65-year-old woman with hematemesis.

PATIENT PRESENTATION

A 65‐year‐old female patient with a history of sigmoid cancer involving the para‐aortic lymph nodes, treated by laparoscopic low anterior resection and para‐aortic lymph node excision, presented to the emergency department with hematemesis a few hours ago. On physical examination, she was alert and afebrile, with a pulse rate of 125 beats/min and blood pressure of 115/63 mmHg. Epigastric tenderness was found. Laboratory tests revealed hemoglobin level of 7.4 g/dL. Upper gastrointestinal endoscopy showed unknown bleeding focus (Figure 1). A computed tomography angiography (CTA) of the abdomen demonstrated a fistula connecting the jejunal lumen and left common iliac artery, with contrast extravasation in the jejunum (Figure 2).

FIGURE 1

Upper gastrointestinal endoscopy revealed copious bloody fluid and blood clot retained in the lumen of stomach and duodenum

FIGURE 2

Computed tomography angiography showed a fistula connecting jejunal lumen and left common iliac artery, with contrast extravasation in the jejunum

DIAGNOSIS

Arterio‐jejunal fistula

The fistula was attributed to recurrence of para‐aortic lymph nodes. The patient underwent treatment with covered endovascular reconstruction of aortic bifurcation technique by a vascular surgeon. Aortoenteric fistula (AEF) is a rare and fatal disease with communication between the aortoiliac tree and adjacent bowel. It can be divided into primary and secondary causes. The most common predisposing disease for primary AEF is abdominal aortic aneurysm. Less common causes include aortitis, diverticulitis, appendicitis, foreign bodies, and gastrointestinal malignancies. , , Secondary AEF is more common and usually associated with aortic stent‐graft placement. Patients with AEF usually present with gastrointestinal bleeding. CTA is the preferred image modality, although 50% of those are diagnosed operatively. The most specific sign on CTA is the direct contrast extravasation from the aorta to the bowel loop. Endovascular surgery is the main treatment with better survival than open surgery.