Unusual cause of gastrointestinal bleeding in an 84-year-old woman: a miraculous survival from an aortoduodenal fistula repair

Abstract

An 84-year-old woman presented acutely with dizziness, fatigue and a total of 800 mL of fresh per rectum (PR) bleeding. The significant history of abdominal aortic aneurysm repair 5 years ago included multiple episodes of endovascular leak around the stent associated with abscess of left psoas major, left abdominal wall abscess with sinus formation, appendicitis with abscess formation, and acute pancreatic and chronic cholecystitis with multiple gallstones in the 7 months prior to this presentation. During the preceding 7 months, the patient was stabilised with an intravenous proton pump inhibitor, blood transfusions and Intensive Care Unit (ICU) management for the assumed diagnosis of stress ulcers over multiple hospital admissions. Imaging with CT scan of the abdomen made the more accurate diagnosis of acute gastrointestinal haemorrhage caused by a fistula between the distal duodenum and aorta, which was later surgically confirmed. Removal of infected stents and axillobifemoral bypass were performed with a successful recovery.

Keywords: GI bleeding; vascular surgery.

Figure 1

Multiplanar reconstruction CT scan images which show the endoleak, arrows illustrating the leakage site.

Figure 2

CT slice which shows duodenum adhesion to the aneurysm wall, arrow illustrating the possible site of aortoduodenal fistula.

Figure 3

After removal of the infected stents, arrow illustrating the aneurysm sac.

Figure 4

Intraoperative picture, arrow illustrating the duodenum and appendix adhesion to the aneurysm wall.

Figure 5

After intraoperative separation of duodenum, appendix and aneurysm wall, blue arrow illustrating the fistula orifice of duodenum, green arrow illustrating clamped aneurysm wall.