Primary Aortoenteric Fistulas Research Articles

Staged Repair of Primary Aortoesophageal Fistula.

Primary aortoenteric fistulas are rare with an incidence reported up to .07% at autopsy. Literature review yields few reported cases, and rarer still is a fistula between a normal thoracic aorta and the esophagus. Rather, 83% of cases are associated with an aneurysmal aorta and 54% involve the duodenum. Patients with aortoesophageal fistula (AEF) usually present with a triad of chest pain, dysphasia, and a herald bleed. Without treatment, AEFs will result in exsanguination and are universally fatal; even with traditional open surgical treatment, mortality is reported over 55%. The complex pathology of AEFs makes repair more challenging, given an infected field, friable tissue, and patients who are often hemodynamically unstable. Staged repair using endografts as initial treatment with the primary goal of controlling bleeding and preventing fatal exsanguination has been reported. We present a case where a descending thoracic aorta to esophageal fistula was repaired, and this strategy was utilized.

Case Report; Primary Aortoenteric Fistula Due to Plum Kernel

Introduction: Aortoenteric fistulas are defined as an abnormal connection between the aorta and any portion of the gastrointestinal tract. It can occur after aortic repair surgery or spontaneously (primary). The common clinical features of primary aortoenteric fistula are upper gastrointestinal bleeding, abdominal pain, and pulsatile abdominal mass. The reasons are inflammatory destruction of an aortic aneurysm, infection, tumors and ingestion of foreign bodies. 
 We represent a case of a primary aortoenteric fistula due to plum kernel which is rarely seen.
 Case Report: A 76-year-old man admitted to emergency department with abdominal pain. On computed tomography angiography, there was hypodense restricted lesion with widespread air image which was located around the abdominal aorta. It was determined that abdominal aorta is surrounded by organised hematoma. A plum kernel, was detected in the operating room, was the reason for the aortoenteric fistula. Graft was placed in the abdominal aorta. He died in the first day after surgery.
 Conclusions: Primary aortoenteric fistulas should be considered in differential diagnosis of abdominal pain, upper gastrointestinal bleeding and shock in patient with aortic aneurysm. Kernels of any fruit considered to be harmless just as plum kernel and should be noted that may cause aortoenteric fistula.

Primary Aortoenteric Fistulae: What Every Surgeon Should Know About Its Diagnosis and Treatment

Aortoenteric fistula is a rare finding that is potentially fatal and is usually seen as a fistula between the aorta or an aortic graft and the third part of the duodenum. The type without the presence of an artificial graft is considered as primary and the other type as secondary. The patients usually present with the heralding symptom of minor hematemesis, which later leads to massive and mortal GI bleeding. The most important factor in the diagnosis of an aortoenteric fistula is to have a high clinical suspicion after taking an appropriate and accurate history. In hemodynamically stable patients with clinical suspicion, performing an intravenouscontrast-CT scan of the abdomen and pelvis is of assistance in diagnosis. In general, stable hemodynamics greatly reduces the suspicion for diagnosis. Treatment is often surgical, and in regard to the severity of abdominal contamination or the level of visible infection, the extra anatomical or insitu graft repair is considered as the method of choice. This article tries to transfer our experiences in two patients, each of whom presented with hematemesis and melena without a history of underlying aortic aneurysm.

S2823 Primary Aortoenteric Fistula as a Rare Cause of Gastrointestinal Bleeding

INTRODUCTION: Aortoenteric fistulas (AEF) are formed by an abnormal connection between the aorta and gastrointestinal tract, usually the duodenum, that can lead to life-threatening gastrointestinal hemorrhages. Fistulas can present de novo, known as primary fistulas, or as secondary AEF, which occur due to surgical aortic interventions such as aortic grafts. The annual incidence of primary AEF is 0.007 per million while the incidence of secondary AEF due to aortic repair is 0.6–2%. We present a case of primary Aortoenteric fistula with no prior surgical interventions. CASE DESCRIPTION/METHODS: A 51-year old patient with a past medical history of hypertension, coronary artery disease, and tobacco use was arrived to the hospital with complaints of bright red blood per rectum. A CT abdomen/pelvis revealed a 6.4 cm infrarenal aortic aneurysm (AA) and a right common iliac artery aneurysm with complete thrombosis of the external iliac artery. An EGD showed the duodenum with an opening and oozing fresh blood suggestive of an AEF, along with a pulsatile mass, most likely the AAA. Patient was then emergently taken to the OR and had an endovascular stent placed with successful exclusion of the infrarenal aortic aneurysm. Thereafter, a colonoscopy performed by colorectal surgery showed a large pulsatile blue mass extrinsically compressing the colon in multiple locations; subsequently aborted at the splenic flexure due to this extrinsic compression. The patient then underwent open repair which found an aortoduodenal fistula in the 4th duodenal segment. The duodenum was resected with primary anastomosis, the aortic stent was explanted, aortic aneurysm resected, and reconstruction performed. After surgery, the patient improved clinically and had no further bleeding. DISCUSSION: Primary AEFs are a devastating condition which are difficult to identify. The likely cause, an abdominal aortic aneurysm, can be clinically silent and typically lack any history of prior aortic surgical interventions. When symptoms do occur, it is typically GI bleeding ranging from mild to an exsanguinating hemorrhage, with other nonspecific symptoms including malaise, weight loss, and abdominal pain. CT angiography is a quick initial diagnostic tool but if there was no prior suspicion of primary AEF, an EGD would reveal a clot or fresh blood in the duodenum. With such findings on endoscopy, it is important to quickly involve vascular surgery for emergent repair via open or endovascular techniques to avoid adverse outcomes.Figure 1.: Endoscopic view of primary Aortoenteric Fistula in the duodenum.

Surgical Management for Secondary Aortoduodenal Fistula

Aortoenteric fistulas (AEFs) are uncommon but life-threatening conditions carrying a high mortality rate. This is defined as an abnormal connection between the aorta and the lumen of the gastrointestinal tract. There are two known forms of AEF, primary and secondary. Primary is most often the result of compression of an abdominal aortic aneurysm against the intestines, whereas secondary is due to an erosion of an aortic prosthetic graft into the surrounding gastrointestinal structures. The relative incidence of primary AEF ranges from 0.1 to 0.8%, and secondary from 0.4% to 2.4%. Mortality rates after surgical treatment of secondary AEFs range from 14% to 70%. This report describes the surgical approach of a secondary aortoduodendal fistula after placement of end to side aortobifemoral bypass for claudication symptoms in a 58-year-old female presenting with gram-negative bacteremia.

Partially Covered Transjugular Intrahepatic Portosystemic Shunt Endograft for Repair of a Primary Aortoenteric Fistula

Aortoenteric fistulae (AEF) are a rare cause of life-threatening gastrointestinal hemorrhage. AEF are divided into primary and secondary types. Secondary fistulae are more common and occur after prior aortic interventions, namely aneurysm repairs. Less common is primary aortoenteric fistulae (PAEF), which most commonly arise de novo from trauma or underlying neoplastic, infectious, or rheumatologic conditions. Although PAEF are associated with high mortality and morbidity, there have been several case reports documenting temporization of PAEF with stent grafts. These measures are effective in acute settings, often with unstable patients. This approach also provides time for the patient, family and their care team to decide on definitive treatment. This is especially important as many of these patients have serious underlying pathology, or will need to undergo extensive treatment for definitive care. Here, we present a case of PAEF in a patent with Stage IV renal malignancy. The bleed was controlled with the use of a 12 mm VIATORR endoprosthesis (W. L. Gore and Associates, Inc., Flagstaff, Arizona, USA), typically used in transjugular intrahepatic portosystemic shunts. The report demonstrates how an endoprosthesis originally designed for hepatic interventions can serve as an endovascular stent graft in extenuating circumstances. This report also aims to highlight the importance of following endovascular principles and the post-treatment care of patients with PAEF.

Aortoenteric Fistula: A Rare Cause of Gastrointestinal Bleed Requiring Emergent Surgical Intervention

Introduction Aortoenteric fistula is a rare life-threatening diagnosis that may initially present as a minor gastrointestinal bleed, but will inevitably become a surgical emergency. This case highlights the need for a high clinical index of suspicion of aortoenteric fistulas in patients with a history of prior aortic surgery to avoid diagnostic delay, which is often fatal. Case A 81-year-old male with a past medical history significant for an abdominal aortic aneurysm repair and partial colon resection who presented to the Emergency Department complaining of bright red blood per rectum over the past 24 hours. Upon arrival, his blood pressure was 133/60, pulse 101, RR 18, temperature 97.7, and O2 saturation of 98% on room air. On physical exam, he had no abdominal tenderness. He was found to have a hemoglobin of 7.8 from a baseline of 10.2. The patient was started on pantoprazole and an emergent upper endoscopy was performed, which showed evidence of necrotic tissue in the D2 portion of the duodenum. Surgery was consulted. An emergent exploratory laparotomy was done, which revealed a fistula between the duodenum and the aorta. GI surgery mobilized the duodenal fistula by removing adhesions, and vascular surgery transected the aorta and removed the graft. The patient was stable after the excision of aorto-duodenal fistula and oversewing of the aorta. Discussion Aortoenteric fistulas (AEFs) are uncommonly encountered but are important to consider in the differential diagnosis of gastrointestinal bleeding in patients who have had prior aortic surgery. Primary AEFs arise de novo between the aorta and bowel, while secondary AEFs (SAEFs) are usually caused by prosthetic vascular grafts eroding into the intestine as in this patient. Pulsation of vascular grafts against the intestine may cause erosion of the duodenal wall, leading to hemorrhage. Any part of the gastrointestinal tract may be involved, but most commonly it is the third part of the duodenum. SAEFs may present as gastrointestinal bleeding and occasionally as sepsis. Patients initially have “herald bleeding” - intermittent episodes of bleeding due to thrombus formation -followed by massive hemorrhaging. A CT abdomen with contrast is the best diagnostic test if an AEF is suspected; AEFs may also be detected on endoscopy as in this patient. Emergency exploratory laparotomy is warranted immediately upon diagnosis, as mortality is 100% if not surgically treated.

Toothpick-induced aortoenteric fistula presenting as sepsis

Aortoenteric fistulas (AEF) are a rare but life-threatening cause of gastrointestinal (GI) bleeding. We present the case of a primary AEF caused by ingestion of a toothpick by a 47-year-old...

Management of bleeding and infections in the context of visceral surgery

Bleeding and vascular infections are serious potential complications during abdominal general surgery. The management of bleeding depends on the extent and localization and can range from the application of hemostatics to vascular sutures, interpositioning and ligatures. The use of prosthetic biomaterials implanted endoluminally or during open reconstruction permits palliation of potentially fatal conditions. The overall incidence of infections involving vascular prostheses is relatively low because of routine antibiotic prophylaxis prior to surgery, refinements in sterilization and packaging of devices and careful adherence to aseptic procedural and surgical techniques. When infections occur detection and definitive therapy of the vascular prosthesis are often delayed and the management is complex and tedious. Infections involving vascular prostheses are difficult to eradicate and in general, surgical therapy is required often coupled with excision of the prosthesis. Keys to success include accurate diagnostics to identify the organism and extent of graft infections, specific long-term antibiotic therapy and well-planned surgical interventions to excise and replace the infected graft and sterilize the local tissue. Regardless of the technique used to eradicate graft infections, success is measured by patient survival, freedom from recurrent infection and patency of revascularization. Even when treatment is successful, the morbidity associated with vascular graft infections is considerable. Aortoenteric fistulas (AEF) are a rare (incidence < 1.5 %) but often fatal complication. Primary diagnosis of AEF remains difficult. Computed tomography (CT) and fluorodeoxyglucose positron emission tomography CT (FDG-PET-CT) are the diagnostic tools of choice. Therapy consists of an urgent individualized interdisciplinary surgical approach with primary axillofemoral bypass and secondary prosthesis explantation or in situ replacement and subsequent bowel resection. Endovascular aortic repair (EVAR) is reserved for primary aortoenteric fistulas in patients with no signs of infection or in emergency cases as a bridging method.

Rifampin Soaking Dacron-Based Endografts for Implantation in Infected Aortic Aneurysms—New Application of a Time-Tested Principle

Infections involving the aorta are associated with high rates of morbidity and mortality, and their management is complex. Saturating Dacron grafts in rifampin (60 mg/mL) inhibits the growth of organisms commonly found to be involved in both primary aortic infections and aortoenteric fistulas. Open repair and replacement of the aorta with rifampin-soaked Dacron grafts is frequently used in clinical practice and is considered a viable option for open repair with a low recurrence of infection; however, the morbidity and mortality of the procedure is significant. More recently, patients who are high risk for open surgery have been managed with endografts to treat infected aortas and aortoenteric fistulas with limited success, a high recurrence rate, and elevated mortality. We describe a technique to expose Dacron endografts with rifampin delivered via injection port or into the sheath before deployment in selected patients with aortic infections. We used this novel technique in 2 patients who were high risk for open repair: 1 with a bleeding aortoenteric fistula and 1 with mycotic abdominal aortic aneurysm. The first patient tolerated 1.5 years without surgical correction of the duodenal defect after placement of a rifampin-treated endograft. This allowed her to recover and ultimately undergo definitive repair under elective circumstances. Our second patient remains without evidence of recurrence 1 year after implantation for a mycotic abdominal aortic aneurysm. Following the principles of rifampin use in open vascular repairs, treating Dacron endografts with rifampin may add similar antimicrobial resistance when used to treat selected aortic infections.

Double Primary Aortoenteric Fistulae: A Case Report of Two Simultaneous Primary Aortoenteric Fistulae in One Patient

Aortoenteric fistula is a rare but potentially fatal condition causing massive gastrointestinal bleeding. In particular, double primary aortoenteric fistulae are vanishingly rare. We encountered a 75-year-old male patient suffering from abdominal pain, hematochezia, hematemesis, and hypotension. His computed tomography images showed abdominal aortic aneurysm and suspected aortoenteric fistulae. During surgery, we found two primary aortoenteric fistulae. The one fistula was detected between the abdominal aorta and the third portion of the duodenum, and the other fistula was detected between the abdominal aorta and the sigmoid colon. We conducted the closure of the fistulae, the exclusion of the aneurysm, and axillo-bifemoral bypass with a polytetrafluoroethylene graft. The patient was discharged with no complications on the 21st postoperative day.

Primary Aortoenteric Fistulae: The Challenges in Diagnosis and Review of Treatment

Primary aortoenteric fistula (PAEF) is a potentially fatal condition which poses a considerable diagnostic challenge because of its infrequency and the nonspecific presentation. We report the case of a 61-year old woman who presented to her general practitioner with nonspecific and intermittent rectal bleeding, hematemesis, and weight loss. Four days later, she presented to the emergency department with worsening symptoms. The investigations revealed a new small 3.8-cm abdominal aortic aneurysm on computed axial tomography (CT), however, no evidence of a fistula was observed either on CT scan or endoscopy. Two days later, she became unstable requiring an emergency laparotomy and was taken to the operation theater for an en bloc resection of a segment of the aorta and duodenum with exclusion of the duodenum with an inline reconstruction of the aorta using a Dacron graft for a PAEF. The published data were reviewed to address the issues of optimal diagnostic methods and management of PAEF.

An Unusual Case of Aortoduodenal Fistula Associated With Acute Pancreatitis: A Case Report

Purpose: Aortoduodenal fistula is a direct communication between the aorta and duodenum, most often secondary to surgery. We present a case of aortoduodenal fistula associated with acute pancreatitis. A 50-year-old lady presented with 2 episodes of massive hematemesis and severe epigastric pain of 12 hour duration. Past medical history was significant for left renal cell carcinoma with metastasis to para-aortic lymph nodes treated by left nephrectomy and chemotherapy 5 yrs prior to presentation. There was no history of alcohol or tobacco abuse. Vital signs showed blood pressure 80/50 mm Hg and heart rate 110/min. Physical examination was significant for pale mucous membranes, severe epigastric tenderness and positive bowel sounds. Lab data showed hemoglobin 8 gm/dl; WBC 20,000/ul; serum creatinine 2 mg/dl; serum amylase and lipase were elevated at more than 6 times and 20 times the upper normal limits of the lab values respectively. Patient was diagnosed with acute pancreatitis and was started on intravenous fluid boluses with bowel rest. Endoscopy showed friable, delicate 4x3 cm blood clot, adherent to the underlying mucosa in the proximal duodenum. Without disturbing it, epinephrine was injected in to the duodenal mucosa surrounding the blood clot. As an effort to stop the bleeding, patient underwent laparotomy, which showed fistula in the aorta communicating with the duodenum at the site of ligament of Trietz. Necrotic debris was found at the aortic end of the fistula. There was mild edema of the pancreas but no evidence of pancreatic necrosis. Patient succumbed to massive blood loss during attempted surgical correction of aortoduodenal fistula. Aortoduodenal fistula is one of the rare and dreaded causes of upper gastrointestinal bleeding. The most common site is the third or fourth part of duodenum. The most common cause of primary aortoenteric fistulas in the U.S. is an atherosclerotic aortic aneurysm. The classic triad of gastrointestinal bleed, pain and a pulsatile mass is present only in 11% of the cases. Endovascular repair and stent graft implantation have important role in the treatment of the aortoenteric fistula. After thorough English literature search, no case report of aortoduodenal fistula associated with acute pancreatitis was found. In our case, aortoduodenal fistula with necrotic debris at the aortic end was most likely secondary to metastasis from renal cell carcinoma. As the other causes of pancreatitis were ruled out, the presence of blood clot in the duodenum and massive blood loss could have triggered intense ischemia and pancreatic inflammation leading to acute pancreatitis in this case.

Gastrointestinal: Aortoenteric fistula

A 65 year old man with diabetes mellitus and hypertension, presented with recurrent hematemesis and melena of 20 days’ duration requiring multiple blood transfusions. Physical examination was unremarkable except for pallor. An upper gastrointestinal endoscopy up to the duodenojejunal flexure and a colonoscopy were performed and found to be normal. He underwent a contrast enhanced computed tomogram (CECT) of the abdomen. The CECT of the abdomen revealed an atherosclerotic aortic aneurysm adherent to the third part of duodenum and adjacent inferior vena cava suggesting an aortoenteric fistula missed on endoscopy (Figure 1A and 1B). He was considered a high risk candidate for surgery and therefore was subjected to endovascular stent graft placement (Advanta V12 covered stent 16 mm × 61 mm, Atrium; Figure 2A and 2B). He did not develop any further bleeding following discharge from hospital. Contrast enhanced computed tomogram (axial image) showing A) an atherosclerotic aortic aneurysm adherent to the inferior vena cava (arrow) and B) The aneurysm is seen adherent to the 3rd part of duodenum (arrow). Digital subtraction angiogram of the abdominal aorta showing A) the aneurysm (arrow) prior to stenting and B) the aneurysm being excluded after stenting. Aortoenteric fistulas are a rare cause of acute gastrointestinal (GI) hemorrhage, but they are associated with high mortality if undiagnosed or untreated. The third portion of the duodenum is the most common site for aortoenteric fistulas. Most patients present with an initial ‘herald’ hemorrhage that is manifested by hematemesis, melena or hematochezia. This may be followed by massive bleeding and exsanguination. The classic presentation is that of an elderly patient with massive upper GI hemorrhage, a pulsatile abdominal mass and abdominal (or back) pain. However, this triad is present in only 11% of patients. Our case was unusual with respect to the intermittent character of the hemorrhage lasting for almost a month. Intermittent bleeding is possible when a blood clot temporarily seals the fistula. A negative upper GI endoscopy can be explained by thrombus formation, presence of a tiny fistula or hypotension. The most common cause of primary aortoenteric fistulas is an atherosclerotic aortic aneurysm (as was seen in our case); other causes include infectious aortitis due to syphilis or tuberculosis. Secondary aortoenteric fistulas are caused by a prosthetic abdominal aortic vascular graft eroding into the duodenum, penetrating duodenal ulcer, tumour invasion, trauma, radiation therapy, and foreign body perforation. CECT of the abdomen is helpful with a detection rate of 30–61%. Surgery is generally the preferred mode of treatment. Age and major coexisting illnesses increase the morbidity and mortality associated with surgery. The advent of interventional radiology and endovascular stent graft placement has resulted in a quicker, safer and more successful management of this life threatening entity. Contributed by

Primary Aortoenteric Fistula Due to a Swallowed Twig in a Three-year-old Child

Aortoenteric fistulae are infrequent causes of gastrointestinal bleeding and usually occur as a late complication of aortic aneurysm repair. Primary aortoenteric fistulae are very rare and most have an aetiological association with atherosclerotic aneurysmal disease. 1,2 We report a primary aortoenteric fistula (PAEF) occurring in a 3 year old as a result of duodenal perforation after ingestion of a twig. To our knowledge this is the first case of a primary aortoenteric fistula reported in a child. Emergency aortic surgery in children needs certain considerations which are briefly discussed.

Primary Aortoenteric Fistula and Endovascular Repair

Primary aortoenteric fistulae are difficult conditions to diagnose and manage. A 35-year-old male developed massive upper gastrointestinal hemorrhage due to a primary aortoduodenal fistula. Previous radiation therapy and retroperitoneal lymph node dissection for germ cell cancer with resultant dense retroperitoneal fibrosis made open aortic repair impossible. Endovascular balloon occlusion of the aorta and stent graft repair of the primary aortoduodenal fistula was performed. At 1-year follow-up, there is no clinical or radiographic evidence of stent-graft infection. Endovascular techniques and repair are important approaches to consider during the management of complicated primary aortoenteric fistulae when open surgical repair is not feasible.

Diagnosis of Aortoenteric Fistulas with CT Angiography

To describe the diagnostic findings of primary and secondary aortoenteric fistulas (AEFs) at computed tomographic (CT) angiography in a cohort of patients known to have AEF and to correlate those findings with those from endoscopic gastroduodenoscopy (EGD) and surgery. CT angiography was performed in nine patients with AEF. There were four men and five women aged 43-85 years (mean age, 67 years). All CT angiograms were retrospectively reviewed for signs of AEF. Reports from EGD, surgery, and pathologic examination were also reviewed. One patient had a primary AEF, and eight patients had a secondary AEF. Findings at CT angiography were suggestive of the diagnosis in all nine patients. The two definitive CT angiographic findings were identification of the graft within the bowel lumen in two patients (22%) and active extravasation in one patient (11%), allowing the definitive diagnosis in three of the nine patients (33%). Secondary signs, which helped predict the high likelihood of the diagnosis but could also be seen in graft infection or inflammation without AEF, were as follows (in descending order of frequency): effacement of the periaortic or perigraft fat plane and the fat plane between the aorta and bowel (nine patients, 100%), perigraft soft tissue (nine patients, 100%), bowel wall thickening adjacent to the graft (eight patients, 89%), perigraft fluid (seven patients, 78%), perigraft hematoma (six patients, 67%), pseudoaneurysm or aneurysm bulge (six patients, 67%), ectopic gas (five patients, 56%), and dystrophic vascular graft calcification (one patient, 11%). The diagnosis was confirmed surgically in seven patients and with clinical follow-up in two. CT angiography is well suited for helping make or suggesting the diagnosis of AEF and is potentially more accurate than EGD.

Paraprosthetic Extravasation of Enteric Contrast: A Rare and Direct Sign of Secondary Aortoenteric Fistula

Peirce RM, Jenkins RH, MacEneaney P(AQ1) n aortoenteric fistula is a communication between the aorta and the gastrointestinal tract. This condition is a rare cause of massive, lifethreatening gastrointestinal hemorrhage. Primary aortoenteric fistulas are typically caused by arteriosclerosis and occur in the elderly. Secondary aortoenteric fistulas (SAEFs) are uncommon complications of vascular surgical procedures. Presentations of SAEF can be straightforward but are notorious for elusive and temporally remote presentations. The symptoms of SAEF are variable and depend on the site of the graft infection. Infected femoral components in a patient may present with a fever, local tenderness, and, occasionally, purulent drainage through a sinus tract in the thigh. Intraabdominal infections tend to be more nebulous; malaise, back pain, elevated white blood cell count (WBC), and abdominal complaints are the usual presentation. These features mimic more common disease entities, making diagnosis difficult. Proving the existence of an SAEF radiographically can be difficult. In this article, paraprosthetic extravasation of enteric contrast, a rare and direct sign of SAEF, verified aorto-to-enteric communication on CT. Case Report A 72-year-old woman arrived at our emergency department with a fever, elevated WBC count, abdominal pain, and purulent groin drainage (Fig. 1). The patient had aortobifemoral prosthesis placement at an outside institution 6 weeks earlier. Because of abnormal renal function, a CT scan of the abdomen and pelvis was performed with enteric contrast only (meglumine diatrizoate [Gastrografin], Mallinckrodt). CT revealed a ring of high-contrast material and air in the paraprosthetic space of the left iliac limb of the graft. The contrast and air tracked superiorly, to the level of the aortic portion of the graft and inferiorly into the groin. This represented leakage of enteric contrast from the bowel. CT findings indicated an aortoenteric fistula and were confirmed at surgical exploration. Laparotomy revealed an infected aortobifemoral graft with a large intraabdominal collection of purulent fluid just behind the duodenum, anterior to the graft. The infected fluid collection extended into the left limb of the graft, with associated erosion into the adjacent sigmoid colon. The infected graft was removed and an aorto-to-popliteal bypass graft was inserted. Culture of the wound drainage revealed mixed bowel flora. The patient was treated with IV antibiotics and experienced a complicated postoperative course. However, the patient fully recovered and returned home weeks later.

Uso de una ‘cápsula endoscópica’ para el diagnóstico de fístulas aortoentéricas. A propósito de un caso

Summary Introduction Aortoenteric fistulas or enteric erosion by prosthetic graft in the aortic territory in septic patients can be difficult to diagnose because of its, sometimes masked and insidious, clinical features, which makes early diagnosis one of the best guarantees when establishing a quick-acting effective therapy. Casereport Male aged 66 who had been submitted to surgery five years earlier for an aortobifemoral bypass because of an aorto-iliac occlusive pathology. At our centre he presented with a septic picture with a large retroperitoneal abscess detected by means of a computerised axial tomography (CAT) scan, and which covered the left branch of the graft. Suspected diagnosis was a secondary aortoenteric fistula caused by pressure from the duodenum on the graft, and the digestive tract was explored by using an ‘endoscopic capsule’, which consists in an encapsulated, disposable colour camera that shows images compatible with the direct visualisation of the graft through the opening of the duodenum. The diagnosis of enteric erosion by prosthetic graft was confirmed during the surgical intervention and the infected graft was removed with ligature of the aortic stump, following an axillo-bifemoral extra-anatomical bypass. The retroperitoneal abscess was also cleaned and drained at the same time. Conclusion The use of capsule endoscopy is considered to be a valid option and another possible method of diagnosis in the management of primary and secondary aortoenteric fistulas or enteric erosion by prosthetic grafts, together with classical endoscopy, when the lesions are located distally to the fourth portion of the duodenum or when other imaging techniques are not conclusive.

Primary Aortojejunal Fistula: A Case Report

Primary aortoenteric fistulae (AEFs) are extremely rare vascular entities, with fewer than 250 cases reported in the world medical literature as of 1996. Incidence is less than 1 per cent, with a mortality ranging from 33 to 85 per cent. Atherosclerosis remains the most common etiology, accounting for more than two-thirds of the cases reported. Other etiologies include carcinoma, ulcers, gallstones, diverticulitis, appendicitis, and foreign bodies. Early diagnosis is crucial for survival and mandates recognition of the typical "herald bleed." Additional findings on initial presentation frequently include flank pain, abdominal pain, hematemesis, melena, and an abdominal mass. More than 80 per cent of primary AEFs involve the duodenum, with the overwhelming majority located in the third or fourth portion. Successful management of primary AEF requires a high index of suspicion for diagnosis and prompt surgical intervention for survival.