S2007 Aorto-Esophageal Fistula Presenting with Acute Upper Gastro-Intestinal Bleeding!

Abstract

INTRODUCTION: Aorto-enteric fistula (AEF) is an abnormal connection between the aorta and the gastrointestinal (GI) tract. Two types are described and consist of primary and secondary AEF. Primary AEF is rare and is due to mechanical factors and native aortic inflammation or infection. Secondary AEF occur after aortic reconstruction. AEF commonly involve small and large bowel. In addition to that AEF remains a challenging entity with elevated morbidity and mortality, esophageal involvement is rare and often misdiagnosed. Thus we report a patient presenting with hematemesis that was attributed to AEF based on endoscopic suspicion. CASE DESCRIPTION/METHODS: An 84 y.o. woman with history of ischemic stroke and hypertension presented with acute hematemesis. Vitals showed sinus tachycardia. Physical exam disclosed generalized weakness and pallor. Hemoglobin was 9.0 g/dL (baseline 12.5 g/dL). Urgent upper endoscopy showed a 1cm necrotic area in the posterior wall of the lower esophagus with active oozing suspicious for an AEF (Figure 1). After epinephrine 1:10,000 injection, a 10 mm Over-The-Scope clip was applied. To achieve hemostasis, two covered stents of 20 mm × 8 cm and 18 mm × 8 cm size were applied in the lower esophagus. A subsequent abdominal CT scan showed a 6.5 × 4 cm pseudoaneurysm at the descending thoracic aorta and confirmed the presence of an AEF (Figure 2-A, B). Patient then underwent an endovascular graft placement and repair of the descending aortic pseudoaneurysm. Intra-procedural contrast injection delineated the AEF connecting the aortic pseudoaneurysm and the distal esophagus. However patient’s course was further complicated by multi-organ failure and patient’s family decided on withdrawal of care. DISCUSSION: AEF is an uncommon but potentially life-threatening condition. It mostly presents with GI bleeding. Diagnosis is difficult thus the frequency of delayed and missed diagnoses. Diagnostic tools include ultrasound, CT angiography and arteriography. Endoscopy can be helpful but some cases are only diagnosed during laparotomy or postmortem. Treatment is controversial due to limited literature. Patients with a relatively lower procedural risk are offered an open surgical repair and high risk patients usually undergo less invasive endovascular approach. Prognosis remains poor despite advances in endovascular and surgical techniques. Heightened awareness of AEF is required in view of its rare occurrence, challenging diagnosis and limited therapeutic options.Figure 1.: Upper endoscopy image showing a 1 cm area of necrosis in the posterior wall of the lower esophagus with active oozing noted suspicious for a possible aorto-esophageal fistula.Figure 2A.: Contrast abdominal computer tomography scan image, coronal view showing a 6.5 × 4 cm pseudoaneurysm at the descending thoracic aorta at 7 cm above celiac axis.Figure 2B.: Contrast abdominal computer tomography scan image, sagittal view showing a 6.5 × 4 cm pseudoaneurysm at the descending thoracic aorta at 7 cm above celiac axis.