Recurrent Aortoenteric Fistula: Case Report and Review

Primary aorto-enteric fistula diagnosed by double-balloon endoscopy

A primary aorto-enteric fistula (PAEF), rarer than a secondary aorto-enteric fistula, is a direct rupture of the bowel by an abdominal aortic aneurysm (AAA). More than 54% of cases were in the duodenum, while jejunum and ileum were affected in only 15% of cases. An 82-year-old woman with hematemesis and hematochezia was admitted to our hospital emergently. Upper and lower endoscopies did not reveal the source of bleeding. We performed an urgent antegrade double-balloon endoscopy, revealing a submucosal tumor-like protuberance with an ulcer in the jejunum. These findings raised suspicion by PAEF. Subsequent computed tomography showed free air near the AAA, confirming PAEF as the hemorrhage source. An abdominal aortic stent graft was implanted, followed by laparotomy. An adhesion between the AAA and small intestinal wall was found. Postoperative recovery was uneventful, with no recurrence observed. This case underscores the importance of considering PAEF as a potential diagnosis in patients with gastrointestinal bleeding and a history of AAA. Endoscopists should be aware of submucosal tumor such as in this case to avoid misdiagnosing PAEF, as diagnosis and intervention are crucial for favorable outcomes.

Clinical and endoscopic features of aorto-duodenal fistula resulting in its definitive diagnosis: an observational study

Background

Upper gastrointestinal (GI) bleeding is the most important presentation of an aorto-duodenal fistula (ADF). Early diagnosis is difficult, and the disease is associated with high mortality. The present study aimed to examine the clinical and the endoscopic characteristics of ADF in eight patients who presented to our hospital. We also sought to clarify the diagnostic approach towards the disease.

Methods

The present study examined the clinical and the endoscopic/computed tomography (CT) characteristics of ADF in eight patients who were definitively diagnosed with this condition in a 12-year period at our hospital.

Results

The patients comprised of five men and three women, with a mean age of 69.8 years. Upper gastrointestinal bleeding was the chief complaint for all the patients. Out of these, two patients presented with shock. The patients’ mean haemoglobin at presentation was 7.09 g/dL, and the mean number of blood transfusions was 7.5. All patients had undergone intervention to manage an aortic pathology in the past. As the first investigation, an upper GI endoscopy in 5 and a CT scan in 3 patients were performed. In cases where CT scan was performed first, no definitive diagnosis was obtained, and the diagnosis was confirmed by performing an upper GI endoscopy. In cases where endoscopy was performed first, definitive diagnosis was made in only one case, and the other cases were confirmed by the CT scan. In some cases, tip attachments, converting to long endoscopes, and marking clips were found useful.

Conclusions

In patients who have undergone intervention to manage an aortic pathology and have episodes of upper gastrointestinal bleeding, ADF cannot be definitively diagnosed with only one investigation. In addition, when performing upper GI endoscopy in cases where an ADF is suspected, tip attachment, converting to a long endoscope, and using marking clips can be helpful.

Aortoenteric fistula following overlap esophagojejunal anastomosis using linear staplers for cancer of the esophagogastric junction: a case report

Background

Aortoenteric fistula (AEF), occasionally reported as a fatal complication after aortic or other vascular procedures, is a communication between the aorta and the digestive tract. AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy has not been reported previously. Herein, we report a case of AEF after laparoscopic proximal gastrectomy and transhiatal lower esophagectomy for cancer of the esophagogastric junction, in which linear staplers were used for overlap esophagojejunostomy.

Case presentation

A 66-year-old woman with advanced cancer of the esophagogastric junction underwent laparoscopic proximal gastrectomy and transhiatal lower esophagectomy with abdominal and lower mediastinal lymphadenectomy. Double tract reconstruction by the overlap method was performed. The patient was discharged from the hospital 10 days after surgery with a good postoperative course. However, she developed sudden-onset massive hematemesis and melena the day after discharge, resulting in death. Autopsy revealed that the stapled edge of the entry hole of the overlap esophagojejunostomy was in direct contact with the descending aorta. AEF was found at the esophagojejunostomy site.

Conclusions

To our knowledge, this is the first report of AEF as a fatal complication of overlap esophagojejunostomy after esophagogastrectomy. Although we could not definitively identify the cause of the AEF, it could be attributed to direct contact between the stapled edge and the bare thoracic aorta over a period of 10 days. To avoid direct contact with the aorta in esophagojejunostomy with linear staplers, all stapled edges should be covered by suturing and attention should be paid to the position of these edges.

Primary aortojejunal fistula: a rare cause for massive upper gastrointestinal bleeding

A 68-year-old man presented to the emergency department with haematemesis and shock. Upper endoscopy and selective angiography could not identify the source of bleeding. He underwent selective embolisation of the gastroduodenal artery. The patient then had a period of about 24 hours with relative haemodynamic stability before having another episode of massive upper gastrointestinal bleed. A second attempt to embolise the common hepatic artery and distal coeliac axis was unsuccessful. Hence, he was urgently taken to the operating room for exploratory laparotomy. The source of bleeding could not be identified in the operating room. The patient went into cardiac arrest and expired. Autopsy revealed a fistula between proximal jejunum and a previously unknown abdominal aortic aneurysm (AAA). We present an entity that has only been described a few times in the literature while highlighting the importance of having a broad differential with upper gastrointestinal bleeding, especially when the source is not clearly evident.

Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

OBJECTIVES

To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs).

METHODS

This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type.

RESULTS

Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups).

CONCLUSIONS

Endovascular surgery, where appropriate, is associated with better early survival than open surgery for secondary AEFs. Most of this benefit is lost during long-term follow-up, implying that a staged approach with early conversion to in situ vein grafting may achieve the best results in selected patients.

Primary aorto-enteric fistula

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Aorto-enteric fistulae are a rare cause of upper GI haemorrhage.

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Patient presented to A&E with an acute upper GI bleed and abdominal pain.

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Upper GI endoscopy inconclusive and too unstable for CT.

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Found to have a primary aorto-duodenal fistula secondary to retroperitoneal metastases.

Introduction

Primary aorto-enteric fistula (PAEF) is a life threatening, spontaneous erosion and communication of the aorta and intestinal tract. Unlike secondary AEF, which occur following aortic surgery, they are extremely rare. The low clinical suspicion and difficulty in obtaining a definitive diagnosis make for a dismal prognosis.

Case presentation

A literature review highlighted aetiology which included gallstone erosion, carcinoma of the pancreas and duodenal diverticulum. With written consent, we present the case of a 59 year old female, brought to the hospital following an episode of haematemesis and later found to have an AEF, secondary to metastatic retroperitoneal carcinoma - an extremely rare aetiology.

Discussion

There is far less literature on primary AEF when compared to secondary AEF. Furthermore, there is a variation in aetiology. Identifying the presence of a ‘herald' bleed appears to be significant.

Conclusion

Aorto-enteric fistulae must always be considered as a potential diagnosis in the setting of an acute upper GI haemorrhage with no apparent cause.

Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm

Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques.

Aortoduodenal fistula following aortic reconstruction of a pseudoaneurysm caused by stab wound 12 years ago

Gastrointestinal bleeding due to aortoenteric fistula is extremely rare. Aortoenteric fistula is difficult to be diagnosed timely and entails a significant morbidity and mortality. Herein, we present an uncommon case of gastrointestinal bleeding caused by aortoduodenal fistula, which was a complication of a successful aortic reconstruction 4 months ago for an aortic pseudoaneurysm resulted from a stab wound 12 years ago. An urgent laparotomy confirmed an aortoduodenal fistula and repaired the defects in aorta and duodenum, but a prolonged shock led to the patient's death. In summary, early diagnosis and surgical intervention for aortoenteric fistula are vital for survival.

Diagnosis and management of primary aortoenteric fistulas--experience learned from eighteen patients

OBJECTIVE

Misdiagnosis of primary aortoenteric fistula (PAEF) frequently occurs in clinical practice owing to the rarity of this condition. Herein we present the experience of diagnosis and management for PAEF.

METHODS

Eighteen patients with PAEF at 2 medical centers in China were reviewed. The clinical data, diagnostic procedures, treatment options, and patient outcomes were evaluated.

RESULTS

The fistulas were located at esophagus (5), duodenum (8), jejunum (3), ileum (1), and transverse colon (1). The etiologies include atherosclerotic aneurysms and foreign body. Typical abdominal triad (pain, upper GI bleeding, and abdominal pulsating mass) was found in 27.8% of patients, and Chiari's triad (mid-thoracic pain, sentinel hemorrhage, and massive bleeding after a symptom-free interval) was present in 3 of 5 cases with thoracic aortoesophageal fistulas. All patients had an average of 3.6 (1-9) episodes of gastrointestinal bleeding. The interval between the first sentinel hemorrhage and ultimate exsanguination ranged from 5 hours to 5 months (median, 4 days). Six patients (33.3%) were diagnosed or suggested by diagnostic tools including endoscopy, computerized tomography, and arteriography. Others were diagnosed by surgical exploration (7) and autopsy (5). One to 5 rounds (mean 1.8) of misdiagnosis occurred in 15 patients. Six patients recovered from surgery and remained well during a 36-month follow-up. The surgical options used included in situ replacement with vascular graft (3), aneurysmorraphy and closure of fistula (1), and endovascular stenting (2).

CONCLUSIONS

A high index of suspicion is necessary for correct diagnosis and prompt management of PAEF, especially in patients with aortoiliac aneurysms presenting with gastrointestinal bleeding. In situ graft replacement and endovascular stent-graft may be the preferred therapeutic options.