Gastroenterology Today Summer 2019

CASE REPORT
GASTROENTEROLOGY TODAY - SUMMER 2019
10
The diagnosis of aorto-enteric fistula typically is delayed, as long as 1
month in 50% of patients in one series, with the diagnosis being made
within 10 days of hospitalization in only 15% of cases [12]. Urgent upper
GI endoscopy is important for exclusion of common causes of massive
upper GI bleeding; but the diagnostic sensitivity for aorto-enteric fistula
has been reported to be as low as 25% [12]. Gastrointestinal bleeding
with endoscopically unclear findings in a patient with aortic aneurysm or
history of aortic repair should points towards an aorto-enteric fistula [13].
The most valuable tool for diagnosing AEF is a CT scan with contrast,
which may reveal gas within the aneurysm, destruction of the fat plane
between the aneurysm and duodenum, proximity and connection
between aorta and intestine and leaking of the contrast into the GI lumen;
all highly suggestive of AEF [14]. MRI is less useful because of its limited
availability in the emergency setting, longer acquisition time, need for
local technical expertise, and potential difficulties differentiating peri-graft
gas from aortic wall calcification. All other investigation modalities like
white blood cell scan are of limited value in diagnosing AEF. Percutaneous
angiography has a sensitivity of 94 percent and a specificity of 85 percent
for detecting aorto-enteric fistula (AEF); but is rarely considered as
most patients are critically ill by the time of a decision is made to do it
[15&16]. ]. A high index of suspicion is paramount, supplemented by the
judicious use of upper endoscopy and CT, and the attending physician
must be willing to recommend exploratory laparotomy if clinical suspicion
is sufficiently high. As immediate and correct diagnosis is difficult, the
mortality is very high and an untreated AEF has 100% mortality. Mortality
of invasively treated patients is approximately 50 %. [17].
Conclusion
Although AEF is an extremely rare cause of upper GI haemorrhage, it
must always be considered and ruled out in GI haemorrhages. A herald
Image [4] Coronal reconstruction on this portal venous CT study
demonstrates A-Abdominal Aortic Aneurysm (AAA) belly which has
increased in size compared to previous CT image B-New gas locule
within the inferior aspect of aneurysm sac C-Inseparable aortic sac
from the proximal duodenum and tracking gas locules suggestive of a
Image communication 4 between aneurysm sac and second part of duodenum
bleed followed by a an endoscopy is usually the first step in diagnosis.
This case highlights the importance of high index of suspicions in
diagnosing AEF, especially if the patient is known to have AAA. PAEF
is rare if the patient is not known to have AAA; but an accurate clinical
evaluation to rule out an abdominal bruit or pulsatile mass should be
done to rule out AEF. AEF is potentially fatal. An early diagnosis with
prompt surgical management has huge prognostic benefits.
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Address for correspondence
Dr Mohammed Shaheer Pandara Arakkal, Senior Clinical fellow in
Gastroenterology, House G, Morriston Hospital, Swansea SA6 6NL