Maulana Azad Medical College Pittsburgh, PA, United States
Rahul Karna, MD, Hannah Todorowski, DO, Nabeeha Mohy-Ud-Din, MD, Abhijit Kulkarni, MD Allegheny Health Network, Pittsburgh, PA
Introduction: An arterio-venous-enteric fistula is an abnormal communication between the arterial, venous, and enteric systems, which is a very rare occurrence that can present as massive GI bleeding Here, we present a case of arterio-venous-enteric fistula in a young female with retroperitoneal mass presenting as hemorrhagic shock.
Case Description/Methods: A 46-year old female with medical history significant for locally advanced cervical cancer with retroperitoneal mass encasing IVC and aorta, treated with radiation with associated retroperitoneal fibrosis, deep vein thrombosis on Coumadin therapy resented to the emergency department with sudden onset of hematemesis and hematochezia. On presentation, she was in hypovolemic shock with BP 80/60 mm Hg, HR 130/min and room air O2 saturation 70%. Massive transfusion protocol was initiated and endotracheal intubation was performed for airway protection. Labs revealed Hb 7.1 gm/dl from baseline 13 gm/dl, WBC 25.44/ µL, Platelets 150,000/µL, BUN 36 mg/dl, Cr 3.57 mg/dl, lactic acid 11 mmol/l and INR 4.0. ABG showed pH 6.87 with HCO3 – 3.5 mEq/L. She continued to have hematemesis and hematochezia and was started on empiric broad spectrum antibiotics and maximum vasopressor support. CTA revealed complex vascular fistula that extended from right common iliac artery into the IVC and the space surrounding IVC. The fistula also communicated with the transverse duodenum with active bleeding into the lumen. She succumbed to the event a few hours after presentation.
Discussion: To our knowledge, this is the first case of a complex three way fistula involving iliac artery, IVC and duodenum. . The clinical course in our patient was catastrophic. These vasculo-enteric fistulas could be missed on EGD/Colonoscopy and are usually diagnosed on CTA of abdomen. We believe retroperitoneal malignancy, distorted anatomy due to retroperitoneal fibrosis, supratherapeutic INR could have been contributing factors leading to fistula formation. Complex vasculo-enteric fistula should be among differential diagnosis of patients presenting with GIB, especially, in patients with history of malignancy, radiation, mycotic aneurysm, foreign bodies and trauma. The management is complex and should involve multidisciplinary approach involving vascular surgery, Intervention radiology and gastroenterology team.
Figure: Image: (A) CT abdomen pelvis without contrast showing a retroperitoneal mass encasing aorta and IVC. CTA abdomen pelvis showing (B) a gas bubble within the soft tissue consistent with fistulous communication involving the lumen, (C) shows an area of contrast extravasation from the right common iliac artery extends into the space around the IVC stent, (D) subtle contrast accumulation in the duodenal lumen consistent with intraluminal blood. The transverse duodenum abuts an area of retroperitoneal hemorrhage external to the IVC stent.
Rahul Karna indicated no relevant financial relationships.
Hannah Todorowski indicated no relevant financial relationships.
Nabeeha Mohy-Ud-Din indicated no relevant financial relationships.
Abhijit Kulkarni indicated no relevant financial relationships.
Rahul Karna, MD, Hannah Todorowski, DO, Nabeeha Mohy-Ud-Din, MD, Abhijit Kulkarni, MD. P1553 - Iliac Artery-IVC-Duodenal Fistula: An Unusual Cause of Massive Gastrointestinal Bleeding, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.