A Rare Case of Aortoduodenal Syndrome

Abstract

Purpose: A 78 yo male with hypertension and CKD presented for evaluation of acute on chronic renal failure. A renal ultrasound incidentally revealed a large 4 cm × 6 cm × 10 cm infra-renal abdominal aortic aneurysm. He was evaluated by vascular surgery who planned an open repair in the near future. 4 days later the patient presented to the emergency department with abdominal pain, nausea and intolerance to po intake. Abdominal exam revealed tenderness, distention and a pulsatile abdominal mass. Significant findings upon work up included hypotension, a creatinine of 5.1 and ST segment changes on EKG. A NG tube was placed which drained 1700 cc fluid with symptomatic improvement. CT showed a proximal duodenum which was obstructed just below the superior mesenteric artery takeoff due to direct compression from the large AAA. The patient underwent cardiac workup for his acute MI. Prior to surgical repair of his AAA he underwent a CABG X 3. Approximately 2 weeks later, after aggressive nutritional support, he successfully underwent an open AAA repair with a tube graft. He is currently in a rehabilitation facility doing well. Methods: Results: Conclusion: Aortoduodenal syndrome is a clinical entity rarely reported in the gastroenterology literature. It was first described in 1905 by William Osler in an article entitled “Aneurysm of the Abdominal aorta.”1 There have been fewer than 30 cases reported in the literature. The AAA compresses the superior mesenteric artery or the transverse segment of the duodenal wall. Patients present with emesis, pulsatile abdominal mass, abdominal pain, weight loss, and electrolyte disturbances.2 The diagnosis should be suspected in a patient with known vascular disease, pulsatile abdominal mass and signs of gastric outlet obstruction. Initial workup should include CT, UGI barium study or EGD to rule out other causes of gastric outlet obstruction. Treatment is initially supportive with attention to nutritional status prior to surgical vascular repair. Osler W. Aneurysm of the abdominal aorta. Lancet 1905;166:1089–96. Deitch J et al. AAA causing duodenal obstruction: 2 case reports and review of the literature. J of Vasc Surg 2004;40:543–7.Figure