Abstract
Primary duodenocaval fistulae are exceedingly rare and associated with high morbidity and mortality rates. The authors report a 56-year-old man with a duodenal ulcer and sepsis associated with persistent Vancomycin-resistant enterococcal (VRE) bacteremia and respiratory distress caused by recurrent pulmonary emboli. Computerized tomography scanning and caval venography identified a suprarenal thrombus and duodenocaval fistula. At laparotomy, caval thrombectomy, internal jugular patch angioplasty, and primary duodenal closure were performed. Microscopic examination disclosed gram-positive bacteria and vegetable matter within the thrombus. Sepsis resolved postoperatively.
Duodenocaval fistulae are a rare clinicopathologic entity with only 23 previously published cases, six from duodenal ulcers. Other inciting conditions include trauma, renal cell cancer with subsequent nephrectomy and irradiation, foreign body ingestion, and caval filter presentation. The clinical presentation is typically sepsis and gastrointestinal hemorrhage. Mortality rate is greater than 50%. The existence of caval thrombus associated with duodenal ulcer and subsequent thrombectomy has not been described previously.
Successful treatment of duodenocaval fistulae requires a high index of suspicion and rapid assessment. Early surgical intervention is the only definitive management strategy.
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