Endoscopy 2009; 41: E88-E89
DOI: 10.1055/s-0029-1214486
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

Acute aortic dissection causing gastroduodenal and hepatic infarction

S.  Jutaghokiat1 , P.  Angsuwatcharakon1 , B.  Imraporn1 , P.  Ongcharit2 , S.  Udomsawaengsup2 , R.  Rerknimitr1
  • 1Division of Gastroenterology, Department of Medicine, Chulalongkorn University Hospital, Bangkok, Thailand
  • 2Department of Surgery, Chulalongkorn University Hospital, Bangkok, Thailand
Further Information

R. RerknimitrMD 

Division of Gastroenterology
Department of Internal Medicine
Faculty of Medicine
Chulalongkorn University

Bangkok 10310
Thailand

Fax: +66-2-2527839

Email: Rungsun@pol.net

Publication History

Publication Date:
15 April 2009 (online)

Table of Contents

A 61-year-old man presented with severe acute epigastric pain for 15 hours followed by hematemesis. On arrival, the patient had high blood pressure, tachypnea, and tachycardia. Bowel sound was absent with mild abdominal distention. Nasogastric lavage revealed fresh blood. Complete blood count and liver function tests were unremarkable. Serum amylase and lipase were 836 U/L (normal range, 28 – 100 U/L), and 1870 U/L (normal range, 13–60 U/L), respectively. Chest radiography demonstrated a wide mediastinum ([Fig. 1]), and a plain film of the abdomen showed small-bowel ileus. He was sent for an emergent esophagogastroduodenoscopy. The findings are shown in [Fig. 2] and [Video 1]. Gastroduodenal infarction was suspected and he was transferred for an emergent computed tomography (CT) scan of the whole abdomen. Acute aortic dissection (Stanford type B) with hepatic and intestinal infarction was diagnosed ([Fig. 3]). After the patient had been stabilized, an exploratory laparotomy was performed. Gangrene of the gallbladder, spleen, descending and sigmoid colon were detected. Cholecystectomy, splenectomy, and left-half colectomy were performed. Within the same day, fenestration of infrarenal abdominal aorta to provide blood flow to the gut was also successfully carried out. After surgery the patient improved and experienced no further abdominal pain or bleeding.

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Fig. 1 Chest radiograph showed a widening of the mediastinum.

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Fig. 2 a Esophagogastroduodenoscopy (EGD) revealed a normal esophagus. b EGD demonstrated gastric ischemia with congested mucosa. c Dark duodenal mucosa with submucosal hemorrhage secondary to infarction.

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Fig. 3 a Computed tomography of the abdomen demonstrated a false track septum in the abdominal aorta. b Intravenous contrast computed tomography of the liver showed the area of left lobe infarction.

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Quality:

Video 1 EGD revealed a normal esophagus whereas gastric mucosa showed ischemic congestion.

We report a patient with acute aortic dissection presenting with acute upper gastrointestinal bleeding from gastroduodenal ischemia. In general, patients with uncomplicated dissecting aortic aneurysm type B are best treated with conservative therapy [1]. However, our patient had a complicated course that compromised all major intra-abdominal aortic branches. Then an emergent aortic fenestration was indicated to effectively protect organs from gangrene. However, this procedure still carries a high mortality rate [2]. By contrast, endovascular stent grafting is a less-invasive alternative and has a lower morbidity rate, especially in subacute and chronic dissection [3]. Unfortunately the outcome is not as good as surgery in acute dissection [4] [5].

Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AD

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References

  • 1 Estrera A L, Miller 3rd C C, Safi H J. et al . Outcomes of medical management of acute type B aortic dissection.  Circulation. 2006;  114 (1 Suppl) I384-I389
  • 2 Panneton J M, Teh S H, Cherry jr. K J. et al . Aortic fenestration for acute or chronic aortic dissection: an uncommon but effective procedure.  J Vasc Surg. 2000;  32 711-721
  • 3 Nienaber C A, Fattori R, Lund G. et al . Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.  New Engl J Med. 1999;  340 1539-1545
  • 4 Dake M D, Kato N, Mitchell R S. et al . Endovascular stent-graft placement for the treatment of acute aortic dissection.  New Engl J Med. 1999;  340 1546-1552
  • 5 Eggebrecht H, Nienaber C A, Neuhauser M. et al . Endovascular stent-graft placement in aortic dissection: a meta-analysis.  Eur Heart J. 2006;  27 489-498

R. RerknimitrMD 

Division of Gastroenterology
Department of Internal Medicine
Faculty of Medicine
Chulalongkorn University

Bangkok 10310
Thailand

Fax: +66-2-2527839

Email: Rungsun@pol.net

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References

  • 1 Estrera A L, Miller 3rd C C, Safi H J. et al . Outcomes of medical management of acute type B aortic dissection.  Circulation. 2006;  114 (1 Suppl) I384-I389
  • 2 Panneton J M, Teh S H, Cherry jr. K J. et al . Aortic fenestration for acute or chronic aortic dissection: an uncommon but effective procedure.  J Vasc Surg. 2000;  32 711-721
  • 3 Nienaber C A, Fattori R, Lund G. et al . Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.  New Engl J Med. 1999;  340 1539-1545
  • 4 Dake M D, Kato N, Mitchell R S. et al . Endovascular stent-graft placement for the treatment of acute aortic dissection.  New Engl J Med. 1999;  340 1546-1552
  • 5 Eggebrecht H, Nienaber C A, Neuhauser M. et al . Endovascular stent-graft placement in aortic dissection: a meta-analysis.  Eur Heart J. 2006;  27 489-498

R. RerknimitrMD 

Division of Gastroenterology
Department of Internal Medicine
Faculty of Medicine
Chulalongkorn University

Bangkok 10310
Thailand

Fax: +66-2-2527839

Email: Rungsun@pol.net

Zoom Image

Fig. 1 Chest radiograph showed a widening of the mediastinum.

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Fig. 2 a Esophagogastroduodenoscopy (EGD) revealed a normal esophagus. b EGD demonstrated gastric ischemia with congested mucosa. c Dark duodenal mucosa with submucosal hemorrhage secondary to infarction.

Zoom Image

Fig. 3 a Computed tomography of the abdomen demonstrated a false track septum in the abdominal aorta. b Intravenous contrast computed tomography of the liver showed the area of left lobe infarction.

Zoom Image