A Rare Cause of an Already Rare Cause of GI Hemorrhage

A 75-year-old male with a three-month history of intermittent melena and a 40 g/L decrease in hemoglobin was referred to gastroenterology for further investigation. His surgical history was significant for an elective percutaneous endovascular aneurysm repair five years ago, complicated by a recurrent Type 2 endoleak, requiring a total of four trans-arterial and trans-lumbar embolization with copolymers, gelfoam, and endocoils. Computed tomography (CT) scan demonstrated a stable aneurysm sac diameter with no disruption of the aneurysm wall, extravasation of contrast material into the bowel, or signs of peri-graft gas (Figure 1). On esophagogastroduodenoscopy (EGD), an aortoenterc fistula secondary to a perforating endocoil was seen in the third part of the duodenum (Figure 2), which was confirmed during a subsequent duodenal diversion procedure. Computed tomography scan of the embolization material and endocoils inside the aneurysm sac. Perforating endocoil in the third part of the duodenum. Secondary aorto-enteric fistula (AEF) is a serious but rare complication of abdominal aortic aneurysm repair (1). Erosion of metallic endocoils into the aortic wall post-endoleak embolization is an extremely rare cause of AEF, with only one published case that was diagnosed at laparotomy (2). While CT is the diagnostic modality of choice in a stable patient, the high sensitivity (94%) and specificity (85%) in this case were likely affected by significant signal artifact from the embolization material (3). In summary, endoscopic examination of the 3rd and 4th portion of the duodenum is a useful diagnostic adjuvant to CT imaging in patients with previous endoleak embolization for the diagnosis of AEF. Conflict of interest statement: The authors have no conflicts to declare. Contribution: YC drafted the initial manuscript. EJC edited and provided final approval of manuscript.