1967 Unexplained Massive Recurrent Upper GI Bleeding: A Case of Missed Connection

Abstract

INTRODUCTION: Erosion of an aortic prosthetic graft into the surrounding gastrointestinal structures leads to formation of Aortoenteric fistula (AEF). It occurs after months to years after aortic surgery and may be related to graft infection and can result in torrential Gl bleeding. Here we present a case of recurrent GI bleeding, the cause of which initially remained obscure despite repeated endoscopies. CASE DESCRIPTION/METHODS: 61 y old male with PMH of peripheral vascular disease and femoropopliteal bypass on ASA and Eliquis presented with 3 days of passing black-tarry stools and dizziness. Initial hemoglobin was 7 gm/dL (normal baseline). Urgent EGD up to 2nd part of duodenum revealed clot in the stomach without any lesion or source of bleeding. EGD was repeated the next day due to ongoing melena, which again was nonrevealing. CTA also did not show any active bleeding. Eliquis was discontinued and the patient was discharged. 2 days later, he presented with ongoing melena and dizziness. EGD, however, this time revealed aortic graft eroding into 3rd part of the duodenal wall. He was transferred to a tertiary care center for repair of the fistula. DISCUSSION: AEF is an uncommon but life-threatening complication of aortic reconstructive surgery. Due to the anatomic proximity, most cases involve the duodenum, with the proximal suture line of an aortic prosthesis. It is imperative to inquire about the history of aortic reconstruction patients presenting with Upper GI bleeding, as these patients are considered to have an AEF until proven otherwise. In our case, the remote history of aortic reconstructive surgery was not put in the clinical perspective and aortic graft was overlooked on the CT scan. Both MRI and CT can fail to diagnose AEF and EGD has 50% sensitivity. Endoscopy should include the fourth portion of the duodenum. Prompt recognition and repair of fistula in highly critical for patient survival.