A Deadly Connection: Aortoenteric Fistula as a Cause of Acute Upper Gastrointestinal Bleeding

A 66-year-old white man with hypertension, hyperlipidemia, COPD, lung cancer, and aortoiliac bypass graft placed 6 years prior for peripheral vascular disease, presented with 3 days of melena and syncopal events associated with bowel movements. The patient reported having coffee ground emesis and dark, tarry stools with onset of his syncope. Physical exam showed bright red blood per rectum and melenic stools. Baseline hemoglobin was 14.5 g/dL, dropping to 7.1 g/dL at admission. He subsequently became hypotensive despite receiving 2 units of packed red blood cells and aggressive intravenous fluid hydration. Emergent esophagogastroduodenoscopy (EGD) showed red blood throughout the esophagus, pale stomach mucosae, and an exposed aortic graft with bright blood in the third part of the duodenum (Figure 1). He underwent emergent laparotomy for takedown of aortoduodenal fistula with repair of duodenal erosion and ligation of the distal aorta. The following day, the patient’s lower extremities had increased pallor and he underwent axillofemoral and femoral-femoral bypass grafting. He went into cardiac arrest perioperatively and died.