Aortoenteric Fistula Diagnosed by Double Balloon Enteroscopy: A Case Report
A 48-year-old man was admitted to our institution because of three episodes of abrupt hematemesis. Four years ago, he underwent graft interposition for abdominal aortic aneurysm. On initial examination, he had acute ill-looking appearance. His blood pressure was 110/70 mm Hg, pulse rate 120/min, respiratory rate 20/min, and body temperature was 36.5℃. Laboratory tests revealed hemoglobin (Hb), 12.0 g/dL (normal, 15.3±3.0); platelet count, 368,000/µL (normal, 220,000±100,000); and white blood count, 11,100/µL (normal, 7,500±3,500). Emergency esophagogastroduodenoscopy (EGD) was performed to detect the bleeding focus in the upper GI tract; however, there were no specific findings in EGD. Hematochezia occurred again on the second day, but we could not find the bleeding site in the lower GI tract by colonoscopy. Also there were no specific findings in ileoscopy with a standard colonoscope and radioactive iodine bleeding scan. Severe hematochezia occurred on the third hospital day, and the level of Hb dropped to 8.4 g/dL. The patient required transfusion with four units of packed red blood cells. Immediately, we performed a DBE via the oral route, which disclosed flat elevated erosion with silk in the proximal jejunum (). Endoscopic findings showed a fistula that opened and closed on the central portion (). This lesion suggested AEF. The patient was finally diagnosed with secondary AEF by emergency multidetector computed tomography (MDCT) () and angiographic findings (). Because he was in a state of hypovolemic shock after massive hematochezia, an embolization was performed during the angiography. After 1 day, he was treated with surgical intervention. The patient recovered and was discharged 27 days after surgery. In our case, the DBE was a helpful approach to make correct diagnosis of AEF.