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06 September 2020: Articles  China (mainland)

Splenic Arteriovenous Fistula Complicated by Severe Diarrhea: A Case Report

Unusual clinical course, Challenging differential diagnosis, Management of emergency care

Zunwei Luo1A, Ziyu Zhou2A*

DOI: 10.12659/AJCR.922067

Am J Case Rep 2020; 21:e922067

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Abstract

BACKGROUND: Splenic arteriovenous fistula is a relatively rare disease. Patients are often admitted to the hospital with gastrointestinal symptoms. It is easy to misdiagnose due to the difficulty of confirming diagnosis only by routine examination.

CASE REPORT: Our patient was critically ill, with an initial diagnosis of severe diarrhea with retroperitoneal hematoma before being referred to our hospital. Upon admission, the diagnosis of splenic arteriovenous fistula was made by computed tomography angiography. This patient with SAVF was successfully cured by distal splenic artery endovascular embolization therapy.

CONCLUSIONS: Clinicians should consider SAVF in the differential diagnosis of patients with severe diarrhea with uncommon causes. Endovascular embolization therapy needs to be considered vs. conventional surgical ligation by open surgery in terms of operation risks and outcomes, along with subsequent exploratory laparotomy.

Keywords: Arteriovenous Fistula, diarrhea, endovascular procedures, Hypertension, Portal, Splenectomy, Embolization, Therapeutic, Splenic Artery, Splenic Vein

Background

Splenic arteriovenous fistula is a rare disease in clinical practice. Patients are often admitted to the hospital with gastrointestinal symptoms. It is easy to misdiagnose due to the difficulty of confirming diagnosis only by routine examination and due to the lack of pertinent data. About 100 cases have been reported in the world medical literature, the first of which was reported based on an autopsy [1,2]. Currently, the diagnosis can be confirmed by the less invasive procedure of digital subtraction angiography (DSA) [3]. An increasing number of reports show that endovascular treatment can achieve good results [4]. This article reports a case of splenic arteriovenous fistula successfully cured by endovascular therapy, with the aim of summarizing the etiology, main symptoms, diagnosis, and treatment options.

Case Report

TREATMENT:

The distal splenic artery was embolized during celiac angiography (Figure 4). An abdominal CT examination 3 days after the operation showed that the intestinal edema was significantly decreased (Figures 5, 6) and ascites was significantly reduced. The frequency of diarrhea on the 5th day after the operation was about 4 times/day. Drainage fluid was not seen in the abdominal drainage bag. At follow-up 2 months later, the general condition of this patient was good and the diarrhea and hematemesis had not recurred.

Discussion

PATHOPHYSIOLOGY RELATED TO DIARRHEA AND OTHER SYMPTOMS IN THIS PATIENT:

Splenic arteriovenous fistula and splenic artery aneurysm formed after splenectomy resulted in portal hypertension and portal system compromise, which then led to intestinal wall edema and ischemia due to an engorged colic vein. Later, the blunt trauma to his abdomen caused the aneurysm rupture, leading to retroperitoneal hematoma, further irritating and compromising the already dysfunctional intestine. Consequently, severe diarrhea and bloody ascites developed.

DIAGNOSTIC EVALUATION OF THE DIARRHEA IN THIS PATIENT:

Before further investigation, the patient had the clear eliciting factor of abdominal trauma. In addition, he had a history of splenectomy. The situation in which the chronic diarrhea did not improve after initial symptomatic control, and emerging manifestations such as abdominal and low back pain, indicated the culprit was an underlying organic disorder.

An abdominal CT scan confirmed intestinal wall edema, suggesting the direct cause of his diarrhea. Subsequently, the bloody ascites and abdominal murmur further indicated there was a root cause indirectly leading to his severe diarrhea, which may be related to a late complication of the splenectomy that he underwent 10 years ago. Then, he was diagnosed as having splenic arteriovenous fistula by contrast-enhanced CT scan and celiac angiography. Subsequent treatment by splenic artery endovascular embolization was carried out, after which his intractable diarrhea, intestinal wall edema, and ascites were significantly improved. Hence, we finally determined that the ultimate cause was a splenic arteriovenous fistula.

Conclusions

INSTITUTION WHERE WORK WAS DONE:

This work was done in the General Hospital of the People’s Liberation Army, Beijing, P.R. China.

Source(s) of financial support: the Fourth People’s Hospital of Zunyi City.

References:

1.. Stener B, Arterio-venous shunt in the spleen diagnosed before operation; case report: Acta Chirur Scand, 1955; 108(5); 344-50

2.. Law ST, Wong CK, Chow KC, Loo KT, Splenic arteriovenous fistula: Unusual cause of portal hypertension complicated with gastric variceal bleeding: J Dig Dis, 2012; 13(10); 549-52

3.. Hung CF, Tseng JH, Lui KW, Intractable oesophageal variceal bleeding caused by splenic arteriovenous fistula: Treatment by transcatheter arterial embolization: Postgrad Med J, 1999; 75(884); 355-57

4.. Guillon R, Garcier JM, Abergel A, Management of splenic artery aneurysms and false aneurysms with endovascular treatment in 12 patients: Cardiovasc Intervent Radiol, 2003; 26(3); 256-60

5.. Woźniak W, Mlosek RK, Miłek T, Splenic arteriovenous fistula – late complications of splenectomy: Acta Gastroenterol Belg, 2011; 74(3); 465-67

6.. Deshpande A, Wolfson D, Madanick RD, Clinical challenges and images in GI: Gastroenterology, 2008; 135(1); 329

7.. Tun TN, Punamiya S, Gastric variceal bleeding precipitated by a mycotic splenic arteriovenous fistula in a cirrhotic patient: Radiological diagnosis and endovascular treatment: Singapore Med J, 2014; 55(11); e180

8.. Van der Meer P, Cossi A, Tsao JI, Splenic arteriovenous fistula in a patient with lymphoma: Am J Roentgenol, 1998; 171(5); 1377-79

9.. Ueda T, Murata S, Yamamoto A, Endovascular treatment of post-laparoscopic pancreatectomy splenic arteriovenous fistula with splenic vein aneurysm: World J Gastroenterol, 2015; 21(25); 7907-10

10.. Madsen MA, Frevert S, Madsen PL, Eiberg JP, Splenic arteriovenous fistula treated with percutaneous transarterial embolization: Eur J Vasc Endovasc Surg, 2008; 36(5); 562-64

11.. Alamri NF, Alhariqi BA, Portal hypertension secondary to splenic arteriovenous fistula: Saudi Med J, 2012; 33(8); 904-7

12.. Siablis D, Papathanassiou ZG, Karnabatidis D, Splenic arteriovenous fistula and sudden onset of portal hypertension as complications of a ruptured splenic artery aneurysm: Successful treatment with transcatheter arterial embolization. A case study and review of the literature: World J Gastroenterol, 2006; 12(26); 4264-66

13.. Keller FS, Rösch J, Dotter CT, Bleeding from esophageal varices exacerbated by splenic arterial-venous fistula: Complete transcatheter obliterative therapy: Cardiovasc Intervent Radiol, 1980; 3(2); 97-102

14.. Garrett HE, Mack L, Coil embolization of spontaneous splenic arteriovenous fistula for treatment of portal hypertension: Am J Case Rep, 2017; 18; 386-90

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923