Emergency Med Case Challenge: Hemorrhoids, Urinary and Blood Infections in a Woman With Rigors

Vimon Seriburi, MD; Ann F. Fisher, MD


November 14, 2022


Recurrent bacteremia and bleeding secondary to an aortoenteric fistula (AEF) were diagnosed in this patient. AEFs are rare clinical entities that often result in fatal exsanguination if not recognized early. Gastrointestinal (GI) bleeding in a patient with a known or repaired abdominal aortic aneurysm should be considered secondary to an AEF until proven otherwise.

On the basis of this patient's symptoms and presentation, bacterial endocarditis, pneumonia, urinary tract infection, and intra-abdominal infection are reasonable differential diagnoses. However, because of an otherwise unremarkable workup and suspicion of an intra-abdominal infectious process (given the recent colonoscopy and the patient's history of an abdominal aortic aneurysm repair), abdominal CT was performed. The scan suggested the diagnosis of AEF (Figure 1); it demonstrated an aorta that was intimately associated with the third portion of the duodenum and, furthermore, a small air bubble at the interface of the aorta and duodenum.

Figure 1.

Other findings on the CT scan that were suggestive of AEF included fat stranding and fluid around the aortic graft and loss of normal tissue planes between the duodenum and the aortic graft.

Another nonradiographic clue to the diagnosis of AEF was the fact that the various blood cultures were positive for multiple different organisms. A previous blood culture had grown S marcescens, and one set of the current blood cultures grew Streptococcus viridans, a common colonizer of the oral and GI tracts.

In addition, the patient had evidence of fungemia, with C glabrata on the second set of blood cultures from the current hospitalization. The diagnosis of AEF was definitively confirmed by esophagogastroduodenoscopy, which revealed ulceration into part of the aortic graft (the white patch seen in Figure 2), visualized about 100 mm distal to the pyloric bulb.[1,2,3,4]

Figure 2.

AEF was first described in 1839 in a patient with a pulsatile abdominal mass and bloody stool who died suddenly. At autopsy, the jejunum was noted to have adhered to the "aneurysmal bag and that sac has ulcerated in the intestine."[5] Since then, two types of AEFs have been described: primary and secondary.


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