A Strange Case of Upper Obstructive Syndrome

The most frequent aorto-enteric fistulae are Aorto-duodenal fistulae (ADF). The most frequent symptom of ADF is upper gastrointestinal bleeding (UGI). A male patient of 59 years who has undergone an aortic-bi-femoral bypass five years ago had been admitted to the emergency room following a persistent occlusive syndrome with dyspepsia and biliary vomiting for five days.  

Computed tomography (CT) scan showed in the third duodenal segment the presence of an area with the characteristics of inflammatory tissue, including air bubbles between the duodenum and aortic-bi-femoral prosthesis adherent to the third duodenal. Microbiological cultures and scintigraphy were unremarkable.

Esophago-gastro-duodenoscopy showed the aortic prosthesis crossing the third segment of duodenal wall occluding the intestinal lumen. At laparotomy, after viscerolisis, the prosthesis was detached from duodenal wall and the intestine failed to close transversely. To protect the intestinal wall, a pediculated fragment of the greater omentum was placed between the duodenum and aortic bypass. Furthermore, a gastrojejunal Roux anastomosis was employed. The prosthesis was not changed because there were no local or systemic signs of infection. The post-operative course was uneventful.

These findings were published in the January 21, 2008 edition of the World Journal of Gastroenterology. ADF may be primarily due to a spontaneous communication between the lumen of aortic aneurysm and intestinal loop, or secondarily due to surgical repair of aneurysms with prosthetic implants. Clinical suspicion is essential in the diagnosis of ADF and the most commonly used techniques for its diagnosis are esophago-gastro-duodenoscopy (EGDS) and CT.