AORTOENTERIC FISTULA IN A 25-YEAR-OLD MAN

Background: Aortoenteric fistula (AEF) is a rare diagnosis that is often considered only in older patients with histories of abdominal aortic aneurysm. Objectives: To remind emergency physicians that traumatic injury and repair put patients at risk for formation of AEF. Case Report: We discuss the case of a 25-year-old man who developed an aortoduodenal fistula weeks after a stab wound to the abdomen. AEF can occur anywhere along the gastrointestinal tract and can therefore present as either upper or lower tract bleeding. The expected triad of pain, pulsatile mass, and gastrointestinal bleeding is unfortunately rarely present, making diagnosis difficult. Patients often present with a self-limited herald bleed that precedes the fatal exsanguination by hours to days. Diagnosing the fistula at the time of the herald bleed can be difficult but lifesaving. Imaging studies are often misleading and only delay definitive operative treatment. Even with prompt diagnosis and treatment, mortality is high; without repair, it is 100%. Conclusion: This case highlights the importance of suspecting and quickly recognizing AEF based on history and physical examination alone. After extensive pre-operative imaging to confirm the diagnosis, this patient nearly died in the operating room as surgeons took down adhesions trying to reach the fistula to repair it. (C) 2013 Elsevier Inc.