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Patient With Unexplained Weight Loss, Anorexia, and Back Pain

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 74-year-old man presented to the primary care physician with a 3-month history of weight loss, anorexia, and back pain. His medical history was significant for hypertension, hyperlipidemia, and kidney stones. His surgical history was significant for a bilateral staged carotid endarterectomy in 1999 and 2000 and an open repair of a 7.4-cm transverse diameter juxtarenal abdominal aortic aneurysm with a knitted Dacron tube graft (18 mm) in 2014. Ligation of the left renal vein adjacent to the inferior vena cava was performed to gain proximal control of the aorta. The patient underwent extraction of a tooth secondary to an abscess 4 months earlier. Physical examination revealed poor dental hygiene and findings in the lower extremity suggestive of postthrombotic syndrome. The patient was afebrile with a heart rate of 108 beats per minute and a leukocyte level of 11 600/cm (normal range, 4000-11 000/cm), with 84% polymorphic neutrophils (normal, <75%); erythrocyte sedimentation rate was 57 mm/h (normal range, 0-10 mm/h), and C-reactive protein level was 15.9 mg/dL (normal, <0.6 mg/dL [to convert to nmol/L, multiply by 9.524]). Computed tomography (CT) of the abdomen and pelvis was performed (Figure 1A and B).

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D. Infected aortic graft with aortoduodenal fistula

The CT scan demonstrated postsurgical changes of the abdominal aorta after the patient’s aneurysmal repair, with the presence of mural fluid and a small amount of gas. There was a sacular out-pouching of the abdominal aorta containing gas at the proximal anastomotic site, which appeared to be inseparable from the duodenum and associated fat stranding. An indium ln 111 altumomab pentetate–labeled white blood cell scan (Figure 1C) revealed abnormal uptake at the midline suggestive of an aortic graft infection, with increased uptake inferiorly consistent with a developing abscess. The patient developed bright red rectal bleeding and was emergently taken to the operating room. Proximal aortic control was obtained using a balloon catheter, which was placed near the celiac axis. Laparotomy revealed an inframesenteric mass near the third and fourth part of the duodenum that was adherent to the proximal aortic graft anastomosis. Further dissection revealed the site of perforation in the duodenum with the proximal anastomosis of unincorporated Dacron graft (aortoduodenal fistula). Culture of grayish-white purulent material obtained from around the graft was positive for Streptococcus constellatus. The opening in the duodenum was closed in 2 layers. The proximal aortic stump was closed with a 3-0 polypropylene suture (Ethicon), and an extra-anatomic bypass was performed after closure of the abdomen. The patient died during the postoperative period due to multisystem organ failure.

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Article Information

Corresponding Author: Robert J. Acho, DO, Henry Ford Macomb Hospital, 15855 19 Mile Rd, Charter Township of Clinton, MI 48038 (racho1@hfhs.org).

Published Online: September 12, 2018. doi:10.1001/jamasurg.2018.3191

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient’s wife for granting permission to publish this information.

References
1.
Han  S-L, Cheng  J, Zhou  HZ, Zeng  QQ, Lan  SH.  The surgical treatment and outcome for primary duodenal adenocarcinoma.  J Gastrointest Cancer. 2010;41(4):243-247. doi:10.1007/s12029-010-9160-1PubMedGoogle ScholarCrossref
2.
Wong  CH, Chow  PK, Ong  HS, Chan  WH, Khin  LW, Soo  KC.  Posterior perforation of peptic ulcers: presentation and outcome of an uncommon surgical emergency.  Surgery. 2004;135(3):321-325. doi:10.1016/j.surg.2003.11.001PubMedGoogle ScholarCrossref
3.
Nypaver  T. Primary and secondary aorto-enteric fistulas. In: Hans  SS, Shepard  AD, Weaver  MR, Bove  P, Long  GW.  Endovascular and Open Vascular Reconstruction: A Practical Approach. Boca Raton, FL: ShepardCRC Press; 2017:257-262.
4.
Kakkos  SK, Bicknell  CD, Tsolakis  IA, Bergqvist  D; Hellenic Co-operative Group on Aortic Surgery.  Editor’s choice–management of secondary aorto-enteric and other abdominal arterio-enteric fistulas: a review and pooled data analysis.  Eur J Vasc Endovasc Surg. 2016;52(6):770-786. doi:10.1016/j.ejvs.2016.09.014PubMedGoogle ScholarCrossref
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