S3689 A Hidden Herald Catastrophe

Résumé fourni par la source

Introduction: Aortoenteric fistulas (AEF) are a rare, but potentially fatal cause of upper gastrointestinal bleeding (UGIB). The incidence ranges from 0.36% to 1.6%, and a high clinical index of suspicion should be maintained for causes of UGIB in patients with a history of aneurysmal disease or aortic surgery. Computed tomography angiography (CTA) is recommended as the initial diagnostic test of choice. Early diagnosis of AEF is crucial due to the high fatality rate without intervention. We present a case of a man with a history of aortic surgery who presented with syncope and an isolated episode of melena, found to have an AEF on endoscopy. Case Description/Methods: A 69-year-old male with a medical history of remote aortoiliac bypass repair presented to the emergency room with an isolated episode of melena, syncope, and worsening of chronic abdominal pain.Upon initial presentation, patient was hemodynamically stable however with a notable decrease in hemoglobin from 15 g/dL one week prior to 10.5 g/dL. During his stay in the emergency department, he had a transient hypotensive episode to 57/37mm Hg which improved with fluids. CTA revealed an aortoiliac bypass with a patent graft with preserved flow, an ill-defined soft tissue infiltration along the proximal graft, and a new irregular filling defect along the lateral aspect of the right bypass limb distal to the origin of the graft. Due to concern for possible AEF, an emergent upper endoscopy was performed which revealed a large amount of blood in the stomach and a nodular 2cm protruding mass with a fistulous orifice with stigmata of recent bleeding, confirming UGIB secondary to AEF. The patient underwent an exploratory laparotomy which confirmed the presence of an AEF. An excision of an end to side aortic graft and placement of a new graft was performed. Discussion: Timely diagnosis and prompt surgical intervention are paramount in the management of AEF. Untreated, mortality rates approach 100%, reducing to 50% at 60 days post-surgical repair. While CTA imaging is the primary diagnostic modality, endoscopy should be strongly considered for patients with negative CTA findings but a high clinical suspicion of AEF. Our case underscores the critical role of endoscopy in diagnosing AEF, particularly in situations where CTA fails to reveal typical findings (see Figure 1).Figure 1.: Endoscopic aortoenteric fistula.

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