An Unusual Recurrence of Obscure Gastrointestinal Bleeding

Abstract

Purpose: A 66-year-old female presented with melena and hematochezia for the past 3 weeks. She had a history of peptic ulcer disease and abdominal aortic aneurysm repair in 1989. She denied NSAID use or abdominal pain. Two months ago, she presented with melena and had an upper endoscopy (EGD) that showed 5 arteriovenous malformations in the duodenal bulb which were treated with thermal therapy successfully. Subsequently, she was seen multiple times in the hospital with melena and hematochezia. Prior work-up with an EGD was normal and a colonoscopy showed bright red blood in the colon with no bleeding source. Tag RBC was negative. After transfer, a repeated EGD up to the distal duodenum was normal and colonoscopy revealed blood in the entire colon but no source of bleeding identified. To evaluate for possible aortoenteric fistula (AEF), a CT showed a graft bypassing the native abdominal aorta and iliac arteries with inflammation around the infrarenal abdominal aortic bypass graft. Also, there was an occlusion of the bypass right iliac artery system with a surrounding fluid collection suggestive of infection. No fistulas were seen. Since the patient continued bleeding, a video capsule was recommended and showed a submucosal mass in the proximal jejunum with failure of the capsule to progress beyond the small bowel. A following enteroscopy showed a foreign body in the mid jejunum suspicious for an endovascular graft eroding through the small bowel wall. She went to surgery for axillary bifemoral bypass. An exploratory laparotomy showed an infected aortic graft with a large AEF connecting the right iliac graft limb with the jejunum. The infected graft was removed and the affected jejunum was resected. AEF is a rare cause of acute GI bleed but is associated with high mortality if undiagnosed and untreated. The distal duodenum is the most common site for AEF, however, in our case, we presented an unusual fistula between the infected iliac limb graft and the jejunum. This should be considered in all patients with recurrent GI bleed and a history of infected prosthetic vascular graft. A high index of suspicion, early diagnosis and prompt appropriate surgical intervention are crucial for survival.Figure: No Caption available.