Haematemesis due to primary aortic aneurysm-duodenal fistula - clinical suspicion is the cornerstone of diagnosis: a case report

Abstract

IntroductionAlthough gastrointestinal haemorrhage from aortoduodenal fistulae secondary to previous aortic grafts are well known, a primary fistula from an aortic aneurysm is a rare consideration resulting in inappropriate management and poor outcomes.Case presentationWe report a previously fit 65-year-old Sri Lankan man who presented with severe anaemia (haemoglobin, 6 gm/dl), recent onset low backache. There was no history of analgesic abuse, peptic ulceration, alcohol excess, weight loss or malena. The abdomen was soft and there was no visceromegaly. A routine ultrasound detected an abdominal aortic aneurysm without signs of a leak. Two days later, while undergoing routine diagnostic tests for anaemia and backache, he had a massive haematemesis. Standard resuscitation was commenced with hope that common sources, either peptic ulcers or varicies would eventually stop bleeding enabling endoscopy and definitive treatment. However, persistent hypotension coupled with the clinical suspicion of an aortoduodenal fistula led to immediate surgical exploration rather than continued aggressive resuscitation. An aortoduodenal fistula was confirmed and both the duodenum and the aorta were successfully repaired by direct suture and synthetic graft replacement respectively. This man remains well nine months later.ConclusionGastrointestinal bleeding in the presence of an ‘asymptomatic’ abdominal aortic aneurysms should be assumed to be from a primary aortoduodenal fistula unless another source can be identified with certainty without delay.

La fistule aortoduodénale primitive : une cause rare d’hémorragie digestive

“…Cependant, cette triade classique n'a été retrouvée que chez 27,8 % des patients dans une série récente de 18 patients [4]. La plupart des patients présentent un antécédent récent de saignement minime et intermittent dit « hémorragie sentinelle » avant la survenue d'un saignement massif [1,2,5].…”

“…La plupart des patients présentent un antécédent récent de saignement minime et intermittent dit « hémorragie sentinelle » avant la survenue d'un saignement massif [1,2,5]. La survenue d'un vasospasme, la formation de thrombus et la contraction intestinale réactionnelle contribuent à la fermeture provisoire du trajet fistuleux [1,[3][4][5].…”

The unusual endoscopic finding in a patient presenting with the chronic duodenal bulb ulcer complicated by hemorrhage

“…Аортодуоденальная фистула (АДФ) наиболее часто встречается из всех патологических соустий ДПК с сосудистыми структурами -ее удельный вес при подобных патологических состояниях достигает 80% [5]. Лишь 33-50% АДФ диагностируют до опе-рации, при этом летальность у данной категории па-циентов составляет 35% [6].…”

Diagnosis of Aortic Aneurysm

“…Secondary fistulae are more common after previous open or endovascular aortic interventions (Saratzis, Saratzis et al 2008) and mycotic aneurysms (Bunt 1983). Although rare, primary fistulae from fusiform aortic aneurysms must be considered when the combination of gastrointestinal bleeding and aortic aneurysm coexist (Wijeyeratne SM, Ubayasiri R et al 2009). Disappointingly, the combination of a pulsatile abdominal mass and gastrointestinal bleeding has been reported in only 23% (Sweeney and Gadacz 1984) to 27.8% (Song, Liu et al 2008) for aortoduodenal fistulae.…”

“…It must also be remembered that percutaneous angiography is of little value since the need for it coincides with the need for immediate surgery (Yeong 1995). Despite technological advances in endoscopy and imaging, the cornerstone in the diagnosis of an AEF remains clinical suspicion (Mehmood, Mushtaq et al 2007;Wijeyeratne SM, Ubayasiri R et al 2009) …”