To the Editor:
In keeping with the statement “Higher peptic ulcer disease incidence has been found to be associated with chronic medical conditions,”
1
the specific association between peptic ulcer disease and abdominal aortic aneurysm needs to be mentioned.2
In one institution, a survey of 7044 patients with necropsies from 1954 to 1966 revealed 99 cases of abdominal aortic aneurysm and 523 cases of peptic ulcer disease. Ninety-four of the patients with abdominal aortic aneurysm were 50 years or older. The incidence of peptic ulcer disease was 22.6% in cases with abdominal aortic aneurysm compared with 7.2% in the general necropsy population.2
Among 106 living patients with unruptured abdominal aortic aneurysm, 8 of the 28 patients with coexisting peptic ulcer disease experienced gastrointestinal bleeding.
3
By contrast, ruptured abdominal aortic aneurysm, with consequent primary aortoenteric fistula, can be the underlying cause of gastrointestinal bleeding in a patient with coexisting, and coincidental, a nonbleeding peptic ulcer.4
In that context, the diagnostic trap to avoid is to misattribute the episode of gastrointestinal bleeding to peptic ulcer disease. When a bleeding peptic ulcer does coexist with abdominal aortic aneurysm, rupture of the abdominal aortic aneurysm may sometimes be the ultimate cause of death, as was the case in a patient who was reported to have “died undiagnosed after an emergency operation for a bleeding gastric ulcer.”5
The classical triad of abdominal aortic aneurysm–related primary aortoenteric fistula comprises gastrointestinal bleeding, abdominal pain, and pulsating abdominal mass.
6
The complete triad was present in only 11% of 81 patients in a study consisting of a Medline search from January 1994 to December 2003.6
The index of suspicion for primary aortoenteric fistula is raised by previous documentation of abdominal aortic aneurysm,7
, 8
or presence of risk factors for abdominal aortic aneurysm such as old age, previous hypertension, and tobacco smoking.9
The index of suspicion for primary aortoenteric fistula should be higher still if emergency endoscopy is nondiagnostic. Urgent abdominal computed tomographic angiography should be the next diagnostic strategy in such cases.References
- Diagnosis and treatment of peptic ulcer disease.Am J Med. 2019; 132 ([Epub ahead of print]): 447-456https://doi.org/10.1016/j.amjmed.2018.12.009
- The association between aneurysm of the abdominal aorta and peptic ulceration.Gut. 1970; 11: 679-684
- Peptic ulcers and abdominal aortic aneurysms.J Gastroenterol Hepatol. 1992; 7: 302-304
- Primary aortoduodenal fistula associated with abdominal aortic aneurysm with presentation of gastrointestinal bleeding: a case report.BMC Cardiovasc Disord. 2018; 18: 113
- Diagnosis and management of 528 abdominal aortic aneurysms.BMJ. 1981; 283: 355-359
- Primary aortoenteric fistula.BJS. 2005; 92: 143-152
- Gagne J-P. A rational, structured approach to primary aortoenteric fistula.Can J Surg. 2008; 51: E125-E126
- Primary aortoenteric fistula: two new case reports and a review of 44 previously reported cases.Eur J Vasc Surg. 1996; 12: 5-10
- Unusual clinical presentation of primary aortoduodenal fistula.Gastroenterol Rep (Oxf). 2015; 3: 170-174https://doi.org/10.1093/gastro/gou040
Article Info
Publication History
Published online: May 22, 2019
Footnotes
Funding: None.
Conflicts of Interest: None.
Authorship: The author is solely responsible for the content of this manuscript.
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© 2019 Elsevier Inc. All rights reserved.
