Aortoenteric fistula
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Aortoenteric fistulafistulas are pathologic communications between the aorta (or aortoiliac tree) and the gastrointestinal tract, and represent an uncommon cause of catastrophic gastrointestinal haemorrhage.
Aortic fistulas may be considered primary (associated with a complicated abdominal aortic aneurysm) or secondary (associated with graft repair).
Epidemiology
The annual incidence of primary aortoenteric fistulas is thought to be around 0.007 per million while that of secondary aortoenteric fistulas is about ~1% (range 0.6-2%) 1.
The incidence of secondary aortoenteric fistulas is found to be greaterhigher in patients following open aortic repair compared to patients with endovascular stent placement.
Clinical presentation
- classically, aortoenteric fistula may initially present with minor "herald" gastrointestinal haemorrhage, followed by a later catastrophic life-threatening gastrointestinal haemorrhage
- primary aortoenteric fistula may present with recurrent septicaemia with enteric pathogens
Pathology
A primary aortoenteric fistula forms when a large abdominal aortic aneurysm closely abuts bowel loops, usually the 3rd or 4th parts of the duodenum. Similarly, in the chest, when a large thoracic aortic aneurysm compresses the oesophagus. Due to long-standing pressure, the aneurysm slowly erodes into the bowel or oesophageal wall. These are most commonly due to infected mycotic aneurysms.
Secondary aortoenteric fistulas are seen as a complication of aortic reconstructive surgery with or without the placement of an aortic stent-graft. Secondary fistulas that result from perigraft infection may occur between 2 weeks and 10 years after surgery.
Radiographic features
CT
Primary aortoenteric fistula
Direct signs include:
- ectopic gas adjacent to or within the aorta
-
thepresence of vascular contrast within the gastrointestinal tract
Indirect signs include:
- bowel/oesophageal wall thickening overlying an aneurysm
- disruption of the aortic fat cover
- retroperitoneal/mediastinal haematoma or haematoma within the bowel wall or lumen
Secondary aortoenteric fistula
- increased perigraft soft tissue
- pseudoaneurysm formation
- disruption of aneurysmal wrap
- increased soft tissue between the graft and aneurysmal wrap
Treatment and prognosis
The only curative treatment is surgery. Without prompt surgical intervention, mortality approaches 100%. Operative mortality itself is as high as 50%.
Differential diagnosis
On imaging, consider:
- perigraft infection without fistulisation
- retroperitoneal fibrosis
- infected (mycotic) aortic aneurysm
- infectious aortitis
History and etymology
First described by Sir Astley Cooper (1768-1841), a British surgeon in the early 19th century 6.
-<p><strong>Aortoenteric fistula</strong> are pathologic communications between the aorta (or aortoiliac tree) and the gastrointestinal tract, and represent an uncommon cause of catastrophic gastrointestinal haemorrhage.</p><p>Aortic fistulas may be considered primary (associated with complicated <a href="/articles/abdominal-aortic-aneurysm">abdominal aortic aneurysm</a>) or secondary (associated with graft repair). </p><h4>Epidemiology</h4><p>The annual incidence of primary aortoenteric fistulas is thought to be around 0.007 per million while that of secondary aortoenteric fistulas is about ~1% (range 0.6-2%) <sup>1</sup>.</p><p>The incidence of secondary aortoenteric fistulas is found to be greater in patients following open aortic repair compared to patients with <a href="/articles/endovascular-aneurysm-repair">endovascular stent</a> placement.</p><h4>Clinical presentation</h4><ul>- +<p><strong>Aortoenteric fistulas</strong> are pathologic communications between the aorta (or aortoiliac tree) and the gastrointestinal tract and represent an uncommon cause of catastrophic gastrointestinal haemorrhage.</p><p>Aortic fistulas may be considered primary (associated with a complicated <a href="/articles/abdominal-aortic-aneurysm">abdominal aortic aneurysm</a>) or secondary (associated with graft repair). </p><h4>Epidemiology</h4><p>The annual incidence of primary aortoenteric fistulas is thought to be around 0.007 per million while that of secondary aortoenteric fistulas is about ~1% (range 0.6-2%) <sup>1</sup>.</p><p>The incidence of secondary aortoenteric fistulas is found to be higher in patients following open aortic repair compared to patients with <a href="/articles/endovascular-aneurysm-repair">endovascular stent</a> placement.</p><h4>Clinical presentation</h4><ul>
-</ul><h4>Pathology</h4><p>A primary aortoenteric fistula forms when a large abdominal aortic aneurysm closely abuts bowel loops, usually the 3<sup>rd</sup> or 4<sup>th</sup> parts of the duodenum. Due to long-standing pressure, the aneurysm slowly erodes into the bowel wall. These are most commonly due to infected <a href="/articles/mycotic-aneurysm">mycotic aneurysms</a>.</p><p>Secondary aortoenteric fistulas are seen as a complication of aortic reconstructive surgery with or without the placement of an aortic stent-graft. Secondary fistulas that result from perigraft infection may occur between 2 weeks and 10 years after surgery. </p><h4>Radiographic features</h4><h5>CT</h5><h6>Primary aortoenteric fistula</h6><p>Direct signs include:</p><ul>- +</ul><h4>Pathology</h4><p>A primary aortoenteric fistula forms when a large abdominal aortic aneurysm closely abuts bowel loops, usually the 3<sup>rd</sup> or 4<sup>th</sup> parts of the duodenum. Similarly, in the chest, when a large thoracic aortic aneurysm compresses the oesophagus. Due to long-standing pressure, the aneurysm slowly erodes into the bowel or oesophageal wall. These are most commonly due to infected <a href="/articles/mycotic-aneurysm">mycotic aneurysms</a>.</p><p>Secondary aortoenteric fistulas are seen as a complication of aortic reconstructive surgery with or without the placement of an aortic stent-graft. Secondary fistulas that result from perigraft infection may occur between 2 weeks and 10 years after surgery. </p><h4>Radiographic features</h4><h5>CT</h5><h6>Primary aortoenteric fistula</h6><p>Direct signs include:</p><ul>
-<li>the presence of vascular contrast within the gastrointestinal tract</li>- +<li>presence of vascular contrast within the gastrointestinal tract</li>
-<li>bowel wall thickening overlying an aneurysm</li>- +<li>bowel/oesophageal wall thickening overlying an aneurysm</li>
-<li>retroperitoneal haematoma or haematoma within the bowel wall or lumen</li>- +<li>retroperitoneal/mediastinal haematoma or haematoma within the bowel wall or lumen</li>
-</ul><h4>Treatment and prognosis</h4><p>The only curative treatment is surgery. Without prompt surgical intervention, mortality approaches 100%. Operative mortality itself is as high as 50%.</p><h4>Differential diagnosis</h4><p>On imaging consider</p><ul>- +</ul><h4>Treatment and prognosis</h4><p>The only curative treatment is surgery. Without prompt surgical intervention, mortality approaches 100%. Operative mortality itself is as high as 50%.</p><h4>Differential diagnosis</h4><p>On imaging, consider:</p><ul>
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