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An 88 yr old female presented to the Emergency Department with black tarry stool for two weeks along with weakness, fatigue and hypotension. Past Medical History was significant for Coronary artery disease, Hypertension, Diabetes and a surgical history of AAA repair 8 years prior to admission. On Physical examination temperature was 95.5 degrees Fahrenheit, Blood Pressure was eighty-seven over fifty-six, Heart rate ninety-three and respirations twenty-eight. She was an elderly female who was confused and lethargic with a visible pulsating abdominal mass and dark melenotic stools. On contrast CT of the abdomen and Pelvis this shows an ulcerated thrombus within the aortic wall adjacent to the duodenum. Here, axial cuts demonstrate anterior out-pouching of the aorta consistent with ulcerated thrombus, the duodenum courses anteriorly and abuts the ulcerated thrombus. This reconstructed image in the sagital plane demonstrates out-pouching of the aorta anteriorly, again showing the duodenum wall abuts the ulcerated thrombus within the aorta. Aortoenteric fistula was suspected but could not be confirmed. An upper endoscopy was then performed in the emergency department to confirm the diagnosis of aortoenteric fistula. As you can see, in the third portion of the duodenum, a pulsating, ulcerated, friable lesion with oozing of blood was noted. No visible aortic stent could be seen eroding through the duodenum. The lesion in question most likely represents the peudo-anneurysm noted on CT scan eroding through the duodenal wall secondary to pressure necrosis. Thus confirming the diagnosis of Aortoenteric fistula. After discussing treatment options with the patient’s family, the decision for non-operative management was made. Supportive care was provided with blood transfusions, diet as tolerated and hospice care. The patient was discharged in stable condition, but readmitted twice for GI bleeding and managed conservatively. The patient expired eighteen days after initial diagnosis of Aorto-enteric fistula. The incidence of Aorto-enteric fistula after surgical repair of aortic aneurysm is up to four percent and may develop months to years after surgical repair. GI bleeding is the most common presenting symptom seen in 80% of patients, followed by pulsatile mass seen in 56%, abdominal pain in 30% and sepsis may be the only obvious sign in up to 20% of patients. Diagnosis can be confirmed by upper endoscopy, and in over 70 % of fistulas the duodenum is involved. Peri-operative mortality is approximately 50%, operative mortality ranges from 14-75% depending on the intervention performed, and mortality without intervention is 100%.
Stanley Yakubov, MD, Albert Einstein College of Medicine, Maimonides Medical Center
Steven Shamah, MD, Albert Einstein College of Medicine, Maimonides Medical Center
Joseph Hanono, MD, Albert Einstein College of Medicine, Maimonides Medical Center
Maryanne Ruggiero, MD, Albert Einstein College of Medicine, Maimonides Medical Center
Ira Mayer, MD, Albert Einstein College of Medicine, Maimonides Medical Center
Jack Braha, DO, Albert Einstein College of Medicine, Maimonides Medical Center
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