FIRST REPORT OF A SECONDARY AORTO-JEJUNAL FISTULA DIAGNOSED BY DOUBLE-BALLOON ENTEROSCOPY

Introduction:

Aorto-jejunal fistula (AJF) is a very rare, life threatening condition which may result in catastrophic gastrointestinal (GI) bleeding. Secondary AJF is usually associated with a history of previous surgical repair of an abdominal aortic aneurysm (AAA).

Methods:

An 86-year-old woman with intermittent severe obscure-overt GI bleeding (with negative upper and lower GI endoscopies) was transferred as a tertiary referral to our institution for further investigation and management. Small bowel capsule endoscopy (SBCE) had shown active bleeding within the proximal jejunum. The patient's history of AAA Dacron-graft repair 9 years previously, raised our suspicion of a possible aorto-enteric fistula (AEF).

Results:

Although cross-sectional imaging (CT) had demonstrated close proximity of a jejunal loop to the aortic Dacron graft, the scan was deemed to be inconclusive. In light of the history, we proceeded to perform an urgent anterograde double-balloon enteroscopy (DBE) for direct endoscopic assessment of the small bowel. Our suspicions were confirmed and a definitive diagnosis of an AJF was clinched when the external surface of part of the Dacron graft was seen to bulge through the jejunal wall at an estimated insertion depth of 60 cm post-pylorus (video).

Conclusions:

Secondary AEFs affect up to 1.6% of patients who undergo AAA repair; the jejunum is involved in only about 9% of these cases. In view of the associated mortality that ranges between 22 – 100%, prompt, definitive diagnosis remains critical. To the best of our knowledge, this is the first report of AJF identified by DBE and highlights the effectiveness of this endoscopic modality in providing an irrefutable diagnosis of an AEF when this lies beyond the duodenum.