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but potentially lethal causes of massive gastrointestinal tract bleeding. Here, we report the typical endoscopic findings of ADFs. A 57−year−old man was admitted to our hospital with intermittent melena for 2 weeks. His medical history included im− plantation of a prosthetic graft for an ab− dominal aortic aneurysm at the age of 56 years. Hemoglobin level decreased from 14.5 g/dL in the previous month to 11.2 g/ dL, and esophagogastroduodenoscopy (EGD) revealed no source of bleeding up to the second part of the duodenum. On day 3, melena recurred and hemoglobin level further decreased to 9.3 g/dL. Con− trast−enhanced computed tomography (CT) scan showed a protruding aorta compressing the third part of the duode− num (l" Fig. 1); EGD at this site revealed a raised lesion covered by an apparently normal mucosa with a central ulcer (l" Fig. 2). Operative findings revealed fistula formation between the aorta ± at 1.5 cm from the cranial margin of the graft ± and the third part of the duode− num. Gastrojejunostomywith graft repla− cement was performed. ADFs are classified as either primary or secondary. Incidences of secondary ADFs after endovascular stent grafting of ab− dominal aortic aneurysms have been re− ported to be about 1%. The duodenum, particularly its third part, is the most common site of fistula formation. Clinical manifestations include gastrointestinal bleeding, abdominal pain, and develop− ment of a pulsatile mass. Endoscopic fea− tures include a submucosal tumor with a small ulcer [1±4]. Diagnosis is difficult as endoscopists do not focus on a history of aortic aneurysm repair or consider the third part of the duodenum in patients with unexplained gastrointestinal bleed− ing. Endoscopy_UCTN_Code_CCL_1AB_2AZ_3AD

Unexplained melena associated with a history of endovascular stent grafting of abdominal aortic aneurysms: aortoduodenal fistula