Primary aortoenteric fistula with a chronic isolated abdominal aortic dissection: Report of a case

Abstract

A 47-year-old woman on long-term hemodialysis due to a chronic isolated abdominal aortic dissection was admitted to our department with severe abdominal pain. She had not suffered any hematemesis or melena. An emergency laparotomy revealed an abdominal aortic aneurysm with a diameter of 60mm, densely adhered to the ileum. An aortoenteric fistula manifesting as intramural rupture into the ileum was found after infrarenal abdominal aortic and bilateral common iliac cross-clamping. The fistula on the ileac side was nontransmural, but that on the aortic side communicated with the pseudolumen of the abdominal aorta, and contained mural thrombus. The infrarenal abdominal aorta and bilateral common iliac arteries were replaced with a collagen-sealed woven Dacron bifurcated graft. Histological examination of the ileum in this portion showed intramural bleeding and xanthomatous granulation with foam cell infiltration in the thickened subserosa. While it is difficult to diagnose nonpenetrating aortoenteric fistula preoperatively, such a fistula must be considered in a patient with severe abdominal pain, for whom previous abdominal aortic surgery has been performed or when an abdominal aneurysm is observed. To our knowledge, no other case of an aortoenteric fistula presenting as an intramural rupture into the ileum in an isolated abdominal aortic dissection has ever been reported.

Unusual clinical presentation of primary aortoduodenal fistula

“…In these cases, PAEF is easily misinterpreted as a chronic GI bleeding, therefore being easily underestimated by patients or confused with peptic ulcer disease by physicians. Herald bleeds may even be so slight as to pass unnoticed until sudden occurrence of massive haemorrhage precipitates the patient into haemorrhagic shock [ 21 ].…”

Characteristics of patients that experience cardiopulmonary arrest following aortic dissection and aneurysm

“…[10] Hematemesis may result from a fistula between the aorta and bowel due to previous adhesion or bleeding from ulceration due to ischemia. [1112]…”

Endoscopy Is One of the Valuable Diagnostic Methods for Primary Aorto‐enteric Fistula

“…Other reports related to PAEF state that endoscopic examination could neither identify the site of the bleeding nor confirm the cause of the bleeding, and that the diagnosis was made by CT 1,8,11,12 . Moreover, in some cases, the cause of repeated episodes of GI bleeding was not confirmed until laparotomy or autopsy 2,3 …”

“…10 Other reports related to PAEF state that endoscopic examination could neither identify the site of the bleeding nor confirm the cause of the bleeding, and that the diagnosis was made by CT. 1,8,11,12 Moreover, in some cases, the cause of repeated episodes of GI bleeding was not confirmed until laparotomy or autopsy. 2,3 Diagnostic procedures should be conducted quickly, and when AAA and GI bleeding exist, surgical treatment should be performed without delay. Nohr et al 13 stated that endoscopic examination and other diagnostic imaging modalities had a high rate of false negatives.…”

“…Although cases of primary aorto‐enteric fistula (PAEF) have been reported, 1–4 it is not generally considered a cause of gastrointestinal (GI) hemorrhage. In many cases of PAEF, the source of the bleeding was extremely difficult to identify by emergency gastroendoscopic examination.…”