Presentation
Sudden onset hematemesis and abdominal pain.
Patient Data
Focal aneurysmal dilation of the infrarenal abdominal aorta with an associated aortoenteric fistula connecting to the third part of the duodenum. A significant volume of high-density contrast exists within the lumen of the duodenum, with mixed density in the jejunum and stomach lumens (presumed blood of varying ages).
Case Discussion
Aortoenteric fistulas are often associated with life-threatening bleeding and hence require prompt diagnosis and management. Etiologically, they are often split into primary or secondary aortoenteric fistulas, where the primary disease occurs de-novo compared with the secondary disease, which arises following surgical or endovascular iatrogenic procedures (e.g., aortic grafting).
Causes of primary aortoenteric fistulas include aortic aneurysms, foreign bodies or trauma, malignancy, radiotherapy, and infection (e.g., syphilis, Q-fever).
The case above involves:
no history of vascular surgeries or procedures, trauma, or radiotherapy
heavy smoking history
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history of Q fever, pneumonia, and sepsis (four years prior to the above imaging) requiring ICU admission
CT chest/abdo/pelvis during this admission prior showed a small atheromatous saccular aneurysm of the infrarenal abdominal aorta (22 mm max transverse diameter), with no features to suggest an infected aneurysm
On presentation to the emergency, the patient was haemodynamically unstable and rapidly progressed to cardiac arrest despite multiple red blood cell transfusions. ROSC was achieved and urgently transferred to the theater. Despite attempts at surgical hemostasis, the patient did not survive the procedure.
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