Introduction: An aorto-enteric fistula is a fistulous communication between the duodenum and the aorta. The non-traumatic form, or primary aorto-enteric fistula (PAEF), is rare and fatal if untreated. This is a case of PAEF in a Filipino patient who presented with upper gastrointestinal bleeding (UGIB).

Clinical Presentation: A 62-year-old Filipino sought consult for hematemesis and melena. He had just been discharged the previous day and sent home on empiric H. pylori eradication therapy after a week of workup, which included an unremarkable esophagogastroduodenoscopy (EGD). He claimed to be hypertensive but was not taking any maintenance anti-hypertensive medication.

Physical Findings: Blood pressure was 80/50 mmHg, and cardiac rate of 94 bpm. He had pale palpebral conjunctivae, and pale nailbeds. Abdominal exam was unremarkable. Rest of physical exam was normal. Stat hemoglobin was 63 g/dL.

Results: Exploratory laparotomy revealed the primary aortoduodenal fistula at the anterolateral aspect of the fourth segment of the duodenum (PADF). Patient was started on metoprolol and atorvastatin. Axillary femoro-femoral bypass, ligation of aorta, wedge resection of aortoduodenal fistula, duodenorrhaphy, tube jejunostomy completed was done. Post-operative course was complicated by peritonitis and sepsis, and eventually went into arrest on his third week.

Significance: This is the first case of PAEF in our institution, and possibly in the country. It is an extremely rare condition that has an annual incidence of 0.007 per million. Since its description in 1843, only 250 cases have been reported in literature.

Recommendations: A high index of suspicion is key to its diagnosis and management. Massive UGIB, a negative endoscopy, and known aortic aneurysm should raise the suspicion for PAEF, as prompt surgical intervention is the only chance for survival among these patients.

Key words: primary aorto-enteric fistula, PAEF, UGIB

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