Primary Aorto-Duodenal Fistula in Association with Chronic Ischemic Enteritis: A Case Report.

Background: Primary aorto-duodenal fistula (PADF) is a rare but life-threatening condition that should be taken into account when considering upper gastrointestinal bleeding in elderly patients with history of abdominal aortic aneurysm. Unfortunately, its diagnosis is often unsuspected until surgery or at postmortem.

Presentation Of Case: We report a case of a 69 years old man with massive gastrointestinal bleeding secondary to a primary aortic duodenal fistula without a history of abdominal aortic aneurysm and with a misleading diagnosis of chronic ischemic enteritis. Repeated endoscopies and a prior CT angiography failed to document a proper diagnosis. Finally, the aorto-duodenal fistula was identified with a further abdominal CT angiography. Despite a prompt endovascular treatment with aortic endoprosthesis placement, the patient died due to a severe hemorrhagic shock consequent to the massive blood loss.

Discussion: Primary aorto-duodenal fistula represents a very rare (<0.1% of incidence) cause of severe upper gastrointestinal bleeding most often leading to patient's death for hemorrhagic shock. It is frequently associated to aortic atherosclerosis. Its prompt diagnosis with endoscopy and CT angiography is very often difficult and almost never immediate. Furthermore, these exams may be misleading. In case of massive upper GI bleeding without a certain diagnosis in patients with severe aortic atherosclerosis, laparotomy with careful inspection of the distal duodenum is strongly recommended for aortic repair and bowel suture.

Conclusions: The diagnosis of PADF should be taken into account in patients with upper gastrointestinal bleeding associated with aortic atherosclerosis with strong suspect of penetrating ulcer.