title: The Importance of Early Diagnosis and Treatment of Patients with Aortoenteric Fistulas Presenting with Herald Bleeds.
abstract: BACKGROUND
  Massive bleeding in patients with aortoenteric fistula (AEF) may be preceded by minor, intermittent gastrointestinal (GI) blood loss, termed the "herald bleed." The aims of this retrospective study were to: (i) analyze the interval between the herald bleed and onset of major GI hemorrhage and/or diagnosis of AEF and (ii) to evaluate the diagnostic roles of endoscopy and computed tomography imaging.
  
  
  METHODS
  Analysis of all patients diagnosed with AEF or iliac-enteric fistulas between 1994 and 2013 in a single institution.
  
  
  RESULTS
  In 31 of a total of 34 fistula cases, GI bleeding was the presenting symptom. Of these, 17 of 31 presented with herald bleed while 14 of 31 presented with massive GI bleeding. In patients with a herald bleed, median time from first bleeding to diagnosis was 14 (2-137) days. In 5/17 patients, herald bleeding preceded major hemorrhage with a median of 6 (4-92) days before a diagnosis of AEF was made or intervention could be initiated. CT angiography (CTA) showed abnormalities associated with a fistula in 27 (79%) cases, of which in 12 (35%) cases a fistula was actually identified. Esophagogastroduodenoscopy (EGD) demonstrated a fistula in 8 (25%) patients, while 50% of EGDs were completely normal.
  
  
  CONCLUSIONS
  Any patient with history of aortic surgery and GI bleeding should be considered to have an AEF until proven otherwise. The sensitivity of CTA for detecting AEF is substantially greater than that of EGD. The time interval between herald bleed and subsequent massive hemorrhage associated with AEF is unpredictable but may be as short as 4 days.
authors.affiliation: Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands. Electronic address: c.deijen@vumc.nl.
authors.forename: Charlotte L
authors.initials: CL
authors.lastname: Deijen
authors.affiliation: Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Yvo M
authors.initials: YM
authors.lastname: Smulders
authors.affiliation: Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Hans M E
authors.initials: HME
authors.lastname: Coveliers
authors.affiliation: Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Willem
authors.initials: W
authors.lastname: Wisselink
authors.affiliation: Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Jan A
authors.initials: JA
authors.lastname: Rauwerda
authors.affiliation: Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors.forename: Arjan W J
authors.initials: AWJ
authors.lastname: Hoksbergen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001018:Aortic Diseases / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy; D000072226:Computed Tomography Angiography; D042241:Early Diagnosis; D016099:Endoscopy, Gastrointestinal; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D006801:Humans; D007412:Intestinal Fistula / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D011237:Predictive Value of Tests; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D016157:Vascular Fistula / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy