1744 Not an Ordinary Ulcer: A Case of an Aorto-Esophageal Fistula

Abstract

INTRODUCTION: Hematemesis is a common manifestation of variceal and non-variceal upper gastrointestinal (GI) bleed with a broad differential. Aortoesophageal fistula (AEF) is a life-threatening and catastrophic cause of gastrointestinal bleeding, which is caused by the abnormal communication between the aorta and the esophagus. We are presenting a rare case aorto-esophageal fistula in a young patient who was found to have a benign appearing esophageal ulcer on endocscopy that subsequently was found to be an (AEF). CASE DESCRIPTION/METHODS: A 33-year-old Caucasian male presented to the hospital for fatigue, non-blood emesis and progressively worsening leg swelling. His history is significant for hypertension, seizure disorder, chronic kidney disease (due to pauci-immune glomerulonephritis), heart failure and a descending aortic transection due to an accident 12 years ago which was repair endovascularly. The patient reported usage of NSAIDs prior to admission for pain control but otherwise denied alcohol or other substance abuse. The patient was admitted for his progressive renal failure and was started on hemodialysis complicated with a DVT for which was started on warfarin. During his hospitalization, the patient had an episode of hematemesis with hemodynamic instability which prompted cessation of anticoagulation. An EGD revealed a 2-3 cm non-bleeding ulcer in the proximal esophagus. The patient had stabilized hematocrit and hemodynamics and was restarted on anticoagulation. A week later, the patient had another episode of massive hematemesis with hypotension. A chest x-ray showed widening of the aortic knob, suggested change in location of the thoracic stent. CT angiogram showed aortoesophageal fistula with a leaking pseudoaneurysm at the proximal aspect of the thoracic aortic endovascular stent. Surgery proceeded with endovascular aortic repair of thoracic pseudoaneurysm. Patient had multi-disciplinary management strategy for staged repair. DISCUSSION: AEF are classified as primary i.e. spontaneous erosion of the aortic wall into the esophagus or secondary caused by either esophageal malignancy, surgeries or foreign body. Exact incidence of the AEF is unknown. Early recognition is important to decrease mortality. Chiari et al described the triad of midthoracic pain, herald hemorrhage, and fatal hematemesis as usual presenting features. Endoscopy plays a significant role in the evaluation however it has a poor rate of detection for AEFs prompting the need of CT imaging with high clinical suspicion.