An autopsy case of a primary aortoenteric fistula: A pitfall of the endoscopic diagnosis

Abstract

A primary aortoenteric fistula (PAEF), defined as a communication between the native aorta and the gastrointestinal tract, is a rare cause of gastrointestinal bleeding. The preoperative diagnosis of PAEF is extremely difficult. Consequently, PAEF may cause sudden and unexpected death. We present an autopsy case of a 68-year-old man who died of massive gastrointestinal bleeding due to a PAEF. Autopsy revealed a pinhole rupture located on the third part of the duodenal mucosa and fistulized into the adjacent abdominal aortic aneurysm (AAA). Our case indicates that the aortoenteric fistula can result in fatal gastrointestinal bleeding. Consequently, a PAEF should be included in the differential diagnosis of gastrointestinal bleeding.

Primary Aorto-duodenal Fistula: A Rare but Potentially Fatal Cause of Gastrointestinal Bleeding

“…There is usually an initial self-limiting hemorrhage (sentinel hemorrhage), which in most cases is followed by a massive hemorrhage that occurs some hours or even a month later. [2][3][4] In up to one-third of patients, massive hemorrhage occurs within 6 h after the initial bleeding, as happened in our patient. This time period is the ideal window of opportunity to make an early diagnosis, although it requires a high index of clinical suspicion.…”

“…According to several published series, the mortality rate with treatment varies between 18 and 93%. 3,4,6 A high percentage of patients die during surgery or during the immediate postoperative period due to hypovolemia, 5 which occurred with our patient.…”

“…1,4,7 Despite the communication between the aorta and the digestive tract, fever and other signs of systemic infection are rare. There is usually an initial self-limiting hemorrhage (sentinel hemorrhage), which in most cases is followed by a massive hemorrhage that occurs some hours or even a month later.…”

“…Primary AEF are less common; in large autopsy series, their frequency is 0.04%-0.07%. 3,4 The most frequent causes of primary AEF are atherosclerosis and aortic aneurysm; less frequent causes include syphilis, TBC, infections, neoplasms, foreign bodies or any other disease that may cause the aorta to erode the wall of the intestine. 3 Most AEF communicate the aorta and the duodenum, especially the third portion of the duodenum 4-6 given the position of this segment in the retroperitoneum and in proximity to the descending aorta.…”

The cause of intestinal bleeding cannot be missed: the case of primary aortic-enteric fistula

“…gastrointestinal hemorrhage, abdominal mass and abdominal or back pain is uncommon. [4][5][6][7] As in our case, the typical bleeding pattern associated with PAEF is usually intermittent, starting with a brief herald bleeding followed by major gastrointestinal hemorrhage having often a fatal outcome. 8 Even if the preoperative examinations are often not helpful and can lead to delayed diagnosis and surgery, we suspected the presence of PAEF by a simple imaging technique such as transabdominal ultrasonography associated with echo-color-Doppler and the final diagnosis was made by contrastenhanced computed tomography that showed the presence of abdominal aneurysm, the linkage between the aneurysm and the duodenum and the presence of blood in the intestinal lumen.…”