Aortoduodenal Fistula Caused by a Mycotic Aneurysm: A Case Report

細菌性主動脈瘤引發主動脈十二指腸瘻管：病例報告

李岳霖(Yueh-Lin Lee) ； 傅真如(Chen-Ju Fu) ； 謝宏昌(Hung-Chang Hsieh) ； 顧逸康(Yi-Kang Ku) ； 劉原彰(Yuan-Chang Liu)

《中華放射線醫學雜誌》 34卷4期 (2009/12) Pp. 289-292

摘要

主動脈十二指腸瘻管是一種少見的疾病，若延遲診斷死亡率很高。此病的臨床表現是隱伏的。我們在此報導一個四十八歲的男性，發燒一個月，腹痛10天，吐血一天。上消化道內視鏡無法做出診斷。電腦斷層掃瞄顯示腹主動脈瘤，腸壁缺損以及腸腔內血腫在十二指腸第三及第四部分內。探索性腹部切開術發現腹主動脈瘤破裂及主動脈十二指腸瘻管。這位病人手術後安然且無症狀。確定診斷主動脈十二指腸瘻管是在斷層掃描影像中發現顯影劑從主動脈溢出到十二指腸，其他可能的發現有：在十二指腸內發現血腫，主動脈與十二指腸間的脂肪層消失，以及發現空氣出現在後腹腔或血栓內。在我們這位病人，螺旋斷層掃瞄影像中發現血管瘤壁產生不連續或缺陷並且與十二指腸直接連結讓我們確定診斷原發性主動脈十二指腸瘻管，因為螺旋電腦斷層的快速掃瞄時間，讓直接偵測瘻管變的可能。正確診斷此疾病需要高度警覺，及早手術探索可以有效的治療。

並列摘要

Aortoduodenal fistula (ADF) is a rare condition with a high mortality rate when diagnosis is delayed. The clinical presentation of this disorder is insidious. We report a 48-year-old male patient who had a fever for 1 month, abdominal pain for 10 days and hematemesis for 1 day. Initial endoscopy failed to lead to a diagnosis. An abdominal aortic aneurysm, bowel wall defect and hematoma in the lumen over the 3 rd and 4th portion of the duodenum were found on computed tomographic (CT) scan. An exploratory laparotomy showed a ruptured mycotic aortic pseudoaneurysm with an aortoduodenal fistula. The patient survived and was symptom-free following the operation. Extravasation of contrast medium from the aorta to the duodenum is definite evidence of ADF on a CT image. Other suggestive evidence includes a hematoma in the duodenal lumen, loss of the fat plane between the aorta and duodenum, and air in the retroperitoneum and within the thrombus. In our patient, loss of continuity or defect in the aneurysmal wall and direct connection to the duodenum were diagnostic for primary ADF on helical CT. The fast scanning time of helical CT makes direct detection of the fistula possible. A high index of suspicion is critical for successful diagnosis, and early surgical exploration is needed for successful management.