Case report: Primary aortosigmoid fistula - A rare cause of lower gastrointestinal bleeding

Massive lower gastrointestinal hemorrhage due to primary internal iliac arterial-sigmoid colon fistula

Primary aortoenteric fistula is a rare entity with high mortality. Depending on the location of the fistula, primary aortoenteric fistulas may lead to upper or lower gastrointestinal hemorrhages. The majority of primary aortoenteric fistulas are associated with atherosclerosis or aneurysms of the aorta, without any previous aortic procedure. Local inflammation, compression, or erosion may lead to rupture of the aneurysm. Owing to difficulties in immediate and correct diagnosis, effective treatment of primary aortoenteric fistulas is often delayed, leading to almost 100% mortality in untreated patients. Here, we report a case of a repetitive mass of lower gastrointestinal hemorrhage due to a primary internal iliac arterial-sigmoid colon fistula. Finally, the patient was managed successfully through endovascular coil embolization.

Fistulating diverticulitis: a distinct clinical entity?

Introduction

Diverticular disease (DD) of the colon has a number of phenotypes, including asymptomatic diverticulosis and complicated diverticulitis with bowel perforation or bleeding. The factor that affects the phenotype of this condition and leads to a wide range of clinical presentations is unknown. The formation of fistulas associated with diverticulitis has long been recognized, and they are treated according to ad hoc indications. We hypothesized that the formation of fistulas in diverticular disease exhibits such a wide range of variable anatomic features that it may be considered a distinct form of the condition, fistulating diverticulitis (FD).

Methods

We conducted a narrative review based on 50 years of publications covering a wide range of diverticulitis-associated fistulas, both common and uncommon.

Results

While there is abundant literature on common fistulas, such as colovesical and colovaginal fistulas, little is known about rarer fistulas, such as coloenteric fistulas, colocutaneous fistulas, and genitourinary tract fistulas. The majority of these fistulas are treated surgically, which is in contrast to the trend toward conservative management that is predominant in acute or chronic diverticulitis.

Discussion

Epidemiological and histological evidence support the hypothesis that FD may be a feature of chronic DD that requires individual management. Histopathology shows similarities with Crohn's disease. It remains unknown which underlying immune or genetic factors may be affecting the clinical presentation of these patients, leading to fistulation. We contend that there is adequate published evidence to characterize a distinct phenotype of FD that can involve the entire GI tract and other organs. Surgical guidelines may need to be modified to treat this small but important group, which predominantly requires surgical treatment.

Misdiagnosis of Primary Iliac Aneurysmo-Colonic Fistula as a Submucosal Tumor Leading to Delayed Treatment: A Case Report

An aortoenteric fistula (AEF) is an uncommon cause of gastrointestinal bleeding that requires prompt diagnosis and intervention owing to its high mortality rate. Moreover, iliac aneurysmo-colonic fistula is an exceptionally infrequent presentation. We report a unique case of a 71-year-old male presenting with hematochezia, later diagnosed with a primary fistula between a common iliac artery aneurysm and the sigmoid colon. Initially, the patient was misdiagnosed as having a gastrointestinal stromal tumor, leading to delayed and emergent surgical intervention due to massive bleeding 2 days later. This case is particularly notable for its rarity, misinterpretation of the initial diagnosis, complicated surgical procedures, and development of complications including ischemic myopathy. This case highlights the criticality of accurate diagnosis with a high index of suspicion, significance of consultation with a vascular surgeon for vascular abnormalities, and importance of considering ischemic time in the sequence of surgical treatments to ensure timely and appropriate management.

Aortoiliac graft-enteric fistula presenting as gastrointestinal hemorrhage: A report on a complex case management

Key Clinical Message

Iliac artery-enteric fistula is a rare cause of lower GI bleeding and can cause life-threatening consequences. A high degree of clinical suspicion is needed in patients with previous aortic surgery to allow early multidisciplinary intervention.

Abstract

This case study discusses the staged management of a 78-year-old patient presenting with life-threatening lower gastrointestinal (GI) bleeding secondary to an aortoiliac graft-enteric fistula (GEF) into the sigmoid colon on the background of an adenocarcinoma and diverticular disease. The patient had an aorto bi-iliac synthetic dacron graft repair of an abdominal aortic aneurysm (AAA) some 20 years ago. Here, we present a case of successful endovascular treatment of massive hemorrhage as a bridge to definitive second-stage dacron graft explant and autologous vein reconstruction with a simultaneous anterior resection.

Periaortic air in native and post-operative aorta on computed tomography

Periaortic air can be seen in various conditions which can be a benign imaging finding or harbinger of a catastrophic event. The causes vary in native aorta and post-operative aorta. A radiologist has an important part in the management process of these patients, as the treatment varies from conservative to radical surgery based on the aetiology. The presence of periaortic air seen in the light of various clinical, laboratory and radiological findings can guide the radiologist towards a particular aetiology. Cross-sectional imaging, mainly computed tomography, is an indispensable tool in recognising ectopic periaortic air and to identify the associated findings and eventually make an accurate diagnosis. We present a pictorial review of various causes of the periaortic air in native and postoperative aorta, the salient features and management of the described conditions.

Extraabdominal Rupture of an Inflammatory Abdominal Aortic Aneurysm in a Patient With Aortodecubital Fistula: A Case Report

Aortodecubital fistula is a pathologic communication between aorta and a decubitus ulcer. It is very rarely encountered vascular condition in abdominal aortic aneurysms (AAA), with difficult diagnostics and high mortality. Patients often present with systemic and local infection and are at risk for hemorrhage. We present a paraplegic patient with fistulous communication between an inflamed abdominal aortic aneurysm and a sacral decubitus ulcer, leading to intermittent bleeding episodes and finally to exsanguination. While extremely rare, this case emphasizes the need for early, accurate diagnosis and salvage intervention when possible.