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

Abstract

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.

A singular case of primary aorto-duodenal fistula without pre-existing abdominal aortic aneurism: why and when you should suspect it

“… 4 Less common causes can be inflammatory or infectious aortitis, diverticulitis, appendicitis, radiations, foreign bodies, and gastrointestinal tumors. 2 …”

“…The most common cause of upper GI bleeding is represented by peptic ulcer disease and accounts for up to 67% of upper GI bleeding cases. 2 When a GI bleeding is suspected, clinical and anamnestic information should be searched regarding the nature of bleeding ( e.g. haematemesis), bleeding diathesis ( e.g.…”

“…abdominal aortic aneurism repair) and prior radiation and family history ( e.g., malignancies). 2 This research could be effective to identify the underlying etiology 3…”

“…Endoscopy is often the initial exam for any suspected upper GI bleeding because it confirms the source of bleeding and tries eventually to stop the bleeding. 2 …”

Aortoenteric fistula: a rare but critical cause of small bowel bleeding discovered on capsule endoscopy

“…AEF’s can be categorised as either primary or secondary. Secondary AEF’s most commonly occur following previous aortic surgery, while primary AEF’s arise de novo, and are even rarer 2 3. The incidence of secondary AEF’s following aortic surgery has been estimated to be around 1%, while primary AEF’s have an incidence of <0.07% 4…”