Recurrent Hematemesis in a Patient With Aorto-enteric Fistula

Abstract

We report a case of an aorto-enteric fistula (AEF) in a patient with history of celiac artery aneurysm and graft repair. AEFs are a communication between the aorta and the adjacent gastrointestinal tract. AEFs are a rare, but life-threatening cause of upper gastrointestinal tract bleeding and should be on the differential in patients with history of abdominal vascular surgery. A 32-year-old woman underwent celiac artery aneurysm resection with aorto-common hepatic artery graft interposition. This was complicated by pancreatic head, common bile duct, and portal vein necrosis requiring Whipple pancreaticoduodenostomy, Roux-en-Y hepaticojejunostomy, and portal vein resection with graft interposition. She also developed a pancreatico-cutaneous fistula, eventually closed by EUS-guided pancreatic pseudocyst gastrostomy. The patient was later reassessed with EGD, which showed a gastro-jejunal (GJ) junction Forrest class III ulcer. The patient presented to our institution with hematemesis, melena, and hemoglobin of 4.2 g/dL. EGD showed the known GJ ulcer with new friability and was treated with epinephrine and argon plasma coagulation. However, the patient returned with hematemesis and repeat EGD showed the GJ ulcer had an adherent clot with a visible vessel which was clipped. Abdominal CT angiography (CTA) did not reveal evidence of acute hemorrhage. The patient returned with GI bleeding and repeat abdominal CTA showed a tubular structure concerning for AEF, with possible erosion of the celiac stump into the jejunal blind limb. Vascular surgery was consulted for endovascular graft of the AEF. AEFs can be spontaneous or secondary to a previous aortic surgery. Aortic pseudoaneurysms and/or grafts can cause fistula through aortic pulsation into the intestinal tract and present with GI bleeding. EGD, CT with contrast, and CTA are the most common imaging modalities that aid in diagnosis. EGD can be useful if a graft or pulsatile mass is visualized, but most AEFs occur in the distal duodenum and may not be seen on EGD. CT with contrast is relatively sensitive for signs of AEF such as loss of peri-aortic fat pad, gas around the graft, fluid or soft tissue collection around the aorta, and IV contrast extravasation into the bowel or around the aorta. As in our case, CTA can be helpful in patients with altered anatomy. In addition to CT findings typical for AEF, CTA has greater spatial resolution allowing better visualization of the aortic contour and side branches.Figure: Gas shadow and inflammation surrounding aorta at the level of celiac stump, likely indicative of anastomotic connection to walled off necrosis, which is adjacent to the jejunum.