Introduction:
Aorto-jejunal fistula (AJF) is a very rare, life threatening condition which may result
in catastrophic gastrointestinal (GI) bleeding. Secondary AJF is usually associated
with a history of previous surgical repair of an abdominal aortic aneurysm (AAA).
Methods:
An 86-year-old woman with intermittent severe obscure-overt GI bleeding (with negative
upper and lower GI endoscopies) was transferred as a tertiary referral to our institution
for further investigation and management. Small bowel capsule endoscopy (SBCE) had
shown active bleeding within the proximal jejunum. The patient's history of AAA Dacron-graft
repair 9 years previously, raised our suspicion of a possible aorto-enteric fistula
(AEF).
Results:
Although cross-sectional imaging (CT) had demonstrated close proximity of a jejunal
loop to the aortic Dacron graft, the scan was deemed to be inconclusive. In light
of the history, we proceeded to perform an urgent anterograde double-balloon enteroscopy
(DBE) for direct endoscopic assessment of the small bowel. Our suspicions were confirmed
and a definitive diagnosis of an AJF was clinched when the external surface of part
of the Dacron graft was seen to bulge through the jejunal wall at an estimated insertion
depth of 60 cm post-pylorus (video).
Conclusions:
Secondary AEFs affect up to 1.6% of patients who undergo AAA repair; the jejunum is
involved in only about 9% of these cases. In view of the associated mortality that
ranges between 22 – 100%, prompt, definitive diagnosis remains critical. To the best
of our knowledge, this is the first report of AJF identified by DBE and highlights
the effectiveness of this endoscopic modality in providing an irrefutable diagnosis
of an AEF when this lies beyond the duodenum.
