Risky endoscopy for acute aortic dissection with hematemesis

We read with interest the article by Jutaghokiat et al. [1] on unique endoscopic features of gastroduodenal infarction caused by acute aortic dissection. They encountered a patient with severe acute epigastric pain followed by hematemesis who had high blood pressure, tachypnea, tachycardia, and absent bowel sound. After they had identified elevated serum pancreatic enzyme levels, a wide mediastinum, and small-bowel ileus, emergent esophagogastroduodenoscopy (EGD) suggested gastroduodenal infarction. Emergent computed tomography (CT) confirmed acute aortic dissection with hepatic and gastrointestinal infarction. Although the patient recovered uneventfully after resection of infracted organs and fenestration of abdominal aorta, we believe that EGD was risky in this patient with several signs of acute aortic dissection.

Acute aortic dissection is a highly lethal medical emergency because these patients are at risk for life-threatening complications [2]. Presentation of acute aortic dissection typically includes chest and/or abdominal pain [3]. Although gastrointestinal symptoms other than abdominal pain are uncommon in such patients, gastrointestinal bleeding, caused by mesenteric infarction, has been described as a dominant symptom [2] [3] [4]. Mesenteric ischemia was reported to be present in 73 / 371 patients (20 %) with aortic dissection [5], and still remains a diagnostic challenge [4]. Because the diagnosis is often difficult and delayed, resulting in high morbidity and mortality, a strong clinical suspicion for mesenteric ischemia and early recognition and treatment may be the only key to preventing a catastrophic outcome in this condition [4].

Angiography has been the criterion standard for the diagnosis of mesenteric ischemia, but it is usually time consuming and not universally available [6]. Noninvasive imaging modalities, such as contrast-enhanced CT and multidetector-row CT angiography can effectively detect aortic aneurysm, aortic dissection, and ischemic organs [4] [6] [7] [8]. Although Jutaghokiat et al. [1] performed EGD in the patient with severe acute epigastric pain and hematemesis, EGD could precipitate a crisis condition in vulnerable patients because of induction of increased intra-abdominal and blood pressures [9]. CT allows rapid and cost-effective evaluation of patients with acute abdominal pain and gastrointestinal bleeding [4] [8]. Because CT can be performed easily and is in widespread use [6], we believe that patients with acute abdominal pain and hematemesis should initially undergo CT before EGD, and be screened for potentially fatal aortic dissection, especially in patients with high blood pressure, tachycardia, and a wide mediastinum.

Competing interests: None

References

• 1 Jutaghokiat S, Angsuwatcharakon P, Imraporn B. et al . Acute aortic dissection causing gastroduodenal and hepatic infarction.  Endoscopy. 2009;  41 Suppl 2 E88-E89
• 2 Di Luozzo G, Tannous H J, Ellozy S H. et al . Delayed repair of acute type A aortic dissection in a patient with gastrointestinal bleeding and pulse deficit.  Ann Thorac Surg. 2007;  84 2097-2099
• 3 Nath H P, Jaques P F, Soto B. et al . Aortic dissection masquerading as gastrointestinal disease.  Cardiovasc Intervent Radiol. 1986;  9 37-41
• 4 Akutsu K, Matsuda H, Sasaki H. et al . A case of acute type B aortic dissection: limited role of laboratory testing for the diagnosis of mesenteric ischemia.  Ann Thorac Cardiovasc Surg. 2007;  13 360-364
• 5 Neri E, Sassi C, Massetti M. et al . Nonocclusive intestinal ischemia in patients with acute aortic dissection.  J Vasc Surg. 2002;  36 738-745
• 6 Sato O, Okamoto H, Matsumoto H. Emergency CT scan for the diagnosis of superior mesenteric artery embolism: report of 2 cases.  Int Angiol. 2003;  22 438-440
• 7 Cademartiri F, Palumbo A, Maffei E. et al . Noninvasive evaluation of the celiac trunk and superior mesenteric artery with multislice CT in patients with chronic mesenteric ischaemia.  Radiol Med. 2008;  113 1135-1142
• 8 Urban B A, Fishman E K. Tailored helical CT evaluation of acute abdomen.  Radiographics. 2000;  20 725-749
• 9 Rice E, DiBaise J K, Quigley E M. Superior mesenteric artery thrombosis after colonoscopy.  Gastrointest Endosc. 1999;  50 706-707