1917 Fatal Gastrointestinal Hemorrhage Secondary to Rare Aortoesophageal Fistula in a Patient With Esophageal Adenocarcinoma

Abstract

INTRODUCTION: Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal bleeding which is associated with extremely high mortality despite timely intervention. We present a fatal case of gastrointestinal hemorrhage from AEF in a patient with esophageal adenocarcinoma who had recently undergone esophageal stent placement and chemoradiation therapy. CASE DESCRIPTION/METHODS: A 77 year-old Caucasian man with a past medical history of cirrhosis and TNM stage IIIA hepatocellular carcinoma, status post Yttrium-90 radioembolization in April 2017, presented with progressive dysphagia in January 2018. Patient underwent esophagogastroduodenoscopy (EGD) revealing a partially obstructing, non-bleeding mass at the gastroesophageal (GE) junction (Figure 1) and placement of an esophageal stent. Dysphagia improved post stent placement. Biopsy was consistent with primary adenocarcinoma of the esophagus. He received concurrent chemoradiation therapy with paclitaxel and carboplatin. In April 2018, patient presented to the emergency department with presyncope, hematemesis and epigastric pain. He was hyptotensive with a blood pressure of 88/56 mm Hg and anemic with a hemoglobin of 7.6 g/dL. Repeat EGD was performed with unintentional migration of stent into stomach, revealing friable and ulcerated mucosa in the lower esophagus (Figure 2). Retrieval of the dislodged stent caused the ulcerated mucosa to bleed. Hemostatic clip could not adhere to inflamed mucosa and a stent was placed to minimize bleeding. Interventional radiology was consulted. Fluoroscopy revealed presence of a small aortoesophageal fistula at the site of active bleeding (Figure 3). Hemostasis was achieved with coil embolization. Unfortunately, a few hours later, patient had a recurrence of massive re-bleed and expired. DISCUSSION: Esophageal malignancy is one of the primary causes of AEF. Thoracic radiation as a standalone cause has also been documented in non-esophageal malignancies. Several reports also document that aortic grafts and esophageal stents increase the risk of AEF development in patients who undergo radiation. This case adds to the growing literature that presence of esophageal stent and subsequent radiation compounds risk of AEF development in patients with esophageal tumors. Further studies are warranted for risk stratification. Such patients presenting with hematemesis and syncope need immediate AEF evaluation and emergent intervention.