Think Twice Before Endoscopic Therapeutic Intervention: Aortoenteric Fistula

Objective: Aortoenteric fistula (AEF) is a rare but potentially fatal cause of gastrointestinal bleeding. It can be classified as primary or secondary, with the latter most commonly occurring after aortic graft surgery. Due to the severe and rapid nature of hemorrhage, the endoscopic diagnosis of AEF is highly challenging, and there is no specific endoscopic appearance of the lesion. Furthermore, invasive endoscopic interventions may precipitate life-threatening rebleeding. This case highlights the endoscopic and radiological findings of a primary AEF presenting with massive upper gastrointestinal bleeding, which subsequently achieved spontaneous hemostasis. Case: A 73-year-old male patient on anticoagulant therapy due to coronary artery disease and atrial fibrillation was admitted to the emergency department after hematemesis, melena, and syncope. Initial assessment revealed hypotension and anemia. Esophagogastroduodenoscopy (EGD) showed a 2.5 cm polypoid lesion with a central fibrin plug in the third part of the duodenum. Given the suspicion of AEF, no endoscopic therapeutic intervention was attempted. Cross-sectional imaging confirmed the presence of a 48×26 mm saccular aortic aneurysm abutting the duodenum. The patient was diagnosed with primary AEF and referred for urgent surgical intervention. Conclusion: AEF should be considered in the differential diagnosis of upper gastrointestinal bleeding, particularly in patients with risk factors such as advanced age, male sex, and cardiovascular comorbidities. Endoscopic interventions should be avoided in suspected cases to prevent catastrophic rebleeding. Rapid diagnostic imaging and prompt surgical referral are essential to improve patient outcomes.