An Extremely Rare Case of Secondary Aorto-enteric Fistula in a Filipino Patient with Herald Bleed

Alyssa H. Chan, MD; Jespeed Marvel Delos Santos, MD; Marc Julius H. Navarro, MD
St. Luke’s Medical Center – Quezon City

Significance: Secondary aortoenteric fistula (SAEF) is a fistulous communication between the duodenum and the aorta. SAEF is a rare yet lethal complication of abdominal aortic reconstruction which arises months to years after aortic surgery. Herald bleeding refers to a bleeding episode associated with abdominal pain that occurs before a severe hemorrhage. This is a case of SAEF in a young male who presented with massive hematochezia.

Clinical Presentation: A 32-year-old male with past medical history of abdominal aortic aneurysm repair presented with herald bleeding of 3 weeks’ duration. Gastroscopy and Colonoscopy showed unremarkable results. Blood pressure was 100/60 mmHg with cardiac rate of 110 bpm. Physical examination revealed generalized pallor and epigastric tenderness without any peritoneal signs. Laboratory analysis showed hemoglobin of 7.9 mg/dL, platelets of 251,000 /?L, and INR of 1.26.

Recommendation: This is the first case of SAEF documented at our institution, and possibly within the nation as well. It is an extremely rare condition with an estimated annual incidence of 0.036–1.6%. Every patient presenting with UGIB with a history of aortic graft surgery should be presumed to have an aortoenteric fistula until proven otherwise. A high index of suspicion is key to its diagnosis and management. All patients should undergo endoscopy as soon as possible as prompt surgical intervention is the key to survival among these patients.

Results: Tagged RBC scan was negative. Antegrade Push Enteroscopy showed a SAEF with eroding graft at segment D3-D4. Mesenteric Angiogram showed the D3 segment adherent to the infrarenal abdominal aorta at the level of the proximal anastomosis. Exploratory laparotomy revealed the secondary aortoduodenal fistula at D3 segment with multiple pockets of necrotic tissue and densely adherent to the native aorta and graft. The patient underwent repair of SAEF and post-operative course was complicated by sepsis and DIC and eventually went into arrest on his fourth week.

Lorem ipsum dolor sit amet, consectetur adipiscing elit. Etiam turpis eros, lacinia eget elementum commodo, laoreet a nisi. Mauris porttitor lectus sed dolor lacinia viverra. Donec lobortis posuere purus, vitae volutpat orci fringilla vitae. Quisque a quam non nunc convallis cursus.

All the manuscripts must be submitted on line thru JRRE Secretariat (jrre2016@yahoo.com.ph). There are no article processing charges for submission, editing, review and publication.

View Instructions