Reply to Matsushita et al.

We thoroughly understand the comment by Matsushita et al., regarding our case, that EGD is a risky procedure in a patient with possible aortic dissection. However, we still believe that EGD is crucial for identifying the cause of bleeding since not all bleeding can be assumed to result from mesenteric infarction; mesenteric ischemia has been found in fewer than ⅕ of cases in an aortic dissection with bleeding series [1]. On the other hand, multidetector CT angiography is not always a harmless investigation, since a significant number of aortic dissection cases have the risk of acute renal failure [2], and the contrast that is used for the study may precipitate worsening of renal function. Although both CT angiography and EGD have significant risks, nevertheless we agree that both are essential for the diagnosis of acute aortic dissection with intestinal bleeding. Though the sequence of the two is debatable, we would like to emphasize that optimal preparation including adequate control in blood pressure and volume are needed prior to both tests. In our patient, before he underwent EGD, the blood pressure was properly managed and we limited the amount of air insufflation in this quick diagnostic run.

Needless to say, therapeutic dilemmas will always arise regarding critically ill patients, and sometimes it is difficult to judge whether it is more ethically and practically appropriate to apply general principles or to act on a case-by-case basis [3].

Competing interests: None

References

• 1 Neri E, Sassi C, Massetti M. et al . Nonocclusive intestinal ischemia in patients with acute aortic dissection.  J Vasc Surg. 2002;  36 738-745
• 2 Estrera A L, Miller C C, Goodrick J. et al . Update on outcomes of acute type B aortic dissection.  Ann Thorac Surg. 2007;  83 S842-S845
• 3 Artnak K E. A comparison of principle-based and case-based approaches to ethical analysis.  HEC Forum. 1995;  7 339-352