Emergency Med Case Challenge: Hemorrhoids, Urinary and Blood Infections in a Woman With Rigors

Vimon Seriburi, MD; Ann F. Fisher, MD


November 14, 2022

Once the diagnosis of AEF is confirmed, removal of the infected graft, repair of the fistula, and revascularization are imperative. A herald hemorrhage should be viewed as an opportunity for prompt surgical intervention, because only about 50% of patients will survive the first 24 hours after the initial bleeding.

Open surgical repair of an AEF is technically demanding, and it is often associated with high morbidity and mortality. Options for revascularization include extra-anatomical bypass with an axillobifemoral bypass, neoaortic replacement using the deep veins of the lower extremity, and aortic replacement with either cadaveric human allografts or antibiotic-soaked prosthetic grafts. Evolving strategies for the treatment of aortoenteric fistulas through endovascular methods should be used only in the most unstable patients, and these methods should only be viewed as temporizing measures to more definitive open surgical repair. The optimal surveillance strategy after repair of an AEF has not been established because of the difficulty in tracking long-term follow-ups.

Data regarding the duration and choice of antibiotic therapy are also limited. So far, recommendations for treatment are largely based on experience with bacterial endocarditis. In general, antibiotics should be given for 4-6 weeks postoperatively in patients with positive blood cultures.[2,3,8,9]

In this case, once the patient's aortoduodenal fistula was confirmed, she underwent emergent laparotomy for repair. An opening was found in the retrobulbar region of the duodenum, which was adherent to the aorta. Gross contamination of the graft with duodenal contents was noted. The infected aortobifemoral bypass was removed, and a new rifampin-soaked thermoplastic resin bifurcated graft was placed. The aortoduodenal fistula was simultaneously closed.

Multiple cultures of the old graft grew Candida albicans and C glabrata. The patient completed a 6-week course of piperacillin/tazobactam for the Streptococcus bacteremia and caspofungin for the Candida fungemia. Her hospital course was complicated by multiple nosocomial infections; however, her anemia eventually improved, and she was discharged to a short-term rehabilitation facility 2 months after surgery.


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