2000 Volume 56 Issue 2 Pages 70-71
An 85-year-old woman was admitted with massive upper gastrointestinal hemorrhage. She had a history of small upper gastrointestinal bleeding on 11 days before admission. On admission, physical examination revealed a pulsatile abdominal mass and her hematocrit was 16.8 per cent. An emergency endoscopic examination revealed no bleeding source in the esophagus and stomach but bleeding from pulsatile submucosal elevation at the third portion of the duodenum. A CT scan demonstrated a 6-cm abdominal aortic aneurysm. Emergency laparotomy revealed an abdominal aortic aneurysm with aortoduodenal fistula at the level of third portion. The fistula was taken down and closed, and the aneurysm was replaced by a graft. Histology of the resected aorta showed the features of atherosclerotic aneurysm with fibrin plug at the fistula. No complication including infection and rebleeding occurred, and endoscopy at 14 days after surgery revealed improvement of the duodenal fistula. Aortoduodenal fistula is rare but invariably fatal without precise diagnosis and prompt surgical treatment. The presence of antecedent nonexsanguinating hemorrhage before hypovolemic shock, socalled“herald bleed”is present in two-thirds of the patients, making it important to establish diagnosis before fatal exsanguination. Physician should consider the diagnosis of aortoduodenal fistula in patients with even mild upper gastrointestinal bleeding of uncertain etiology and abdominal pulsatile mass.