Fatal secondary aortoduodenal fistula diagnosed with postmortem computed tomography angiography
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CASE REPORT
Fatal secondary aortoduodenal fistula diagnosed with postmortem computed tomography angiography Ariel Gershon 1 & D’Arcy Little 2 & Christopher G. Ball 1,3 & Andrew S. Williams 1,3 Accepted: 24 April 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Secondary aortoduodenal fistula (AEF), although less rare than its primary form, is an uncommon and frequently lethal cause of gastrointestinal (GI) bleeding. We report a case of fatal GI hemorrhage in a woman with a remote history of endovascular graft repair of an abdominal aortic aneurysm. Postmortem examination included computed tomography (PMCT) and CT angiography (PMCTA), which revealed air in the aorta, loss of the fat plane between the aorta and duodenum, and direct extravasation of contrast from the aorta into the duodenum. To our knowledge, this is the first published report of secondary AEF diagnosed by PMCT and confirmed with PMCTA. We propose a set of imaging criteria by which PMCTA can be used to supplant traditional anatomical dissection in the medicolegal investigation of deaths due to AEF. Keywords Postmortem computed tomography angiography . PMCTA . Aortoenteric fistula . Aortoduodenal fistula . Virtual autopsy
Case description An 84-year-old woman presented to hospital feeling unwell and was found to have anemia on the background of a medical history of abdominal aortic aneursym with graft repair 4 years earlier, chronic kidney disease, type 2 diabetes mellitus, and benign colorectal polyps. There was no history of liver disease, alcoholism, or hemophilia. Medical workup included upper and lower GI endoscopy and CT. The CT was reported as showing no definitive evidence of aorto-enteric fistula. No cause for her anemia was identified. On the day of her death, she presented to the emergency department with abdominal pain and fatigue, with bloodwork demonstrating worsening anemia. She developed hematemesis, melena, and hypotension overnight. She was
* Andrew S. Williams [email protected] 1
Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
2
Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
3
Provincial Forensic Pathology Unit, Ontario Forensic Pathology Service, University of Toronto, Toronto, Ontario, Canada
treated with multiple infusions of packed red blood cells, fresh frozen plasma, tranexamic acid, and proton pump inhibitors. She was later found without vital signs in her room; resuscitation attempts were not successful. PMCT identified luminal gastrointestinal tract contents with high attenuation, averaging 65–75 HU, in keeping with hemorrhage (Fig. 1 a & c). An infrarenal abdominal aortic aneurysm was present with a graft repair in close approximation to the duodenum. There was no definite soft tissue plane separating the aorta and duodenum. A small locule of air was present in the aorta near this level. PMCTA demonstrated extravasation of contrast material from the aorta into the duodenum at th
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