Potentially lethal enteric bleeding in the ED

Primary aortoduodenal fistula: A case report and review of literature

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Primary aortoduodenal fistula (PADF) is extremely rare.

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A PADF case was treated by in situ aortic reconstruction and omental coverage.

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An elderly man with hematemesis was diagnosed with PADF.

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The patient had uneventful recovery and discharged 86 days after surgery.

Background

Primary aortoduodenal fistula (PADF) is an abnormal connection between the aorta and the duodenum and is a life-threatening condition. It is a very rare cause of gastrointestinal bleeding, which often leads to delay in its diagnosis. Prompt diagnosis and surgical treatment are crucial to improve the outcome of patients with PADF.

Presentation of case

An 82-year-old man with a history of untreated abdominal aortic aneurysm (AAA) presented to the emergency department with hematemesis. Computed tomography (CT) revealed an AAA with air within the thrombus wall and disruption of the fat layer between the AAA and duodenum, indicating PADF. Emergent surgery, in situ aortic reconstruction using a Dacron graft, and omental coverage were performed. Although the patient needed another surgery for postoperative chylous ascites, he made good recovery and was discharged 86 days after initial surgery.

Discussion

In our case, the patient presented with hematemesis and a pulsatile abdominal mass on physical examination and had a history of untreated AAA, which helped in prompt diagnosis of PADF. CT findings suggesting PADF include disappearance of the fat plane between the aneurysm and duodenum, air in the retroperitoneum or within the aortic wall, and contrast enhancement within the duodenum. The recommended surgical approach for PADF consists of aortic reconstruction (in situ aortic reconstruction or extra-anatomical bypass) and duodenal repair.

Conclusion

Our report affirms that CT and open surgery are effective diagnostic and treatment options, respectively, for PADFs.

Gastrointestinal causes of sudden unexpected death: A review

Gastrointestinal conditions are a less common cause of sudden unexpected death when compared to other conditions such as cardiovascular conditions, but they are equally important. Various congenital and acquired gastrointestinal conditions that have resulted in sudden unexpected death are discussed. The possible lethal mechanisms behind each condition, along with any associated risk factors or secondary diseases, have been described. Through this article, we aim to highlight the need for physicians to prevent death in such conditions by ensuring that subclinical cases are diagnosed correctly before it is too late and by providing timely and efficacious treatment to the patient concerned. In addition, this review would certainly benefit the forensic pathologist while dealing with cases of sudden unexpected death due to gastrointestinal causes. This article is a review of the major gastrointestinal causes of sudden unexpected death. In addition, related fatal cases encountered occasionally in forensic autopsy practice are also included. There are several unusual and rare causes of life-threatening gastrointestinal bleeding that may lead to sudden unexpected death to cover all the entities in detail. Nevertheless, this article is a general guide to the topic of gastrointestinal causes of sudden unexpected death.

A rare and forgotten diagnosis of gastrointestinal bleeding: primary aortoduodenal fistula

Upper gastrointestinal (UGI) bleeding is a common medical condition among adults. Bleeding is mainly caused by the gastric or proximal duodenum, but rarely by the distal duodenum. Aortoduodenal fistula is one of the causes of UGI bleeding that results in a life-threatening condition if not treated properly. It is commonly observed in patients who have undergone previous aortic surgery and rarely occurs in patients without a history of aortic surgery. Diagnosis of aortoenteric fistula is difficult unless there is a high level of clinical suspicion. In this article, we aim to present a patient with aortoduodenal fistula and discuss the clinical presentation, as well as the diagnostic and therapeutic options of this disease.