An 80 year old man with a history of abdominal aortic aneurysm, repaired 10 years previously, presented to the emergency room with a four hour history of severe epigastric pain. Examination demonstrated a distended, tender, but non-rigid abdomen. ECG was unremarkable. Shortly after arrival the patient suffered a sudden onset of massive haematemesis requiring replacement of large volumes of intravenous colloid and blood. Following successful resuscitation urgent endoscopy was undertaken, but failed to demonstrate a bleeding point because of large amounts of fresh blood in the stomach. Abdominal multidetector computed tomography (CT) (Siemens Forchheim, Somatom plus 4) was then performed. Axial images of the abdomen (panel A), at a level just inferior to the renal arteries, showed intravenous contrast medium in a slightly aneurysmal abdominal aorta (black solid arrow). Intravenous contrast medium is also seen outlining the inner wall of the third part of the duodenum (white arrow). An aortoenteric fistula is clearly identified between the two structures (black dashed arrow). Early renal cortical contrast enhancement is seen in the left kidney demonstrating preservation of blood supply. On a sagittal maximal intensity projection reconstruction (panel B), the aortoenteric fistula is once again demonstrated (black arrow) connecting the abdominal aorta to the third part of duodenum. The latter is outlined by intravenous contrast medium (white arrow).

Immediately following CT the patient was sent to the operating room, but rapidly deteriorated during transit and further attempts to resuscitate were unsuccessful.