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Aortoduodenal syndrome: a rare cause of duodenal obstruction in a patient with previous aortic aneurysm repair

Aortoduodenal syndrome is a rare clinical presentation where duodenal obstruction is caused by the aneurysmal sac of an aortic aneurysm. Here, we report the case of a 73-year-old gentleman who was found to have a 6.3-cm aortic aneurysm obstructing the third part of the duodenum (D3). To our knowledge, it is the first presentation of aortoduodenal syndrome in a patient who has a previous endovascular aneurysm repair. The patient presented to the emergency department with abdominal pain, persistent vomiting and a distended abdomen. This was on a background of 3 weeks of increasing abdominal pain, nausea and intolerance to solids. Three days prior to presentation, the patient had a 24-h period of diarrhoea and 2 days of unopened bowels. In his past history, he had an endovascular aneurysm repair for a 6.3-cm aortic aneurysm 2 years previously and a right middle lobectomy for adenocarcinoma 1 year previously. He had type 2 diabetes mellitus, hypertension and had previously had a myocardial infarction, and was taking medication for all these conditions. On initial assessment, his observations were stable. On examination, he had a distended abdomen, which was tender to palpation in the epigastrium. He was dehydrated but not cachectic. His blood tests showed a normal blood count with normal electrolytes. A chest radiograph was suggestive of gastric distention. The initial impression was of small bowel obstruction, and he was managed with intravenous fluids, nasogastric tube insertion and catheter insertion. Within a 3-h period, 2 L of gastric contents was drained and symptomatically the patient improved. He proceeded to abdominal computed tomography (CT) which showed an obstruction of D3 from the aortic sac (Fig. 1). There was no concern of endoleak or of aorta-enteric fistula. He failed a trial of gastrografin and proceeded to laparotomy after adequate resuscitation over 36 h. At initial laparotomy, adhesions were noted between the aorta and D3. With gentle dissection, a space large enough to put two fingers through was created between D3 and the residual aortic sac. A nasojejunal (NJ) tube was positioned. The patient initially improved in the following 48 h and the NJ tube was removed. He continued to have an oral diet; however, the patient deteriorated clinically with similar symptoms to presentation over the next 48 h. A repeat CT scan showed recurrent obstruction at the level of D3 (Fig. 2). The decision was made to return to theatre and a gastrojejunostomy was performed. The patient had delayed gastric emptying after this procedure and required prolonged parenteral nutrition, nasogastric tube for stomach decompression and prokinetic medication. He recovered over 2 weeks following the second procedure and was discharged to rehabilitation. Duodenal obstruction secondary to a dilated aortic aneurysm – also known as aortoduodenal syndrome – was first described in