UPPER GASTROINTESTINAL BLEED (UGIB) SECONDARY TO AN AORTA-DUODENAL FISTULA

Clinical case:

We present the case of a 58 year old male, smoker, ex alcoholic with occasional cocaine use and multiple cardiovascular risk factors. He underwent surgical intervention for symptomatic infrarenal pseudoaneurysm with insertion of aortic-bifemoral prosthesis without complications.

Three months afterwards he represented with general malaise, weight loss, nocturnal fever associated with progressive dyspnea and symptomatic hypotension. Physical examination and digital rectal examination was unremarkable. Laboratory test showed anemia with hemoglobin of 7.7 g/dL, 4 gr/dL below his previous level. He received a transfusion of 2 packed red blood cells and an urgent abdominal CT that showed signs of peri-prosthetic infection and of the juxtarenal aorta.

Management:

He was started on empiric antibiotic therapy, but presented with melenas stool suggestive of UGIB. Clinically an aortoenteric fistula was suspected and he was rushed to operating theatre where a covered prosthesis was placed over the existing prosthesis with successful control of the hemorrhage.

Gastroduodenoscopy:

Postoperatively he presented with abdominal pain and poor oral tolerance and an endoscopy was performed that showed the pulsating aorta occupying the totality of the lumen into the second portion of the duodenum.

Management: Due to these findings, the decision was made to surgically intervene to exclude the aortoduodenal fistula by means of a duodenal- jejunum derivation. Despite this the patient presented a torpid clinical course presenting with a massive UGIB three weeks after the intervention.

Conclusion:

Aortoenteric fistulas are infrequent conditions, with high mortality that consist in an abnormal communication between the aorta and the gastrointestinal tract. Classically it presents as an active UGIB, which appears as a bleeding through a small orifice. In rare occasions it is possible to see the entire aortic artery occupying the lumen as in this case.