Abstract
ABSTRACTAortoduodenal fistula (ADF) is the most common type of aortoenteric fistula (AEF). This is a rare entity, which produces communication between an abdominal aortic aneurysm (AAA) and the gastrointestinal tract (GIT), resulting in massive gastrointestinal bleeding. AEF/ADF is difficult to recognize clinically, with the classical triad of symptoms including a pulsating, palpable mass, abdominal pain, and GIT bleeding. AEF/ADF can be classified into primary when a communication between an AAA and the GIT develops with no history of prior aortic reconstructive surgery, and secondary, where the communication is on the background of previous aortic reconstructive surgery. Herein we present a case report of a 75-year-old Caucasian male patient with a clinical history of AAA, who presented with massive GIT bleeding and expired shortly after. An autopsy revealed communication between an atherosclerotic AAA and the lower third of the duodenum.
Highlights
Aortoenteric fistulas (AEF) can be classified based on their location, with the most common site being the lower third of the duodenum - aortoduodenal fistula (ADF), with other sites including the stomach, other parts of the small intestine, colon, and esophagus.[2,5,6]
Histopathology of the specimens from the area of the primary ADF (PADF) revealed an atherosclerotic nature of the aneurysm, fibrinoid necrosis of the aortic wall, and hemorrhagic changes in the wall and mucosa of the adjacent duodenal wall, without any evidence of duodenal ulcers or ischemic change (Figure 4)
The cause of death was determined as complicated atherosclerosis of the abdominal aorta, with two atherosclerotic abdominal aortic aneurysm (AAA) and bilateral subtotal atherosclerotic occlusion of the femoral arteries, a PADF with massive gastrointestinal tract (GIT) hemorrhage, and acute severe post-hemorrhagic anemia
Summary
Aortoenteric fistulas (AEF) are communications between an abdominal aortic aneurysm (AAA) and the gastrointestinal tract (GIT), resulting in massive intraluminal hemorrhage.[1,2,3] These conditions are difficult to diagnose clinically as patients present in a severely deteriorated condition, hemodynamically unstable, with severe gastrointestinal bleeding such as hematemesis, melena, rectorrhagia, or a combination of these.[2]Clinical history of AAA or aortic reconstructive surgery, a palpable, pulsating abdominal mass, and abdominal pain can be of aid; due to the rarity of the condition, the only specific findings and the gold standard for diagnosis remains an abdominal computer tomography (CT) scan.[2,3,4]AEF can be classified based on their location, with the most common site being the lower third of the duodenum - aortoduodenal fistula (ADF), with other sites including the stomach, other parts of the small intestine, colon, and esophagus.[2,5,6] Similar conditions have been described with connections to the bronchial tree (aortobronchial fistula), aorto-cardiac fistulas, and aorta-venous (aortocaval) fistulas.[6,7,8,9] Further AEF/ADF can be classified into primary fistulas, developing de novo from direct communication between an AAA and the GIT, and secondary, where the communication between the aorta and GIT develops on the background of previous aortic reconstruction surgery.[1]. Clinical history of AAA or aortic reconstructive surgery, a palpable, pulsating abdominal mass, and abdominal pain can be of aid; due to the rarity of the condition, the only specific findings and the gold standard for diagnosis remains an abdominal computer tomography (CT) scan.[2,3,4]. AEF can be classified based on their location, with the most common site being the lower third of the duodenum - aortoduodenal fistula (ADF), with other sites including the stomach, other parts of the small intestine, colon, and esophagus.[2,5,6] Similar conditions have been described with connections to the bronchial tree (aortobronchial fistula), aorto-cardiac fistulas, and aorta-venous (aortocaval) fistulas.[6,7,8,9] Further AEF/ADF can be classified into primary fistulas, developing de novo from direct communication between an AAA and the GIT, and secondary, where the communication between the aorta and GIT develops on the background of previous aortic reconstruction surgery.[1]
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