Primary aortoenteric fistula

A complicated case of primary aortojejunal fistula: A case report

BACKGROUND

Aortoenteric fistulas are rare and life-threatening pathology characterized by an abnormal connection between the aorta and the gastrointestinal tract.

CASE PRESENTATION

The patient is a 61-year-old male who initially presented with hypogastric pain, hematemesis, and melena. Computed tomography angiography (CTA) revealed an abdominal aorta aneurysm but not a fistula. Imaging modalities were inconclusive in the diagnosis. The patient became unstable hemodynamically and was transferred to the operation room. The definitive diagnosis of aortoenteric fistula was confirmed during surgical exploration. Urgent surgery was performed; however, the patient experienced a cascade of complications, including rebleeding, intestinal leakage, and hemodynamic instability due to aortic bleeding. Despite rigorous interventions, the patient expired due to multiple organ failure 53 days after the first repair surgery.

CLINICAL DISCUSSION

There is no definite imaging method due to the lack of guidelines, and the absence of exact findings has led to intraoperative diagnosis in up to 50 % of cases. This is one of the modalities of choice to examine suspected aortoenteric fistulas. Many authors prefer Computed tomography (CT) with intravenous contrast for suspected AEF despite its limitations in clarity. Others recommend CT angiography as the preferred modality. It is worth noting that, as reported in a comprehensive retrospective review, the mortality rate is approximately 46 % within 60 days after AEF repair surgery.

CONCLUSION

This report adds to the limited data about primary aortojejunal fistulas, an extremely rare type of aortoenteric fistulas which has been reported in only a few cases. Understanding the importance of promptly suspecting, diagnosing, and intervening is crucial, emphasizing the importance of sharing such cases for medical guidance and better patient outcomes.

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.

Primary Aorto-Enteric Fistula With a Subsequent Secondary Aorto-Enteric Fistula

Objective

Primary aorto-enteral fistula (PAEF) is a connection between the gastrointestinal tract and the aorta that occurs without previous aortic surgery. The aetiological factors include, but are not limited to, aneurysm, infection, and tumours. It is a life threatening condition if untreated and requires emergency vascular surgical repair. A secondary aorto-enteric fistula (AEF) can occur to a previously reconstructed aorta. This case report presents a unique case of a male patient who developed a primary AEF and subsequent secondary AEF with successful surgical outcomes, suggested to be due to tuberculous aortitis.

Report

The patient was diagnosed and treated for tuberculosis and developed a saccular aneurysm within six months. The PAEF was surgically corrected with a tube graft using a bovine pericardial patch, the defect in duodenum was sutured, and a retrocolic omental flap was created between the duodenum and aorta. He developed a small stable pseudoaneurysm during follow up, and then a secondary AEF two and a half years later, in which a connection between the pseudoaneurysm and duodenum was corrected using a new bovine aorto-aortic interposition graft using a bovine pericardium patch. The defect in the duodenum was also sutured in two layers and a new omental flap was created.

Discussion

The mortality rate of AEF is high and it is very unlikely that a patient will survive two AEFs without major complications. It is believed that there are extremely few double AEF cases described in the literature. The aetiological factor in the development of PAEF in this case was most likely the patient's aortic aneurysm, which was most likely of mycotic origin due to tuberculosis. The patient developed a pseudoaneurysm during follow up and it is uncertain whether the pulsatile pressure of the pseudoaneurysm led to the recurrence of the AEF.

Case report - Computed tomography diagnosis of an abdominal aortic aneurysm complicated with primary aortoduodenal fistula

Abdominal aortic aneurysm has been described as a rare condition touching 1% of the population over the age of 50 years with a high percentage of mortality. Aneurysms progress in size, causing deadly complications such as ruptures and fistulas. Computed tomography angiography is considered the gold standard imaging exam for the evaluation of abdominal aortic aneurysms and their complications. We report the case of an elderly patient admitted to the emergency room due to recurrent gastrointestinal bleeding. The computed tomography imaging findings were in favor of an abdominal aortic aneurysm complicated with a primary aortoduodenal fistula.

Secondary aortoenteric fistula: a narrative review of the view of the surgeon

Aortoenteric fistula (AEF) is defined as the abnormal communication between the aorta and the gastrointestinal tract. AEFs are divided into primary and secondary usually after abdominal aortic aneurysm (AAA) recovery and are a rare but quite dangerous cause of gastrointestinal bleeding that the general surgeon may face during his/her career. Secondary AEF was first described in 1953 to a 44-year-old woman 3 months after an AAA operation. This review presents the role of the surgeon in the management of secondary aortoenteric fistulas. AEFs are a rare but fatal gastrointestinal bleeding cause that the general surgeon may be asked to manage. Diagnosis requires the combination of strong clinical suspicion and the presence of a history of AAA surgery. Although a vascular surgery case, general surgeons play a role in choosing the technique of restoring the intestinal tract, which seems to be significantly related to subsequent morbidity and mortality.

A Modern Series of Secondary Aortoenteric Fistula - A 19-Year Experience

OBJECTIVES

Secondary aortoenteric fistula is a rare and life-threatening condition. Clear evidence on the ideal therapeutic approach is largely missing. This study aims to analyze symptoms, etiology, risk factors, and outcomes based on procedural details.

PATIENTS AND METHODS

All patients with secondary aortoenteric fistula admitted between 2003 and 2021 were included. Patient characteristics, surgical procedure details, and postoperative outcomes were analyzed. Outcomes were stratified and compared according to the urgency of operation and the procedure performed. Descriptive statistics were used. The primary endpoint was in-hospital mortality.

RESULTS

A total of twentytwo patients (68% male, median age 70 years) were identified. Main symptoms were gastrointestinal bleeding, pain, and fever. From the twentytwo patients ten patients required emergency surgery and ten urgent surgery. Emergency patients were older on average (74 vs 63 years, P = .015) and had a higher risk of postoperative respiratory complications (80% vs 10%, P = .005). Primary open surgery with direct replacement of the aorta or an extra-anatomic bypass with an additional direct suture or resection of the involved bowel was performed in sixteen patients. In four patients underwent endovascular bridging treatment with the definitive approach as a second step. Other two patients died without operation (1x refusal; 1x palliative cancer history). In-hospital mortality was 27%, respectively. Compared to patients undergoing urgent surgery, those treated emergently showed significantly higher in-hospital (50% vs 0%, P = .0033) mortalities.

CONCLUSION

Despite rapid diagnosis and treatment, secondary aortoenteric fistula remains a life-threatening condition with 27% in-hospital mortality, significantly increased upon emergency presentation.

Aortoduodenal fistula and abdominal aortic aneurysm as a complication of Brucella Aortitis managed with Insitu aortic aneurysm repair: A case report

Key Clinical Message

Brucella aortitis should be one of the differential diagnoses of inflammatory aortic aneurysms. In situ repair of intermittent aortoenteric fitulae and repair of infrarenal aortic aneurysm with synthetic graft can be used in clean scarred fistulae.

Abstract

Arterial aneurysms are very rare complications of Brucella infection. The purpose of this case report is to document a case of abdominal aortic aneurysm and primary aorto-duodenal fistula as a complication of Brucella infection, along with the management of brucella induced aortoenteric fistula with insitu synthetic graft. We report a 53-year-old man with a complaint of abdominal pain and melena. Radiological evaluation revealed an inflammatory abdominal aortic aneurysm and a primary aorto-duodenal fistula was identified during surgery. The patient underwent laparotomy, and surgical repair of the aneurysm with a bifurcated Dacron graft, while the entry of the aorto-duodenal fistula was closed with intra-aortic sutures. One month later, the patient tested positive for the Wright agglutination test (1:80) and Coomb's test (1:640) for brucella, and was treated with doxycycline, rifampicin, and ciprofloxacin for brucellosis. Though rare, brucella aortitis should be considered as one of the differential diagnoses of inflammatory aortic aneurysms. In situ repair of intermittent aortoenteric fistula and repair of the infrarenal aortic aneurysm with synthetic graft could be considered in a clean scarred fistula.

Rare finding of primary aortoduodenal fistula on single-photon emission computed tomography/computed tomography of gastrointestinal bleeding: A case report

BACKGROUND

Primary aortoduodenal fistula is a rare cause of gastrointestinal (GI) bleeding consisting of abnormal channels between the aorta and GI tract without previous vascular intervention that results in massive intraluminal hemorrhage.

CASE SUMMARY

A 67-year-old man was hospitalized for coffee ground vomiting, tarry stools, and colic abdominal pain. He was repeatedly admitted for active GI bleeding and hypovolemic shock. Intermittent and spontaneously stopped bleeders were undetectable on multiple GI endoscopy, angiography, computed tomography angiography (CTA), capsule endoscopy, and 99mTc-labeled red blood cell (RBC) scans. The patient received supportive treatment and was discharged without signs of rebleeding. Thereafter, he was re-admitted for bleeder identification. Repeated CTA after a bleed revealed a small aortic aneurysm at the renal level contacting the fourth portion of the duodenum. A 99mTc-labeled RBC single-photon emission CT (SPECT)/CT scan performed during bleeding symptoms revealed active bleeding at the duodenal level. According to his clinical symptoms (intermittent massive GI bleeding with hypovolemic shock, dizziness, dark red stool, and bloody vomitus) and the abdominal CTA and 99mTc-labeled RBC SPECT/CT results, we suspected a small aneurysm and an aortoduodenal fistula. Subsequent duodenal excision and duodenojejunal anastomosis were performed. A 7-mm saccular aneurysm arising from the anterior wall of the abdominal aorta near the left renal artery was identified. Percutaneous intravascular stenting of the abdominal aorta was performed and his symptoms improved.

CONCLUSION

Our findings suggest that 99mTc-labeled RBC SPECT/CT scanning can aid the diagnosis of a rare cause of active GI bleeding.

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.

Timely Endoscopic Recognition of Aortoesophageal Fistula With Successful Treatment

Aortoesophageal fistula (AEF) is a devastating cause of upper gastrointestinal bleeding that occurs because of pathologic communication of the esophagus with the aorta. Bleeding AEF has high mortality even with appropriate interventions. In this study, we present a case of a 52-year-old man who presented with hematemesis, which was found to be due to an actively bleeding AEF. Prompt identification of the fistula led to multiple endoscopic interventions that stabilized the patient and allowed him to undergo emergent endovascular aortic stent placement with successful bleeding control.

Rare causes of acute non-variceal upper gastrointestinal bleeding: A comprehensive review

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common gastroenterological emergency associated with significant morbidity and mortality. Gastroenterologists and other involved clinicians are generally assisted by international guidelines in its management. However, NVUGIB due to peptic ulcer disease only is mainly addressed by current guidelines, with upper gastrointestinal endoscopy being recommended as the gold standard modality for both diagnosis and treatment. Conversely, the management of rare and extraordinary rare causes of NVUGIB is not covered by current guidelines. Given they are frequently life-threatening conditions, all the involved clinicians, that is emergency physicians, diagnostic and interventional radiologists, surgeons, in addition obviously to gastroenterologists, should be aware of and familiar with their management. Indeed, they typically require a prompt diagnosis and treatment, engaging a dedicated, patient-tailored, multidisciplinary team approach. The aim of our review was to extensively summarize the current evidence with regard to the management of rare and extraordinary rare causes of NVUGIB.

Aortoesophageal fistula complicated by mycotic aneurysm secondary to endoscopic procedures: A case report

Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal bleeding that often receives little attention in the emergency department. The classic presentation includes the Chiari triad of central chest pain, sentinel arterial bleeding, and subsequent evacuation after an asymptomatic period. For patients suspected of having AEF, a CT scan with IV contrast is the preferred diagnostic modality. In our patient, the presence of an aortic wall outpouching, ectopic gas, periaortic fat stranding, and leukocytosis, even in the absence of fever and positive blood culture, suggested mycotic aneurysm with AEF. The unique aspect of this case report is the occurrence of AEF as a rare complication of endoscopic procedures, which should be considered. Treatment options for AEF include surgery and thoracic endovascular aortic repair (TEVAR). TEVAR is a good option for stabilizing the patient's condition and reducing mortality in the short term. Once the patient's condition is suitable for AEF repair surgery, surgical intervention can be performed.

Primary aortoenteric fistula after intravesical instillation of Bacillus Calmette-Guérin for bladder cancer

OBJECTIVE

Primary aortoenteric fistulas (PAEFs) are a rare entity with high morbidity, and their relationship with Bacillus Instillation of Calmette-Guérin is anecdotal.

METHODS/RESULTS

We present a 68-year-old male with a primary aortoenteric fistula after instillation of Bacillus Calmette-Guérin (BCG) for a non-muscle-invasive bladder cancer. Diagnosis was made by CT angiography, subsequently confirmed by intraoperative findings and results of anatomopathological studies of aortic wall samples. We performed an in-situ reconstruction with a silver prosthesis impregnated in rifampicin with satisfactory evolution at one year.

CONCLUSIONS

Primary aortoenteric fistula is an extremely rare complication, and although its relationship with intravesical BCG therapy is anecdotal, it should be considered in patients with gastrointestinal bleeding who have previously undergone this treatment. Its diagnosis requires clinical suspicion, and its treatment should be carried out without delay. Long-term targeted anti-biotherapeutic treatment is a fundamental pillar for its management. Reconstruction with an antibiotic-impregnated silver prosthesis is a valid option in cases of controlled infection.

Successful Management of Aorto-Oesophageal Fistula Following Accidental Ingestion of Chicken Bone

Accidental ingestion of foreign bodies is common in clinical practice. It is usually seen to pass through the gastrointestinal tract easily. However, in the case of impaction in the esophagus, it can lead to catastrophic conditions. Aorto-esophageal fistula is one such disastrous complication with a high fatality rate. Despite treatment, mortality rates of up to 80% have been reported in the literature, with the condition being uniformly fatal in untreated patients. We describe a case of aorto-esophageal fistula secondary to a chicken bone impaction presenting with sentinel hemorrhage and managed expeditiously and successfully with simultaneous endoscopic removal and surgical repair of the fistula.

Case report: Aortoesophageal fistula-an extremely rare but life-threatening cardiovascular cause of hematemesis

Aortoesophageal fistula (AEF) is an extremely rare cardiovascular etiology of hematemesis and upper gastrointestinal bleeding. As such, its recognition and diagnosis are challenging and may be delayed when such patients present to the emergency department (ED). Without timely surgical intervention, AEF is almost always fatal. Awareness of AEF as a possible diagnosis and consequently early identification of these patients presenting to the ED are therefore crucial in optimizing clinical outcomes. We report a 45-year-old male presenting to the ED with the classical triad of an AEF (Chiari's triad)-midthoracic pain or dysphagia, a sentinel episode of minor hematemesis, then massive hematemesis with risk of exsanguination. The case report highlights the importance of considering the differential diagnosis of AEF when evaluating patients presenting to the ED with hematemesis, especially if they have predisposing risk factors such as prior aortic or esophageal surgeries, aortic aneurysms, or thoracic malignancies. Patients suspected of having AEF should be prioritized for early computed tomography angiography to expedite diagnosis and treatment.

Chicken Bone Ingestion Leads to Aortoesophageal Fistula With Catastrophic Bleeding

Aortoesophageal fistula (AEF) is an uncommon, but potentially fatal cause of upper gastrointestinal bleeding. Aortoesophageal fistulas caused by foreign body ingestion are rare but devastating. The classic clinical triad of AEF consists of mid-thoracic pain or dysphagia, a herald episode of hematemesis, followed by fatal exsanguination after a symptom-free period (Chiari's triad). Computed tomography angiography (CTA) is the preferred diagnostic tool for identifying AEF and is substantially more sensitive than upper endoscopy for detecting AEF. Endoscopy can detect AEF as it might show pulsatile blood, pulsatile mass, hematoma, or adherent blood clot in the esophagus, or a deep esophageal tear. However, endoscopy has a low sensitivity and may delay definitive treatment. Several management options for AEF have been suggested; however, the definitive treatment is surgery performed on the thoracic aorta and esophagus, including esophagectomy, surgical replacement of the thoracic aorta, thoracic endovascular aortic repair, or omental flap. We report a case of a 63-year-old man who presented with hematemesis 2 weeks after chicken bone ingestion.

It Is Not Always Diverticular Bleeding: Fatal Subtle Primary Aorto-Duodenal Fistula Associated With Abdominal Aortic Aneurysm

Primary aorto-duodenal fistula (PADF) is a connection between the aorta and duodenum without prior aortic surgery. We present a case of an 80-year-old female who presented with hematochezia. She was vitally stable but later developed a large episode of hematemesis followed by cardiac arrest. A computed tomography angiogram (CTA) chest scan showed an abdominal aortic aneurysm (AAA) with no leakage or rupture. Esophagogastroduodenoscopy (EGD) demonstrated blood in the stomach and duodenum, but no source was identified. Tagged RBC scan showed massive hemorrhage in the stomach and proximal small bowel. Further review of the CT images identified a subtle PADF. The patient underwent endovascular aneurysm repair but died shortly after. Physicians should maintain a high awareness of PADF, particularly in elderly patients with obscure gastrointestinal bleeding with or without known AAA. Herald bleeding in the setting of an aortic aneurysm should raise suspicion for PADF even in the absence of extravasation on CTA.

A systematic review of the surgical management of secondary aortoduodenal fistula

OBJECTIVE

Secondary aortoduodenal fistulae (SADF) are uncommon but life-threatening conditions that occur as complications of aortic reconstructive surgery. Data on the mortality and morbidity of procedures associated with SADF remain scarce.

METHODS

Comprehensive literature search was conducted on the MedLine, Scopus, Embase, and Web of Knowledge databases for cases of SADF. Data regarding patient demographics, fistula anatomy and treatment interventions performed were extracted for further analysis.

RESULTS

The study pool consisted of 127 case reports, 28 case series and 1 retrospective study published between 1973 and 2021. A total of 189 patients were operated for SADF. Among the 189 patients, 141 patients (74.6%) had aortic graft excision, 26 (13.8%) aortic primary repair, and 22 (11.6%) EVAR. Although patients undergoing EVAR were older with higher Charlson Comorbidity Index, compared with patients who had graft excision and primary aortic repair these differences were not statistically significant (P = .12 and P = .22, respectively). Primary bowel repair was performed in 145 patients (76.7%), duodenectomy in 25 (13.2%), and no bowel repair in 19 (10.1%). Additional omentoplasty was performed in 65 patients (34.6%). Mortality was comparable with respect to the type of aortic and bowel repair, with no statistically significant differences recorded (P = .54 and P = .77, respectively). Omentoplasty significantly decreased the risk of death (odds ratio, 0.4; 95% confidence interval, 0.2-0.8, P = .01).

CONCLUSIONS

Optimal operative management should address both the aortic and duodenal defects and be complemented with appropriate reconstructive procedures. Endovascular aortic approaches seem feasible in carefully select patients in whom duodenal repair may be omitted.

Primary Aortoesophageal Fistula Presenting as Upper Gastrointestinal Bleed

Aortoenteric fistula is a rare condition that can be primary or secondary. The primary type is less common than the secondary. The secondary aortoenteric fistula is an uncommon fatal complication after reconstructive surgery for an aortic aneurysm or other aortic diseases. Here we present a case of a 59-year-old man who presented to our emergency department with sudden onset of massive hematemesis. Imaging studies were done and the patient was diagnosed to have aortoesophageal fistula. Upper gastrointestinal endoscopy showed an intraluminal bulge in the posterior wall of the esophagus with an ulcer and hematoma. The patient was planned for emergency surgical intervention, but the patient had recurrent bouts of hematemesis and, unfortunately, expired. Hence patients presenting with massive hematemesis, aortoenteric fistula can be the underlying cause, and all surgeons should be aware of such conditions and the need for emergent surgical intervention.

Two unique cases of primary aortoenteric fistula following a small aneurysm and penetrating ulcer of the abdominal aorta

A primary aortoenteric fistula (PAEF) is a rare condition, and its associated mortality has remained high. We have presented two challenging cases of PAEF related to a small abdominal aortic aneurysm and an abdominal penetrating aortic ulcer. In both cases, a definite diagnosis was established intraoperatively, and the PAEF was repaired with in situ aortic reconstruction. Despite the successful outcome for the first patient, the postoperative complications were fatal for the second patient. The diagnosis of PAEF requires high suspicion and should be a part of the differential diagnosis in every case of gastrointestinal bleeding, especially when a history of, or risk factors for, aortic pathology are present.

A Rare Cause of Gastrointestinal Bleeding: Aorto-Enteric Fistula

Aorto-enteric fistula is defined as an abnormal connection between the gastrointestinal system and the aorta. The patients who develop this condition usually have a grim prognosis and the cases are universally fatal unless intervened with an endovascular repair or open surgical repair. Given the rarity and the relative unfamiliarity of this condition, an understanding of the presentation, pathogenesis, and management is vital to prevent catastrophic complications.

Gastrointestinal bleeding: imaging and interventions in cancer patients

Gastrointestinal bleeding (GIB) among cancer patients is a major source of morbidity and mortality. Although a wide variety of etiologies contribute to GIB, special considerations should be made for cancer-related factors such as the type of malignancy, location and extent of disease, hemostatic parameters, and treatment effects. Key imaging modalities used to evaluate GIB include computed tomography angiography (CTA), radionuclide imaging, and catheter-based angiography. Understanding the cancer and treatment history and recognizing the associated imaging manifestations are important for identifying the source and potential causes of GIB in cancer patients. This article will review the common clinical presentations, causes, imaging manifestations, and angiographic management of GIB in cancer patients.

Primary and secondary aorto-digestive fistulas in Behçet's disease: A case report and review of the literature

Behçet's disease (BD) is a multisystem chronic autoimmune inflammatory disorder that involves multiple organs. Arterial involvements in BD are rare. One of severe manifestation is the aortic aneurysm which can lead to a rupture. Aorto-duodenal fistulas (ADFs) are the most frequent aorto-digestive fistulas. In this article we will describe and discuss primary and secondary ADFs which occurred in a same patient.

Case Report: Successful Repair of Primary Aortoesophageal Fistula With an Endovascular Stent Graft and an Esophageal Stent

Aortoesophageal fistula (AEF), secondary to thoracic pseudoaneurysm as a result of upper gastrointestinal bleeding, is a rare condition and will be undoubtedly lethal without prompt surgical intervention. The estimated annual incidence of primary AEFs and secondary AEFs is about 0.0015% and 0.6%–2%, respectively. The challenges of the therapy posed by AEF are control of the hemorrhage, arterial reconstruction in an infection field, control of sepsis, and re-establishment of the alimentary tract. We present a case of a 58-year-old man who suffered from chest pain and hematemesis and was finally diagnosed with pAEF caused by descending thoracic pseudoaneurysm. Our team successfully deployed an endovascular stent graft and esophageal stent to seal ruptured thoracic aorta and esophageal defects, which provided a new surgical strategy for aortoesophageal fistula in the endovascular era.

Successful management of life-threatening aortoesophageal fistula: A case report and review of the literature

BACKGROUND

Aortoesophageal fistula (AEF) is a rare but life-threatening cause of upper gastrointestinal bleeding. Only a handful of cases of successful management of AEF caused by esophageal cancer have been reported. The purpose of this study is to report a case of AEF managed by endovascular aortic repair and review the relevant literature.

CASE SUMMARY

A 66-year-old man with upper gastroenterology bleeding presented at the Emergency Department of our hospital complaining of chest pain, fever and hematemesis for 6 h. He had vomited 400 mL of bright-red blood and experienced severe chest pain 6 h prior. He had a past medical history of advanced esophageal cancer. He received chemoradiotherapy but stopped 8 mo prior because of intolerance. A chest contrast computed tomographic scan revealed communication between the esophagus and the descending aorta as well as a descending aortic pseudoaneurysm. According to the symptoms and imaging findings, AEF was our primary consideration. The patient underwent aortic angiography, which indicated AEF and descending aortic pseudoaneurysm. Emergency percutaneous thoracic endovascular aortic repair (TEVAR) of the descending aorta was performed, and bleeding was controlled after TEVAR. He received antibiotics and was discharged after treatment. However, he died 2 mo after the TEVAR due to cancer progression.

CONCLUSION

Although AEF is a lethal condition, timely diagnosis and TEVAR may successfully control bleeding.

Endovascular Treatment of Abdominal Infection-induced Aortoenteric Fistula

Primary aortoenteric fistulas is a rare clinical entity but with fatal outcome, usually arise from atherosclerotic aneurysm, but induced by abdominal infection is extremely rare. We present a case of 54-year-old man with history of Aortic arch replacement and elephant trunk stent implantation 6 years ago for Stanford type A aortic dissection. He underwent enteroscopy and had gastrointestinal perforation during enteroscopy 11 months ago. Since then he had episodes of syncope and Haemorrhage. Finally, a fistula was found on imaging. Endovascular treatment and digestive tract repair was accomplished. At 13-month follow-up, he did not have hematochezia and fever again.

A Case of Successful Endovascular Aortic Repair of Primary Aortoenteric Fistula Without Aortic Explantation

PURPOSE

The objective of this study is to report a case of a primary aortoenteric fistula successfully treated with endovascular repair without aortic explant.

CASE REPORT

A 48-year-old man presented with a 24-hour history of hematemesis and malena. A computed tomography (CT) abdomen and pelvis demonstrated a 6 cm infrarenal aortic aneurysm with periaortic stranding and contrast enhancement within the lumen of the third part of the duodenum. The patient underwent emergency Endovascular Aortic Repair (EVAR). The patient was discharged on day 8 of his admission on oral antibiotics. He returned 7 weeks postindex procedure and underwent a laparotomy with omental patch repair of the aortic defect. Intraoperative cultures grew candida albicans, and the patient was discharged on lifelong oral Fluconazole and Amoxycillin-Clavulanic Acid. At 18 months postoperatively, the patient was clinically stable with improved appearances on CT aortogram.

CONCLUSION

We discuss the use of EVAR without aortic explant as a possible treatment option in the management of patient with primary aortoenteric fistulae. This may potentially avoid the significant morbidity and mortality associated with aortic explant in suitable candidates without perioperative signs of sepsis.

Fatal Aortoduodenal Fistula Caused by a Ruptured Abdominal Aortic Aneurysm - a Case Report

Introduction: Ruptured abdominal aortic aneurysm (AAA) has a high mortality, even when the patients reach the hospital in time and the intervention is expeditious. Case presentation: We present the case of a 66-year-old male patient, with a known history of AAA, presenting to the emergency room in a state of hypovolemic shock due to massive bleeding in the upper and lower gastrointestinal tract and acute abdominal pain, which presented an abrupt onset one hour before presentation. The computed tomography angiography identified an aortoduodenal fistula with a trajectory toward the D3 segment of the duodenum, as well as a common iliac artery occlusion and extensive atherosclerotic stigmas. The patient was rushed to the operation room where he was resuscitated with intravenous fluids, two units of packed red blood cells, and hemostatic agents. The bleeding was stopped by clamping the aorta above the aneurysm. The duodenum was sutured, and the aorta was reconstructed with an aortobifemoral graft. Unfortunately, even though intensive care procedures continued for a few hours after surgery, all therapeutic efforts failed and the patient had succumbed.

Aortoesophageal Fistula Secondary to Esophageal Diverticulum Resulting in Sudden Unexpected Death

Aortoesophageal fistula (AEF) is a rarely encountered clinical outcome that is often fatal. It is most commonly a postoperative complication of vascular surgery (secondary AEF). Reported primary causes of AEF include aortic aneurysm, atherosclerosis, infection, foreign objects, achalasia with megaesophagus, gastrointestinal malignancy, and radiotherapy. Aortoesophageal fistula is often not a top diagnostic consideration for clinicians or pathologists and has the potential to be overlooked. This report describes a rare case of AEF secondary to an esophageal traction diverticulum and associated abscess that resulted in the sudden unexpected death of a 78-year-old male. Aortoesophageal fistula is an important consideration for pathologists and requires careful consideration in the postmortem setting.

Under the Radar: A Case Report of a Missed Aortoenteric Fistula

Introduction

An aortoenteric fistula (AEF) is an abnormal connection between the aorta and the gastrointestinal tract that develops due to a pathologic cause. It is a rare, but life-threatening, cause of gastrointestinal (GI) bleeding. Although no single imaging modality exists that definitively diagnoses AEF, computed tomography angiography (CTA) of the abdomen and pelvis is the preferred initial test due to widespread availability and efficiency.

Case Report

Many deaths occur before the diagnosis is made or prior to surgical intervention. We describe a case of a patient with a history of aortic graft repair who presented with active GI bleeding.

Conclusion

Although CTA can make the diagnosis of AEF, it cannot adequately rule it out. In patients with significant GI bleeding and prior history of aortic surgery, vascular surgery should be consulted early on, even if CTA is equivocal.

Primary aortoduodenal fistula: a rare cause of massive gastrointestinal hemorrhage

Aortoduodenal fistula (ADF) is the most common type of aortoenteric fistula (AEF). This is a rare entity, which produces communication between an abdominal aortic aneurysm (AAA) and the gastrointestinal tract (GIT), resulting in massive gastrointestinal bleeding. AEF/ADF is difficult to recognize clinically, with the classical triad of symptoms including a pulsating, palpable mass, abdominal pain, and GIT bleeding. AEF/ADF can be classified into primary when a communication between an AAA and the GIT develops with no history of prior aortic reconstructive surgery, and secondary, where the communication is on the background of previous aortic reconstructive surgery. Herein we present a case report of a 75-year-old Caucasian male patient with a clinical history of AAA, who presented with massive GIT bleeding and expired shortly after. An autopsy revealed communication between an atherosclerotic AAA and the lower third of the duodenum.

Stent graft treatment of an ilioenteric fistula secondary to radiotherapy

Fistulas between the arteries and the gastrointestinal tract are rare but can be fatal. We present a case of an ilioenteric fistula between the left external iliac artery and sigmoid colon caused by radiotherapy for cervical cancer, which was treated with endovascular management using a stent graft. A 38-year-old woman underwent concurrent chemoradiotherapy for cervical cancer recurrence. Approximately 9 months later, the patient suddenly developed hematochezia. On her first visit to the emergency room of our hospital, computed tomography (CT) images did not reveal extravasation of contrast media. However, 8 hours later, she revisited the emergency room because of massive hematochezia with a blood pressure of 40/20 mmHg and a heart rate of 150 beats per minute. At that time, CT images showed the presence of contrast media in almost the entire colon. The patient was referred to the angiography room at our hospital for emergency angiography. Inferior mesenteric arteriography did not reveal any source of bleeding. Pelvic arteriography showed contrast media extravasation from the left external iliac artery to the sigmoid colon; this was diagnosed as an ilioenteric fistula and treated with a stent graft. When the bleeding focus is not detected on visceral angiography despite massive arterial bleeding, pelvic arteriography is recommended, especially in patients with a history of pelvic surgery or radiotherapy.

Endoscopic treatment of primary aorto-enteric fistulas: A case report and review of literature

BACKGROUND

Primary aorto-enteric fistula (PAEF) is a rare condition, traditionally treated in the acute, bleeding phase with open surgery or endovascular repair. However, these approaches have high morbidity and mortality, indicating a need for new methods. With advances in endoscopic techniques and equipment, haemoclipping of fistulas has now become feasible. Therefore, we present a systematic review of the English literature and a rare case of a PAEF successfully treated by endoscopic haemoclipping.

CASE SUMMARY

A 74-year-old man with an abdominal aortic aneurysm presented with symptoms of haemorrhagic shock and bloody stools. An oesophago-gastro-duodenoscopy was performed with haemoclipping of a suspected PAEF in the third part of the duodenum. Afterward, a computed tomography-angiography showed a contrast filled protrusion from the abdominal aortic aneurysm. Based on the clinical presentation and the combined endoscopic and radiographic findings, we argue that this is a case of a PAEF.

CONCLUSION

Endoscopic therapy appears capable of achieving haemodynamic stabilisation in patients with bleeding PAEF, serving as a bridge to final therapy.

Primary aortoduodenal fistula in testicular cancer: A fatal complication associated with retroperitoneal lymph node metastasis

A primary aortoduodenal fistula (PADF) has rarely been reported as a complication of testicular cancer. A 48-year-old Japanese male with relapsed retroperitoneal lymph node metastases received four courses of paclitaxel, ifosfamide, and cisplatin (TIP). On day 19 of the fourth cycle of TIP, he developed hematochezia and hypovolemic shock. Angiography confirmed the presence of a PADF, and we then deployed an endovascular stent graft in the aorta. Although the bleeding improved, the patient died of re-bleeding that developed 18 days later. It is important to recognize this severe complication in order to achieve its early diagnosis and optimal surgical intervention.

Imaging features of mycotic aortic aneurysms

Infectious aortitis (IA) is a rare and life-threatening cardiovascular disease. Early diagnosis and timely intervention are crucial for reducing mortality associated with mycotic aortic aneurysms (MAAs); however, early diagnosis is challenging due to the nonspecific symptoms. Some cases are diagnosed at an advanced stage or after developing complications, such as rupture or aortic fistula. Current state-of-the-art imaging modalities-including computed tomography (CT), magnetic resonance imaging (MRI), and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT-can detect infected aneurysms in clinically suspicious cases. MAA features on imaging include lobulated pseudoaneurysm, indistinct irregular arterial wall, perianeurysmal gas, perianeurysmal edema, perianeurysmal soft tissue mass, aneurysmal thrombosis, and high metabolic activity with increased uptake of FDG. Enlarged lymph nodes are often found adjacent to the aneurysm, while iliopsoas abscess (IPA), spondylitis, and aortic fistulas are commonly associated complications. After surgery or endovascular repair, radiological features-including ectopic gas, peri-graft fluid, thickening of adjacent bowel, pseudoaneurysm formed at the graft anastomosis, and increased uptake of FDG-may indicate an infection of aortic graft. This article provides an overview of the clinical and imaging features of MAAs. Thus, familiarity with the imaging appearances of MAAs may assist radiologists in the diagnosis and facilitation of timely treatment.

Concurrent Ilio-Enteric and Ilio-Vesical Fistula From Large Aorto-Iliac Aneurysm

Iliac artery aneurysms (IAA) are associated frequently with abdominal aortic (AAA) and other degenerative large-vessel aneurysms. Concurrent fistulization of the aortoiliac tree into the gastrointestinal tract (GIT) and bladder is exceptionally rare. We herewith report a unique case of concurrent ilio-enteric and ilio-vesical fistula arising from a large aorto-iliac aneurysm.

Management of an Aortoenteric Fistula in a Patient with End Stage Renal and Liver Disease, Prior Endovascular Aortic Repair With Type II Endoleak

Primary aortoenteric fistula (AEF) is an uncommon but life-threatening condition. We present a case of primary AEF in an octogenarian with previous endovascular aortic repair, type II endoleak and end stage liver and renal disease. He was successfully treated with accessory renal artery ligation, duodenojejunostomy, aneurysm sac debridement and irrigation and closure of the aneurysm sac over a drain. The patient made an excellent recovery and was discharged on POD #7, with no complications noted after over a year of follow up. This approach may represent a valuable option to manage primary AEF versus open endograft explant, particularly in severely ill patients.

Primary Aortoduodenal Fistula Causes Massive Melena: A Case Report

A primary aortoenteric fistula is defined as the spontaneous development of communication between the gastrointestinal tract and the native aorta. This is unlike a secondary aortoenteric fistula that occurs after surgery, such as a vascular graft. A primary aortoenteric fistula is an extremely rare cause of upper gastrointestinal bleeding. The condition is often overlooked because of its extremely low incidence. This paper reports a case of a 75-year-old man who presented with massive melena. Esophagogastroduodenoscopy revealed an ulcer measuring approximately 1.3 cm with a huge pulsating vessel in the third portion of the duodenum. Later, the diagnosis of primary aortoduodenal fistula was confirmed. The patient died in the preoperative stage due to massive bleeding. The findings of this case suggest that the endoscopists should recognize aortoenteric fistula as a potential cause of gastrointestinal bleeding.

Diagnostic and Management Difficulty of Bleeding Aorto-Duodenal Fistula Associated with Hodgkin's Lymphoma

Primary aorto-enteric fistula (AEF) resulting from abdominal malignancy is a rare and often fatal complication. The few reports to date are mostly secondary to solid tumors. We present a case of a patient with refractory Hodgkin's lymphoma who developed life-threatening AEF. We describe the diagnostic and therapeutic efforts, requiring a multi-disciplinary team of interventional radiology, gastroenterology, and transfusion medicine, resulting in a favorable outcome. Importantly, we offer several insights regarding the identification and management of high-risk patients, with an emphasis on pre-treatment considerations and urgent diagnosis and intervention.

Midthoracic Pain, Sentinel Arterial Haemorrhage and Exsanguination after a Symptom-Free Interval (Chiari's Triad) is Diagnostic of Arterio-Oesophageal Fistula: A Life-Threatening Cause of Gastrointestinal Bleeding

Introduction

Arterio-oesophageal fistulae are a very uncommon cause of severe gastrointestinal bleeding, and mostly result from an aberrant right subclavian artery and mediastinal surgery or prolonged endotracheal/nasogastric intubation.

Material and Methods

We present the case of a patient with an oesophageal adenocarcinoma and haematemesis due to a subclavian arterio-oesophageal fistula after mediastinal radiotherapy.

Conclusion

We discuss the rare, life-threatening condition of acute erosion of the left subclavian artery caused by an oesophageal tumour and presenting with Chiari's triad.

LEARNING POINTS

Subclavian arterio-oesophageal fistula is an uncommon, life-threatening cause of gastrointestinal bleeding.Knowledge of Chiari's triad enables early recognition of potentially fatal gastro-intestinal bleeding.A high level of suspicion is essential for prompt diagnosis and referral for surgical treatment especially in patients with malignancies of the upper gastrointestinal tract.

Case series of aortoenteric fistulas: a rare cause of gastrointestinal bleeding

BACKGROUND

Aortoenteric fistula (AEF) is a rare cause of gastrointestinal bleeding and is often misdiagnosed in clinical practice. Herein, a case series of AEFs are presented and the clinical characteristics, diagnosis, and management strategies are summarized.

METHODS

A retrospective analysis was performed on consecutive hospitalized patients with a final diagnosis of AEF at Beijing Friendship Hospital, Capital Medical University, between January 1, 2007 and March 31, 2020. The clinical data including diagnostic and management procedures as well as outcomes were collected and summarized.

RESULTS

A total of nine patients were included in this study, five with primary AEF and four with secondary AEF. Eight of the patients were male, and the median age was 63 years. The fistulas were located in both the small intestine and the colon. All patients presented with gastrointestinal bleeding and pain, followed by weight loss, anorexia, and fever. A typical abdominal triad was found in only two cases. Seven patients experienced complications with preoperative abdominal infections and sepsis, and multiple organ failure occurred in four of these patients. All patients were assessed by computed tomography and five underwent abdominal and/or iliac aorta angiography. Two of these patients showed contrast agent leakage from the abdominal aorta into the intestine. Two cases were diagnosed with AEF by endoscopy before the operation. Eight patients received surgery and six patients survived.

CONCLUSIONS

AEF is a rare cause of gastrointestinal bleeding that is associated with high mortality. Gastrointestinal bleeding and pain are the most common presentations. Timely diagnosis and multidisciplinary management are crucial to achieve a positive outcome.

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.

Cross-Sectional Imaging Evaluation of Vascular Lesions in the Gastrointestinal Tract and Mesentery

Gastrointestinal (GI) tract and mesenteric vascular lesions can have various clinical presentations, of which GI bleeding is the most common. This collection of pathology is highly variable in etiology ranging from occlusive disease to vascular malformations to trauma to neoplasms which makes for a challenging workup and diagnosis. The advent of multiple imaging modalities and endoscopic techniques makes the diagnosis of these lesions more achievable, and familiarity with their various imaging findings can have a significant impact on patient management. In this article, we review the gamut of GI tract and mesenteric vascular lesions and their associated imaging findings.

Primary aortoduodenal fistula - overlooked because of guidelines?

Primary aortoduodenal fistula is an uncommon yet mostly lethal finding. We present a case of a 63 year-old male who exhibited significant upper gastrointestinal bleeding and hemorrhagic shock. Repeated endoscopies did not detect any source of bleeding. Emergency laparotomy disclosed an aortoduodenal fistula. Despite intense medical efforts for several months the patient did not fully recover and treatment was limited to palliative care. In light of the substantial mortality associated with this condition, computed tomography imaging should be performed in case of doubt to prevent delayed diagnosis.