Clinical Case Summary
Secondary aortoenteric fistula (AEF) is an abnormal connection between the aorta and gastrointestinal tract (GT) resulting from reconstructive surgery for an abdominal aortic aneurysm (AAA), including open repair surgery and endovascular treatment. Despite the low incidence (1.6 to 4%) [1–4], it is life-threatening and has a high mortality rate (24 to 45.8%) [5–6].
A 79- year-old man reported to the emergency department of our hospital with overt bleeding from the stoma. The patient had a history of open Dacron graft repair for a ruptured AAA eight months previosly, which became complicated on the 5th postoperative day by sigmoid ishemia that required an emergency Hartmann procedure.
His blood pressure was 90/60 mmHg, heart rate 93/minute and hemoglobin level 7.5 g/dL.
The patient was admitted to our department. He underwent upper and lower endoscopy and no bleeding lesions were found. After endoscopy the patient presented another episode of overt bleeding from the stoma and we decided to perform Small-bowel capsule endoscopy (SBCE) which showed activ bleeding within the proximal ileum. The contrast-enhanced CT demostrated an aneurysm sac enlargement, a close proximity of the small bowel loops with the aneurysm sac in the pelvic cavity and a suspected leakage at the distal part of the aneurysm sac.
The patient was therefore admitted to the Surgical Derpatment and underwent an emergency endovascular repair of the leakage caused by distal detachment of the aorto-aortic prosthesis using a bifurcated stant graft. No more bleeding from the stoma occurred and the patient was discharged three days later with a diagnosis of distal aortic anastomosis leakage with aorto-ileal fistula.
The duplex ultrasound of the graft after one, three and six months showed no sign of endoleak.
This case shows that the SBCE may be useful in patients with history of recostructive surgery for AAA who manifest overt bleeding from the GT and no lesions are found in upper and lower endoscopy.
References
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2.Champion MC, Sullivan S, Coles J, Goldbach M, Watson WC. Aortoenteric fistula. Incidence, presentation recognition, and management. Ann Surg. 1982;195(3):314–7
3.Hallett JW Jr, Marshall DM, Petterson TM, Gray DT, Bower TC, Cherry KJ Jr, Gloviczki P, Pairolero PC. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36-year population-based experience. J Vasc Surg. 1997;25(2):277–84. discussion 285-276
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5.Malik MU, Ucbilek E, Sherwal AS. Critical gastrointestinal bleed due to secondary aortoenteric fistula. J Community Hosp Intern Med Perspect. 2015;5(6):29677
6.Gnus J, Ferenc S, Koscielna M, Paprocka-Borowicz M, Dawidczyk P, Dziewiszek M, Witkiewicz W. Secondary Aortoenteric Fistula After Abdominal Aortic Graft Implementation in Our Own Material. Adv Clin Exp Med. 2016;25(6):1265–71