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Internal Medicine

Aortoenteric fistula (AEF)

Connections between the aorta and gastrointestinal (GI) tract.


Aetiology

Primary aortoenteric fistula (PAEF) (<1% cases)

  • Abdominal aortic aneurysms (AAAs)
  • Rare causes:
    • Syphilis, tuberculosis, peptic ulcer disease, and malignancy

Secondary aortoenteric fistulas (SAEF) (M/C)

  • Aortic reconstruction 

Clinical features

Classic triad (11% cases):

  • Palpable abdominal mass
  • Abdominal pain
  • GI bleed: Hematemesis/melena (M/C symptom, 32-78% cases)

Primary aortoenteric fistulas (PAEFs):

  • Self-limited GI bleeds called “herald bleeds,”
  • Fistula often goes undiagnosed until patients undergo laparotomy for a massive GI bleed

Diagnosis

  • Esophagogastroduodenoscopy (EGD) (first-line investigation)

Imaging

CECT (imaging of choice):

  • Air within the aortic wall
  • Focal bowel wall thickening
  • Disruption of pre-aortic fat
  • Contrast in proximity or in the bowel

CT-angiogram:


Management

Endovascular treatments:

  • Retrograde balloon occlusion of the aorta
  • Stent-graft deployment
  • Coil, fibrin, and glue embolization of the fistulous tract

Surgical management:

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En-bloc resection of the aortic segment and small bowel. | Rhéaume, P., Labbé, R., Thibault, E., & Gagné, J.-P. (2008). A rational, structured approach to primary aortoenteric fistula. Canadian Journal of Surgery. Journal Canadien de Chirurgie, 51(6), E125–E126. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/19057723

Patients likely require lifelong antibiotics and remain at risk for secondary infection and refistulation.

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