A239 BRISK GASTROINTESTINAL BLEED: AN ATYPICAL CULPRIT

A 68 year-old female is referred to the Gastroenterology consultation service from the Emergency Department (ED) for brisk gastrointestinal bleeding. Five months prior, she was admitted for multiple intra-abdominal abscesses from perforated appendix, requiring right hemicolectomy and small bowel resection. She was also known for deep vein thrombosis on low-molecular-weight heparin and ovarian cancer considered in remission. Case report and review of the literature See above She presented to the Royal Victoria Hospital for witnessed syncope and significant hematochezia of acute onset. She was profoundly hypotensive, requiring aggressive fluid resuscitation. Her physical exam showed mild epigastric and right lower quadrant pain, as well as bright red blood on the digital rectal examination. Her initial hemoglobin of 80 dropped to 32, with ongoing hematochezia. Nasogastric tube insertion was unsuccessful. A gastroscopy showed normal mucosa with no blood seen up to the distal duodenum. Overnight, she suffered from a recurrent episode of brisk hematochezia, requiring the activation of a massive transfusion protocol. Given her ongoing blood loss, she was sent for a mesenteric angiogram which identified an actively-bleeding fistula from the right external iliac artery to the transverse colon. The interventional radiologist decided to deploy a balloon-assisted covered stent to close off the fistula. Immediately after deployment, the patient’s hemodynamics improved. The vascular surgery team decided against operative management in view of a suspected low operative success from multiple prior surgeries and radiation therapy. Asymptomatic, she was discharged eleven days after her presentation. This rare case highlights the importance of early recognition of life-threatening conditions, such as arterioenteric fistulas (AEF). It also illustrates a rare mechanism of fistula formation. Most cases of AEFs are described as secondary, namely as a complication of prior aortic reconstruction. Approximately 250 cases of primary AEF have been reported in the published literature, of which only 15% affected the colon. In our patient’s case, the main risk factors for primary AEF were encasing peri-iliac abscesses, subsequent bowel manipulation and prior radiation therapy. Prompt investigation is a key component of AEF prognosis. Angiography permits direct AEF visualization and potential placement of a covered stent graft, either as a bridge to open surgery or as a definitive therapy for patients with high operative risk. However, stent placement harbours significant rebleeding rates and infectious complications. Optimal management in these cases remains controversial, such as the use of prophylactic antibiotics or serial imaging. Even though high-quality evidence is scarce, angiography with endovascular intervention is considered first-line treatment in patients with hemodynamic instability. None

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