Korean J Gastroenterol.  2010 Jan;55(1):62-67. 10.4166/kjg.2010.55.1.62.

Cytomegalovirus Infection-related Spontaneous Intestinal Perforation and Aorto-enteric Fistula after Abdominal Aortic Aneurysmal Repair

• Ahn SY
• Lee SY
• Kim BS
• Rhee KH
• Kim JH
• Sung IK
• Park HS
• Jin CJ

• KMID: 1775928
• DOI: http://doi.org/10.4166/kjg.2010.55.1.62

Abstract

Gastrointestinal complications (GI) after thoracoabdominal aortic repair can be classified as biliary disease, heptic dysfunction, pancreatitis, GI bleeding, peptic ulcer disease, bowel ischemia, paralytic ileus, and aortoenteric fistula. Theses complications are associated with high post operative morbidity and mortality. Most of the aortoenteric fistulae after thoracoabdominal aortic surgery are found at the duodenum, near the surgical site. These rare complications are caused by an indirect communication with abdominal aorta that originated from an aneursymal formation ruptured into the duodenum. Such aorto-duodenal fistula formation is considered as a result of inflammatory change from secondary infection near the surgical instruments. Herein, we report two cases of massive upper GI bleeding from aorto-duodenal fistulae and spontaneous lower GI perforation related to cytomegalovirus infection after abdominal aortic aneurysmal repair operations.

Keyword

Abdominal aortic aneurysm; Bleeding; Cytomegalovirus; Peptic ulcer; Perforation

MeSH Terms

Aged
Aged, 80 and over
Aorta, Abdominal/*surgery
Aortic Aneurysm, Abdominal/complications/*surgery
Aortic Diseases/*diagnosis/surgery/virology
Cytomegalovirus Infections/*complications/diagnosis/pathology
Endoscopy, Gastrointestinal
Gastrointestinal Hemorrhage/etiology
Humans
Intestinal Fistula/*diagnosis/surgery/virology
Intestinal Perforation/*diagnosis/virology
Male
Vascular Fistula/*diagnosis/surgery/virology

Figure

• 

  Fig. 1. Endoscopic findings of the first case (a 77 year-old man). (A) Gastroscopic finding. Several deep and variable sized ulcers were noted on the proximal aspect of the stomach. (B) Duodenoscopic finding. Active bleeding was noted of the duodenal second portion beneath the ampulla of Vater. Main bleeding focus was captured as a linear blood stream at 9 to 10 o'clock direction. (C) Duodenoscopic finding after hemostasis by band ligation. Bleeding point on the duodenal second portion was ligated with a black band with the aid of endoscopic variceal ligation method. There was no further bleeding after the hemostasis.

• 

  Fig. 2. Pathologic findings of the endoscopic biopsy of the first case. (A) Hematoxylin and eosin stain. Inclusion bodies were noticed from the gastric biopsied specimen (H&E stain, ×100). (B) Immunohistochemical stain for cytomegalovirus. Inclusion bodies were stained as dark brownish color (Immunohistochemical stain, ×100).

• 

  Fig. 3. Endoscopic findings of the second case (a 82 year-old man). (A) Gastroscopic finding. A deep ulcer with clear margin was noted on the high-body of the stomach. (B) Duodenoscopic finding. Active bleeding was noted on the duodenal second portion. (C) Sigmoidoscopic finding. A 1 cm sized hole was noted on the mid sigmoid colon. This lesion was a cause of intestinal perforation that led to spontaneous pneumoperitoneum before the sigmoidoscopic examination.

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  Fig. 4. Pathologic findings of the resected sigmoid colon. (A) Gross finding. A 1 cm sized round and deep perforation was noted on the sigmoid colon. (B) Microscopic finding. Inclusion body indicating cytomegalovirus infection was noted on hematoxylin and eosin stain (H&E stain, ×100).

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  Fig. 5. Common findings found in two patients after abdominal aortic aneurymal operation. Under cytomegalovirus infection, three common pathologies were noted in two patients 2-3 weeks after the operation. The pathologies were consisted of perforation and bleeding of the gastrointestinal tract related to cytomegalovirus infection.

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