Aortoesophageal Fistulae (AEF): An Imperative Diagnosis

Abstract

A 58 year old man, with no significant medical history, presented with bright red hematemesis. He denied any abdominal pain, episodes of hematochezia, melena, any medications including NSAIDs, or significant familial history. He admitted to chronic alcohol and tobacco use. In the ED, he had a melanotic bowel movement followed by an episode of large volume hematochezia and 500mLs of hematemesis. The patient became hypotensive and was intubated. In addition to blood product transfusion, he underwent emergent endoscopy which revealed a large amount of blood in the stomach and two darkly pigmented protuberances with adherent clot within the esophagus which could not be removed. Epinephrine and hemostatic clips were applied and the patient was transferred to the MICU. Following additional large volume hematemesis, a second endoscopy revealed active bleeding in the esophagus at 30cm from the incisors. Epinephrine was injected and a hemostatic clip was applied which effectively controlled bleeding until endovascular aortic stenting could be performed. CT scan showed pseudoaneurysm of the proximal descending thoracic aorta with an aortoesophageal fistula (AEF) identified by the adjacent endoscopic clip. AEF are rare and associated with a poor prognosis; 54.2% are associated with primary aortic disease, 19.2% foreign body, 17% esophageal carcinoma, and 4.8% as postoperative events (50% aortic surgery, 50% esophageal). Increased use of endovascular stenting has led to an increase in iatrogenic aortoenteric fistulae, however, the incidence of frank rupture is declining largely due to early detection and treatment of thoracoabdominal aneurysms. Diagnosis is aided by Chiari's triad, aortoesophageal syndrome, (chest pain, sentinel hematemesis, massive exsanguination) with an associated poor prognosis due to an inability to localize hemorrhage. Endoscopy is valuable as CTA may fail to identify fistulous tracts. Additionally, it allows therapeutic advantages (heater probe, clips) and should be considered in combination with other modalities to control bleeding and as temporalizing measures to surgical intervention. Esophageal stents may be an effective alternative to surgery in some cases. AEF is an imperative diagnosis that must be made expeditiously and treatment initiated. Endoscopy is an important tool in diagnosis and a bridge to treatment and repair that should be considered in patients with suspected AEF.Figure: Endoscopic clip identifying the level of aortoesophageal fistula.