[Upper gastrointestinal bleeding after long term, high dose NSAID medication: a wolf in sheep's clothing?].

A 71-year-old patient with melena, abdominal and lower back pain was admitted to hospital under suspicion of upper gastrointestinal bleeding. He had mild anemia and an elevated C-reactive protein. Endoscopy and ultrasound failed to localize the source of bleeding. The patient died 2 1/2 days after admission on an exsanguinating hemorrhage. On pathologic examination a fistula between the small aortic aneurysm and duodenum and periaortic inflammation in contact with a spondylitis were found. When clinical presentation is subtle, with a herald bleeding followed by a period of grace, the diagnosis of aortoenteric fistula may be extremely difficult.