Earlier this week I saw a very interesting, yet extremely critical patient.
A man in his early 50s presented at about 4:00AM after two episodes of throwing up a very large amount of bright red blood at home. He arrived to the ER very pale, diaphoretic, mildly hypotensive, tachycardic, and complaining of severe abdominal pain. Basically, he looked like crap when he rolled in. Upon further probing into his medical history, we discovered he was recently diagnosed with a 5.5cm AAA but never followed up with vascular surgery. He also noted a hx of alcohol abuse, but on exam was adamant that he had not had any alcohol whatsoever for several months. He smoked and had HTN, but other than the aforementioned aneurysm and alcohol abuse, had no other history, including abdominal surgery.
On exam, the pt is awake and alert, although writhing around in the bed in severe distress, with pretty diffuse abdominal tenderness, but no distention. He was tachy at about 120 with a blood pressure of 95/61. He looked pretty pale, with pale conjunctiva and delayed capillary refill. Of note also was the dried blood caked onto his chin and clothing. He also had not had another episode of hematemesis (throwing up blood) since arriving to the ER.
Considering his past medical history and presentation, the differentials are all serious. Our differentials included Esophageal Varices (due to the history of alcohol abuse) and Peptic Ulcer Disease (perhaps he perforated). However, although rare, his recent diagnosis of a AAA made an Aortoenteric fistula the main differential. An aortoenteric fistula is a very rare, very serious, very deadly cause of GI bleeding. It is essentially the connection of the Aorta to part of the intestines, in this patient probably in an area close to the stomach such as the duodenum or jejunum. It has a high mortality, and is often somewhat difficult to diagnose.
Initial management consisted of the usual labs (with the added lactate level and Type & Screen). Because of the critical nature of the patient, I also called and had the lab come to a bedside creatinine (a measure of a patient’s renal function) in order to get him to CT more quickly so he could get IV contrast. Very aggressive fluid resuscitation was started as well. He showed improvement with fluids so the decision was made by the physician to hold off an vasopressors unless he deteriorated. Luckily, the ultrasound tech happened to stroll through the ER at that moment, so we had them do a bedside ultrasound which was largely inconclusive other than to say that there was no free fluid in the peritoneum.
The patient went to CT, and the CT looked pretty bad, with a large 6.5cm AAA, with a large amount of blood in the stomach, and the appearance of contrast leaking into the wall of the aneurysm, especially around the stomach. There was also the presence of air in the very enlarged wall of the aortic lumen. This was just based off my own personal interpretation at that time, and because we were waiting for the off-site radiologist to read the scans, we were stuck in a bit of a waiting game..
The patient appeared to be improving with fluids, until several things happened all at once (as per usual when all things go to hell):
- Radiology called with the results
- The patient had another MASSIVE episode of hematemesis
- His pressure tanked to 40/20
Everything started to go downhill from there. The physician ran into the room to place a central line, I took the CT report (per radiologist: AAA with possible rupture and probably aortoenteric fistula; CLINICAL CORRELATION RECOMMENDED). I then called the blood bank to get as much O- blood as possible, asking for 10 units (the lab later freaked out at as and only sent us 4 units). The physician was still placing the central line, so I paged vascular surgery at that point and spoke to the vascular surgeon and basically said in as few as words possible that we had an patient with an aortoenteric fistula that was very unstable and they needed to come to the ER, at which point all they said was “I’m coming” and hung up.
The physician and I traded placed for a bit after that so he could put in orders. I really didn’t do a lot at this point except for make sure he got started on pressors (norepi in this case) and helped hang some fluid. Blood finally arrived and the patient began to somewhat, temporarily, improve with fluids, pressors, and meds. Vascular surgery finally swooped in right in time and after about 20 minutes took the patient to surgery. Before the surgery, the surgeon was very honest with the patient, and told him (He was surprisingly awake) and the family that the mortality from this condition/surgery is at least 50%. Then he left. Off to surgery he went. at about 6:40AM.
Since I was supposed to leave at 3:00AM, and be back at 9:00AM, I ended up just staying at the hospital for about 24 hours working. I found out a few hours later that the patient, against all odds, miraculously made it out of surgery alive.
Overall this was probably one of the more rare things I’ve seen in my tenure in the emergency department, one of the more exhilarating cases, and one that I will never forget.
Sometimes you find Zebras even when you’re not looking for them.