title: Life-threating upper gastrointestinal bleeding due to a primary aorto-jejunal fistula.
abstract: BACKGROUND
  Primary aorto-enteric fistula (AEF) is an uncommon life-threating condition. Only 4% of them involve the jejunum or ileum and its mortality ranges from 33 to 85%.
  
  
  METHODS
  A 54-year-old female was admitted to the Emergency Department with syncope and hematemesis. The esophagogastroduodenoscopy found a pulsatile vessel in the second portion of the duodenum. A computed tomography scan showed an AEF with an infrarenal aortic aneurysm and iliac artery thrombosis. During surgery, an infrarenal aortic aneurysm complicated with an aorto-jejunal fistula was found. An axilo-bifemoral bypass, open repair of the aneurysm and segmental small bowel resection with primary suture of the jejunal defect were performed.
  
  
  CONCLUSIONS
  Depending on previous aortic grafting, AEF can be classified as primary or secondary. Primary AEF is usually caused by an untreated abdominal aortic aneurysm, commonly presenting an infectious etiology. The main clinical sign is a "herald" hemorrhage. The EGD is considered as the first step in diagnosing AEF. The treatment of choice for AEF is emergent surgery. Use of broad-spectrum antibiotics is mandatory in the postoperative period to avoid fistula recurrence.
  
  
  CONCLUSIONS
  AEF is a rare entity with a high mortality. High clinical suspicion is essential to make a correct diagnosis, which is crucial for the prognosis of these patients, such is the case of our patient. If hemodynamic stability is achieved, it allows to employ surgical strategies in which extra-abdominal bypass is performed before fistula is treated.
authors.affiliation: Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain.
authors.forename: Elena
authors.initials: E
authors.lastname: Fernández de Sevilla
authors.affiliation: Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain.
authors.forename: Juan Andrés
authors.initials: JA
authors.lastname: Echeverri
authors.affiliation: Department of Angiology and Vascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
authors.forename: Miriam
authors.initials: M
authors.lastname: Boqué
authors.affiliation: Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain.
authors.forename: Silvia
authors.initials: S
authors.lastname: Valverde
authors.affiliation: Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain.
authors.forename: Nuria
authors.initials: N
authors.lastname: Ortega
authors.affiliation: Department of Angiology and Vascular Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain. Electronic address: efsevilla@gmail.com.
authors.forename: Anna
authors.initials: A
authors.lastname: Gené
authors.affiliation: Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain.
authors.forename: Nivardo
authors.initials: N
authors.lastname: Rodríguez
authors.affiliation: Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain.
authors.forename: José María
authors.initials: JM
authors.lastname: Balibrea
authors.affiliation: Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Passeig de la Vall d'Hebron 119-129, 08035 Barcelona, Spain.
authors.forename: Manel
authors.initials: M
authors.lastname: Armengol
keywords: Abdominal aneurysm; Aorto-enteric fistula; Esophagogastroduodenoscopy; Surgery; Upper gastrointestinal bleeding