Alexandra R. Fiedler, MD, Banreet S. Dhindsa, MD, Shailender Singh, MD University of Nebraska Medical Center, Omaha, NE
Introduction: Duodeno-caval fistula (DCF) is a rare, life-threatening condition primarily seen in middle-aged men in association with trauma, inferior vena cava (IVC) filter migration, peptic ulcer disease (PUD), foreign body ingestion, and retroperitoneal radiation. There have been only a few reported cases in the literature of DCF. We present a rare case of DCF presenting as gastrointestinal hemorrhage and sepsis in a young patient with prior spinal radiation.
Case Description/Methods: An 18-year-old male with a history of metastatic osteosarcoma of the femur status post chemotherapy, partial surgical resection of femur and spine, and spinal radiation presented with fever and hematemesis. On admission, the patient was on Lenvatinib and nonsteroidal anti-inflammatory drugs. He was febrile, tachycardic, hemoglobin (Hgb) was 10.8 g/dL and blood cultures grew Lactobacillus rhamnosus. Esophagogastroduodenoscopy (EGD) showed multiple Forrest III duodenal ulcers and a large 2-3 cm Forrest IIb ulcer in the 2nd of the duodenum. Interventional radiology was consulted and performed empiric gastroduodenal artery coil embolization. Ten days later, he had recurrent hematemesis and Hgb declined to 6.8 g/dL. Previously described actively bleeding ulcer was seen with unsuccessful hemostasis status post bipolar cauterization and hemostatic clip placement. Computed Tomography Angiography showed a near occlusive thrombus with scattered foci of gas in the IVC and a possible fistulous connection to the duodenum due to the proximity of the ulcerated IVC. Vascular, transplant, and emergency general surgery were consulted. However, given DCF is exceedingly rare, surgical specialties thought septic phlebitis without concomitant DCF was more likely. His condition stabilized temporarily until he developed repeat large-volume hematemesis with worsening hemodynamic instability and acute blood loss anemia a week later. Emergent EGD was performed with unsuccessful hemostasis. The patient underwent emergent exploratory laparotomy which confirmed DCF and suppurative IVC thrombophlebitis. Surgeons performed DCF repair, perforated duodenal ulcer repair, and a Roux en Y to the duodenum. The culture of the IVC clot grew Lactobacillus.
Discussion: DCF has a high mortality rate of 40% due to profuse bleeding and delay in diagnosis. Despite multiple episodes of bleeding and suspected DCF, surgery was delayed by a week in our patient. Early recognition and intervention are crucial to prevent mortality in DCF.
Figure: Figure 1. 1A and 1B. CT imaging demonstrates multiple foci of gas within the IVC extending 6.8 cm craniocaudally from the level of the third portion of the duodenum to the level of GDA embolization consistent with CDF in sagittal (A) and coronal (B) views. 1C. Endoscopic view of 10 mm ulcer with suspected contained perforated ulcer base located in the second portion of the duodenum.
Disclosures:
Alexandra Fiedler indicated no relevant financial relationships.
Banreet Dhindsa indicated no relevant financial relationships.
Shailender Singh indicated no relevant financial relationships.
Alexandra R. Fiedler, MD, Banreet S. Dhindsa, MD, Shailender Singh, MD. P3511 - A Rare Case of Duodeno-Caval Fistula Presenting as Gastrointestinal Bleeding in the Setting of Vena Caval Phlebitis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.
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