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Making the Diagnosis—Acute Primary Aortoduodenal Fistula Bleeding Presenting in a Blunt Trauma Patient

Rapid assessment for the hemorrhagic source after blunt trauma is crucial. We present a rare case of acute primary aortoduodenal fistula (PADF) bleeding after motor vehicle crash (MVC). A 63-year-old unrestrained driver presented with hypotension and abdominal pain. Chest/pelvis X-rays and Focused Assessment with Sonography in Trauma (FAST) examination did not reveal a significant bleeding source. He underwent an emergent exploratory laparotomy. Intraoperative findings showed no solid organ injury but blood-filled intestine. Initial esophagogastroduodenoscopy (EGD) showed large clots in the stomach and duodenum. Repeat postoperative EGD showed active bleeding in the second portion of the duodenum, which was temporized with hemostatic clips. Subsequent CT scan showed findings suggestive of PADF. Urgent vascular surgery consultation allowed for endovascular aneurysm repair. On day five, he underwent pyloric exclusion, gastrostomy and feeding tube placement, and abdominal closure. The patient was placed on a three-month antibiotic course. The patient followed up in the clinic at three months for feeding tube removal, tolerating a diet, and on oral antibiotics. He is closely monitored for graft contamination. PADF is a rare cause of gastrointestinal bleeding associated with high mortality. PADF presenting after MVC adds to the complexity in diagnosis. This case highlights the importance of a collaborative approach for diagnosis and treatment of PADF. Hypotension in the trauma bay after blunt trauma is a life-threatening emergency, with hemorrhagic shock being the most common cause. Rapid assessment for the hemorrhagic source is crucial. Traditional trauma principles focus on five compartments as potential sources of life-threatening hemorrhage: chest, abdomen, pelvis/retroperitoneum, femur, and “the street.” We present a rare case of acute PADF bleeding in a patient presenting after a MVC. A 63-year-old unrestrained driver presented to our Level-1 trauma center with florid hypotension and abdominal pain after MVC. He underwent intubation and immediate blood transfusion. Chest and pelvis X-rays and FAST examination did not reveal a significant bleeding source. He underwent an emergent exploratory laparotomy, given his ongoing hypotension. Intraoperative findings showed no solid organ injury and blood-filled intestine, suggesting a gastrointestinal source of bleeding. Initial intraoperative EGD showed large clots in the stomach and duodenum without active bleeding. The patient was left with an open abdomen (ABThera) device because of the ongoing transfusion requirement. Repeat postoperative EGD showed active bleeding in the second portion of the duodenum, which was temporized with hemostatic clips. The postoperative CT scan showed a large 8-cm infrarenal abdominal aortic aneurysm (AAA) with evidence of recent bleeding into the gastrointestinal tract, suggestive of PADF (Fig. 1). Urgent vascular surgery consultation was placed with the diagnosis of PADF and active bleeding. The patient underwent an endovascular aneurysm repair with bilateral internal iliac artery coil embolization on the night of admission. This allowed for effective hemorrhage control. During the first 24 hours of admission, he received a total of 19 units of pRBC, 20 units of FFP, eight packs of platelets, and 2 units of cryoprecipitate. The patient returned to the operating room on day two for abdominal compartment syndrome with removal of the ABThera device. On day five, he underwent pyloric exclusion, gastrostomy tube placement, jejunostomy feeding tube placement, and abdominal closure. The patient was placed on a 3-month IV antibiotic therapy for graft contamination and was discharged. Our patient presented in acute hemorrhagic shock from massive gastrointestinal bleeding after an MVC, adding to the complexity in diagnosis. Bleeding patients Address correspondence and reprint requests to Rahul J. Anand, M.D., Division of Acute Care Surgical Services, Department of Surgery, Virginia Commonwealth University, West Hospital, 15th Floor, East Wing, 1200 East Broad Street, Richmond, VA 232980454. E-mail: Rahul.Anand@vcuhealth.org.