Portal Vein-Duodenal Fistula After Sequential Abdominal Surgery

Endoscopic Findings

1. The first EGD showed a large adherent clot occupying the pyloric channel. The underlying lesion could not be characterized.
2. Second-look endoscopy after clot evacuation identified a fistulous orifice in the duodenal bulb.
3. There was no active bleeding at the moment of inspection.

Endoscopic Technique

1. Emergent EGD was performed for hematemesis and a hemoglobin of 6.4 g/dL.
2. The pyloric clot was evacuated and a second-look examination of the bulb was completed.
3. Dedicated endoscopic hemostatic tools (coils, hemostatic powder or sponge, over-the-scope clip) were not available, so endoscopic closure was not attempted.
4. Urgent contrast-enhanced CT was obtained, then the patient was transferred for transcatheter embolization of the portal vein pseudoaneurysm.

Discussion

A portoenteric fistula forms when a portal vein pseudoaneurysm, produced by local inflammation, surgical dissection, or erosive injury, ruptures into adjacent bowel. The duodenum is the usual target because it sits against the portal triad in the hepatoduodenal ligament. Most published cases follow penetrating peptic ulcer, biliary or pancreatic surgery, chronic pancreatitis with a pseudocyst, or pancreaticoduodenectomy.

This fistula appeared after two closely spaced operations: laparoscopic cholecystectomy, then exploratory laparotomy for perforated appendicitis ten days later. Local inflammation and dissection near the porta hepatis and duodenum can leave a portal vein pseudoaneurysm that later opens into the bulb. Bleeding ranges from occult to massive. The diagnosis is often late because the entity is almost never on the first differential for upper GI hemorrhage, and mortality rises when recognition is delayed.

Endoscopy may show only a hole, an ulcer look-alike, or a clot. Contrast-enhanced CT then has to do the vascular work: confirm the pseudoaneurysm, name the branch, and map hematic collections or pneumoperitoneum. Management options include endoscopic hemostasis (including EUS-guided coil embolization), transcatheter or transhepatic portal venous embolization, stent-graft placement, and surgery. The available toolkit decides the first move. Here, missing endoscopic hemostatic devices made prompt IR transfer the correct first-line therapy. Follow-up CT showed complete resolution of the pseudoaneurysm, with no recurrent hematemesis or melena and a later hemoglobin of 8.8 g/dL.

References

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