Submitted, Not Presented: Clinical Vignettes/Case Reports-GI Bleeding.

Abstract

Aortoenteric fistula (AEF) is a pathological communication between the aorta and the gastrointestinal tract. We report a rare presentation of a secondary AEF diagnosed by esophagogastroduodenoscopy (EGD), after going unidentified on computed tomography angiography (CTA), in a patient with a history of bilateral aortoiliac bypass for peripheral arterial disease (PAD) who had a one month history of unexplained, intermittent gastrointestinal bleeding. An 85 year-old male, nursing home resident, with extensive history including dementia and PAD with remote bilateral aortoiliac bypass graft presented to the medical intensive care unit with one month of intermittent hematochezia and new onset hematemesis. The month prior, he had several admissions to a local hospital for hematochezia and anemia in which he was evaluated with both EGD and colonoscopy which failed to identify the source of bleeding. This presentation, patient had hematochezia and hematemesis. His presenting hemoglobin (Hgb) was 6.6 g/dL and nasogastric tube returned 550 mL of bright red blood. Upon transfer, his post transfusion Hgb was 12 g/dL and vitals were stable. CTA showed findings concerning for infected aortobifemoral bypass graft. Urgent EGD revealed a normal esophagus, stomach, duodenal bulb and second portion of the duodenum, but an exposed aortic graft was encountered in the third portion of the duodenum without active bleeding (Image 1 and 2). After further discussion with the patient's family detailing the risks and benefits of surgery, the decision was made to provide the patient with comfort measures only and inpatient hospice. He died one day later. An AEF is a conduit between the aorta and the gastrointestinal lumen. Primary AEF forms in patients with no preexisting aortal surgeries, while a secondary AEF occurs in patients with previous history of reconstructive surgery to the aorta. The most common presentation of an AEF is gastrointestinal bleeding. This can vary from herald bleeding to hemorrhagic shock. The diagnosis of AEF can be made using computed tomography. In our case, a secondary AEF was unidentified on CTA and a subsequent EGD was useful in the final diagnosis. Early recognition and diagnosis of AEF is essential as a delay is diagnosis and surgical exploration is almost always fatal (1).Figure: Secondary Aortoenteric Fistula.Figure: Secondary Aortoenteric Fistula.