Primary aortoduodenal fistula after radiotherapy

Primary aortoduodenal fistula is an uncommon cause of massive upper gastrointestinal hemorrhage; it is most commonly caused by the erosion of an abdominal aortic aneurysm into the third portion of the duodenum. This report describes a 73-yr-old man who developed uncontrollable hematemesis due to a primary aortoduodenal fistula in the fourth portion of the duodenum approximately 20 yr after radiotherapy and para-aortic lymph node dissection for seminoma. Surgical and postmortem examination revealed encasement of a normal-size aorta by dense fibrous tissue, ischemic necrosis of the aortic wall, and distinct chronic radiation changes of the duodenum. We propose that radiation may have played a significant role in the pathogenesis of the aortoduodenal fistula in this case. A history of radiotherapy may be relevant in the etiology of massive gastrointestinal bleeding and should prompt rapid attempts at visualization of the distal duodenum if the source of bleeding is unclear.