Stage 1 Rescue: I-Endovascular Stent-Graft Relining ("EVAR Bridge to Surgery"): Ngaphansi kwe-SVS kanye nemihlahlandlela ye-ESVS, esikhundleni se-laparotomy evulekile esheshayo (ethwala ukufa okungamaphesenti angu-50 kuya kwangu-70 phakathi nokopha okusebenzayo), odokotela abahlinza imithambo babhoboza umthambo we-femoral kanye ne-evascular deploma i-stent-graft* ngaphakathi kwe-graft endala ngaphesheya kwe-fistula (noma faka ibhaluni elithi REBOA le-aorta ekuboshweni). Phakathi nemizuzu engu-20, ukopha kuyayeka futhi umfutho wegazi uzinzile. Amagciwane e-Broad-spectrum IV (piperacillin-tazobactam noma meropenem + vancomycin) kanye ne-IV antifungal (fluconazole noma i-micafungin) aqalwa ngokushesha.
6. Ukulungisa Okuqondile Kwesigaba 2: Uma sebevuselelwe, odokotela abahlinzayo bakhipha futhi balungise i-duodenum yesithathu, bafake i- i-omentum enkulu phakathi kwamathumbu ne-aorta, bakhiphe i-graft yokwenziwa ethelelekile, futhi babuyisele ukugeleza kwegazi ngokusebenzisa i-extra-anatomic axillobifemoral bypassion** noma kusetshenziswa i-automatic bypassion** noma*** i-femoral-popliteal vein (NAIS), i-cryopreserved homograft, noma i-rifampin/i-Dacron efakwe ngesiliva.

Izinombolo zezimo eziphuthumayo zesifunda kanye nezinqubomgomo ze-ejensi¶

I-aortoenteric fistula okusolakala ukuthi idinga ukuthuthwa nge-ambulensi ngokushesha ukuya esikoleni esiphakeme Isikhungo Sokuhlinzwa Kwemithambo esifakwe ihora elingu-24 le-CT Angiography, Ama-Hybrid Endovascular Operating Rooms, I-Massive Transfusion Protocol, kanye Nokunakekelwa Kakhulu Kokuhlinzwa:

• I-United States ne-Canada: Dayela u-911*. Tshela abezimo eziphuthumayo ukuthi isiguli sike saba nokulungiswa kwe-aorta yesisu futhi sidinga isibhedlela esikhulu esine 24/7 Ukuhlinzwa Kwemithambo (akukaze kube yi-ER ezimele noma umtholampilo womphakathi). Kuphethwe ngaphansi kwe-Society for Vascular Surgery (SVS) Practice Guidelines on the Care of Patients aneAbdominal Aortic Aneurysm kanye ne-American Heart Association (AHA) I-Vascular Graft Infection Scientific Statements.
• E-United Kingdom: Dayela u-999* ukuze uthole i-ambulensi Yesigaba ½ endaweni ekhethiwe yesifunda I-Arterial Vascular Hub. Iphethwe ngaphansi kwe-National Institute for Health and Care Excellence (NICE NG156) kanye ne-Vascular Society of Great Britain and Ireland (VSGBI) amaphrothokholi.
• I-European Union: Shayela 112. Iphethwe ngaphansi kwe European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections.
• I-Australia ne-New Zealand: Dayela u-000* e-Australia noma 111 eNew Zealand. Kuphethwe ngaphansi kwe- Australian and New Zealand Society for Vascular Surgery (ANZSVS) amaphrothokholi.
• I-India ne-Asia-Pacific: Dayela u-112* (noma 108 e-India), 995 e-Singapore, 119 e-Japan naseNingizimu Korea, noma 999 e-Malaysia nase-Hong Kong. Cela isikhungo semfundo ephakeme esinekhono lokuhlinzwa kwe-endovascular kanye ne-cardiothoracic/vascular.

Imibuzo evame ukubuzwa¶

Yini "i-herald bleed" (i-sentinel bleed) ku-aortoenteric fistula?¶

I-herald bleed iyisiqephu esikhohlisayo, esizibekela umkhawulo sokopha emathunjini (njengokuhlanza inani elincane legazi noma i-coffee-ground material, ukwedlula i-tarry eyodwa emnyama noma i-maroon stool, noma ukuquleka isikhashana) okwenzeka kumaphesenti angu-60 kuya kwangu-80 eziguli ezine-aortoenteric fistula ngaphambi kokugadla kwenhlekelele. Lapho i-aorta graft egugulekayo kuqala yenza imbobo yokungena ku-duodenum, ukwehla kwesikhashana komfutho wegazi kanye ne-arterial vasospasm kuvumela ihlule elincane legazi ukuthi livale imbobo, limise ukopha ngokuphelele amahora ambalwa kuya ezinsukwini ezimbalwa. Lapho i-asidi yesisu, ama-enzyme e-pancreatic, kanye nomfutho wegazi okhuphukayo kuncibilika noma kuqhume lelo plug lehlule elintekenteke, ukopha okukhulu kwemithambo esongela ukuphila kuqala. Ukushayela abezimo eziphuthumayo ngesikhathi sewindi elithule le-herald bleed yisibikezelo esisodwa esikhulu sokusinda.

Ingabe i-aortoenteric fistula ingenzeka eminyakeni engu-10 noma engu-15 ngemva kokuhlinzwa kwe-aortic aneurysm yesisu?¶

Yebo. Nakuba amanye ama-fistula e-aortoenteric yesibili akhula phakathi nezinyanga ezimbalwa zokuhlinzwa okuvulekile kwe-aortic graft noma ukulungiswa kwe-endovascular stent-graft (EVAR), isikhathi esijwayelekile kusukela ekuhlinzweni kwe-aorta kwasekuqaleni kuya ekwakhekeni kwe-fistula yiminyaka emi-3 kuya kwemi-5, futhi amacala abhalwe kahle ayenzeka njalo eminyakeni eyi-10, engu-15, noma engu-20 ngemva kokulungiswa kwe-aneurysm. Kuyo yonke impilo yesiguli ngemva kwanoma iyiphi inqubo ye-aorta yesisu noma inqubo yokuqina, noma isiphi isiqephu segazi lokuhlanza, indle emnyama, ukopha kwe-maroon rectal, noma imfiva engachazeki enobuhlungu obuphakathi nomhlane kufanele iphathwe njenge-aortoenteric fistula engaba khona kuze kukhishwe i-CT angiogram.

Kungani i-CT Angiogram (CTA) ingcono kune-Upper Endoscopy (EGD) evamile njengokuhlola kokuqala kwe-aortoenteric fistula okusolwa ukuthi iyini?¶

Ububanzi obujwayelekile be-endoscopy engenhla yakhelwe ukuhlola umminzo, isisu, nengxenye yokuqala neyesibili ye-duodenum, ime kancane ezingxenyeni ezijulile ezivundlile zesithathu nesesine ze-duodenum lapho amaphesenti angama-75 kuya kwangu-80 awo wonke ama-aortoenteric fistula atholakala. Ngenxa yalokho, i-endoscopy engenhla evamile igeja ngaphezu kwesigamu sayo yonke i-aortoenteric fistula futhi ingase isole ngephutha ukopha kwe-gastritis yesisu esincane. Ngokuphambene, i-multiphasic CT Angiogram (CTA) yesisu ne-pelvis ithatha imizuzu engaphansi kwemi-5, ibona ngeso lengqondo yonke i-aorta ne-duodenum ngesikhathi esisodwa, futhi ithola amaphesenti angama-85 kuya kwangu-95 e-fistula ngokubonisa amabhamuza omoya avaleleke eduze kwe-aortic graft, ukulahlekelwa kwendiza enamafutha phakathi kwe-graft noma i-jetine ehlukanisiwe kusuka emathunjini.

Kungani abezimo eziphuthumayo kanye nodokotela bezimo eziphuthumayo kufanele bagweme ukuphakamisa umfutho wegazi ophakeme kakhulu ("permissive hypotension") ngemva kokopha kwe-herald?¶

Ngemva nje kokuba i-herald iqede ukopha ngokwayo, okuwukuphela kwento evimbela i-aorta yesisu enomfutho omkhulu ekumpompeni amalitha egazi emathunjini amancane ihlule elincane, elintekenteke le-platelet-fibrin elixhuma ipheshana le-fistula. Uma amaqembu ezokwelapha enikeza uketshezi olungena emthanjeni olunamandla noma ukumpontshelwa igazi ngokushesha ukuze kusunduze umfutho wegazi we-systolic wesiguli ufike kumazinga avamile noma aphezulu (afana no-130 kuya ku-150 mmHg) ngaphambi kokuba udokotela ohlinza imithambo evale i-aorta, lokho kukhuphuka okungazelelwe komfutho wegazi kungakhipha ihlule futhi livale i-heel trigger. Ngaphandle kwalapho isiguli sine-ischemia enzima yobuchopho, amaqembu emithambo agcina “i-permissive hypotension” (umfutho wegazi we-systolic ongama-80 kuya ku-100 mmHg, owanele nje ukugcina isiguli siphapheme futhi sikhuluma) kuze kube yilapho i-endovascular stent-graft noma i-clamp yokuhlinzwa ivala i-aorta.

Kungani umuntu okusolakala ukuthi wopha kungafanele aphuze amanzi noma aphuze umuthi wezilonda emlonyeni?¶

Okokuqala, amanzi okuphuza, ukudla ukudla, noma ukuphuza imithi ephuzwayo kushukumisa isisu, inyongo, namanyikwe ukuba akhiphe i-hydrochloric acid, i-bile, nama-enzyme anamandla okugaya amaprotheni (trypsin ne-chymotrypsin) aqonde ngqo engxenyeni yesithathu ye-duodenum, lapho ancibilikisa ngamakhemikhali ihlule legazi elivikelayo elixhuma i-aortic fistula. Okwesibili, isiguli sizodinga ukuqhathanisa okusheshayo kwe-CT scan kanye ne-anesthesia ejwayelekile yezimo eziphuthumayo yokuhlinzwa kwe-endovascular noma i-aortic evulekile, lapho ukuba noketshezi noma ukudla esiswini kudala ingozi enkulu yokuhlanza nokufisa emaphashini ngesikhathi sokuthunjwa.

Liyini "ibhuloho le-EVAR" futhi likuthuthukise kanjani ukusinda ku-aortoenteric fistula?¶

Esikhathini esidlule, okuwukuphela kwendlela yokumisa i-aortoenteric fistula eyopha kakhulu kwakuyi-laparotomy evulekile ephuthumayo (ukusika isisu sonke, ukuhlinza ngezicubu eziminyene, nokubopha i-aorta), eyayithwala izinga lokufa elingamaphesenti angu-50 kuya kwangu-70 ngenxa yokulahlekelwa igazi nokushaqeka. Namuhla, odokotela abahlinza imithambo basebenzisa "ibhuloho le-EVAR": ngokubhoboza inaliti encane emithanjeni ye-groin, bashelela i-stent-graft embozwe phezulu ngaphakathi kwe-graft endala ye-aorta bese beyifaka embobeni engaphansi kwemizuzu engama-20. Lokhu kumisa ngokushesha ukopha kwangaphakathi futhi kusimamise isiguli ukuze ukulungiswa okuqondile kwe-duodenum kanye nokuxhunyelelwa okuthelelekile kungenziwa ngokuphepha uma isiguli sesivuselelwe ngokugcwele.

Imithombo neziqondiso ezisemthethweni¶

• I-European Society for Vascular Surgery (ESVS, Europe): ESVS 2020 Clinical Practice Guidelines on the Management of Vascular Graft and Endograft Infections (Chakfe et al., European Journal of Vascular and Endovascular Surgery, Isigaba Sesecondary Aortoenteric Fistula, i-heald recognition yokuqala ye-Chéraldiagnostic CTA indlela, i-endovascular EVAR ibhuloho ezigulini ezingazinzile, kanye ne-in-situ ngokumelene nokwakhiwa kabusha kwe-extra-anatomic).
• Umphakathi Wokuhlinzwa Kwemithambo (SVS, United States): I-Society for Vascular Surgery Practice Guidelines on the Care of Patients aneAbdominal Aortic Aneurysm (Chaikof et al., Journal of Vascular Surgery, ukuxilongwa nokuphathwa okuphuthumayo kwe-aortoenteric erosion ye-primary neyesibili).
• Inhlangano Yenhliziyo YaseMelika (AHA, United States): Izifo Ezixhunywe Emisipha, I-Mycotic Aneurysms, kanye Nezifo Ze-Endovascular: Isitatimende Sesayensi esivela ku-American Heart Association (Circulation, microbiology, biofilm pathogenesis, antimicrobial and antifungal coverage, kanye nokuphathwa kokuhlinzwa kwe-aortoenteric).
• I-American College of Gastroenterology (ACG) kanye ne-European Society of Gastrointestinal Endoscopy (ESGE): Iziqondiso Zomtholampilo Zokulawulwa Kokopha Okubukhali Kwesisu Esiphezulu (ukuqashelwa kwe-aortoenteric fistula ezigulini ezine-prosthetic aortic grafts, imikhawulo ye-EG3zing D4D esezingeni kanye nokufinyelela kuqala kwe-D3D4D ekufinyeleleni).
• I-National Institute for Health and Care Excellence (NICE, United Kingdom): Abdominal Aortic Aneurysm: Ukuxilongwa Nokuphathwa (I-NICE Guideline NG156).

Iziqondiso ezihlobene¶

• I-aortic dissection kanye ne-aortic aneurysm yesisu ephukile
• Ukopha emathunjini, igazi lokuhlanza (hematemesis), kanye ne-melena
• Ukuqhuma komminso (i-Boerhaave syndrome), izinyembezi zikaMallory-Weiss, nokuhlanza ubuhlungu besifuba
• I-Esophageal varice iyaphuka, ukopha kwe-cirrhosis, kanye ne-hepatic encephalopathy
• Usizo lokuqala olushaqisayo kanye nokubonwa kokuwohloka kokujikeleza kwegazi