Abstract Introduction Aortoenteric fistula (AEF) is a rare but often fatal cause of gastrointestinal bleeding that may occur years after aortic graft surgery and presents a challenging diagnostic dilemma. The transient sentinel or herald bleed can appear deceptively benign, and prompt recognition is essential for survival. Case Presentation A 70-year old man with a history of abdominal aortic aneurysm status post open repair with an aortic bi-iliac graft greater than ten years prior, presented to the emergency department with a single episode of hematemesis followed by a syncopal episode and subsequent dark red and bright red blood admixed in stool. He was found to have anemia with a hemoglobin level of 11 grams per deciliter on admission which trended to 9.0 grams per deciliter and remained stable. His vital signs were stable, however, he was noted to have positive orthostatic blood pressure. He was completely asymptomatic upon arrival and had no further bleeding through index hospitalization. He underwent both upper and lower endoscopic evaluations with esophagogastroduodenoscopy and colonoscopy which were unremarkable. Given his vascular history, computed tomography angiography (CTA) of the abdomen and pelvis was obtained, revealing findings concerning for AEF between the aortic graft and the duodenum, consistent with secondary AEF (Figure 1). The patient was emergently transferred to a tertiary center and definitive management with exploratory laparotomy and repair of secondary AEF. He tolerated the procedure well, recovered without major complication and was discharged. Figure 1: CTA of the abdomen and pelvis with contrast showing fistula between aortic graft and duodenum filled with contrast. Discussion AEF should be strongly considered in any patient with a history of abdominal aortic aneurysm or aortic graft repair who presents with gastrointestinal bleeding, even when initial endoscopic studies are negative. The sentinel or herald bleed often precedes catastrophic hemorrhage, and CTA is the diagnostic modality of choice for early identification. Despite historically high mortality, survival is possible with rapid diagnosis and surgical intervention. Conclusion This case highlights the critical importance of maintaining a high index of suspicion for AEF in patients with abdominal aortic aneurysms or prior aortic grafts who present with gastrointestinal bleeding. Recognition of the herald bleed and expedited imaging can be lifesaving in this otherwise frequently fatal condition. This abstract is funded by: None
Singh et al. (Fri,) studied this question.