PMC4942730_01
The first emergency endoscopy revealed scars of previous ulcer disease along with blood clots, but no fresh bleeding was noted in the stomach or duodenum.
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Approximately 2 h after admission, the patient experienced a rapid increase in both hematemesis and melena associated with hypotension. (Table 2) An emergency endoscopy was performed, revealing scars of previous ulcer disease along with blood clots (Fig. 1), but no fresh bleeding was noted in the stomach or duodenum.
The second emergency endoscopy showed the duodenum was full of fresh blood, making identification of the site in the hemorrhage impossible.
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On repeat examination, the duodenum was full of fresh blood, making identification of the site in the hemorrhage impossible (Fig. 2).
Angiography revealed the extravasation from the proximal side of prosthesis.
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After insertion of the balloon, angiography revealed extravasation of dye from the abdominal aorta into the duodenum (Fig. 3), establishing that the cause of bleeding was a secondary aortoenteric fistula.
There was a fistula between the proximal end of graft and the third portion of duodenum.
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Laparotomy revealed that there was a large blood clot in the intestine and confirmed the presence of a fistula between the graft and the third portion of duodenum but no intraabdominal hemorrhage (Fig. 4).