Aortoduodenal Fistula: Not Always Bleeding

1Division of Gastroenterology, Department of Medicine; 2Division of Vascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia Correspondence: Dr Michael F Byrne, Division of Gastroenterology, Department of Medicine, University of British Columbia, 5153-2775 Laurel Street, Vancouver, British Columbia V5Z 1M9. Telephone 604-875-5640, fax 604-875-5378, e-mail michael.byrne@vch.ca Received for publication March 17, 2013. Accepted May 12, 2013 Case Presentation A 73-year-old woman presented to a community hospital with three months of intermittent, followed by continuous epigastric pain. There was no gastrointestinal bleeding, nausea, vomiting or fever. A noncontrast abdominal computed tomography scan identified gas locules around an aortobifemoral bypass graft performed in 1992, with surrounding inflammatory fat stranding (Figure 1A). Graft infection was suspected. Metronidazole was prescribed with outpatient follow-up by a vascular surgeon who referred her for gastroscopy. At the third part of the duodenum, a wall defect 3 cm × 2 cm in size was replaced by a yellow-coloured foreign body suspected to be the external surface of an aortic Dacron graft (Figure 1B). The aortoduodenal fistula was treated with an axillofemoral graft, removal of the infected graft and a duodenal-jejunostomy, in which the lateral wall defect at the junction of the third and fourth parts of the duodenum was closed with a loop of proximal jejunum (Figure 1C). Cultures from the excised graft had growth of Candida lusitaniae and Streptococcus constellatus. Antimicrobials were commenced, with recovery in two months.