S2646 Role of Point-of-Care Ultrasound in Diagnosis of Upper GI Bleed Secondary to Aorto-Esophageal Fistula

Abstract

Introduction: Aorto-esophageal fistula (AEF) is a rare etiology of upper gastrointestinal bleed (UGIB) with a high mortality rate. In patients with vascular pathology or aortic aneurysms presenting with hematemesis and Chiari’s triad (midthoracic pain, sentinel arterial hemorrhage and exsanguination after symptom-free interval), there should be high suspicion for AEF as mortality is high even with timely diagnosis and surgical intervention. Diagnostic endoscopy, aortography, or thoracic computed tomography angiography (CTA) are current standards of care but may be unobtainable in emergent cases. Here, we report a case of UGIB in which bedside Point-of-Care Ultrasound (POCUS) facilitated prompt diagnosis of AEF. Case Description/Methods: A 75-year-old male with history of diabetes, uncontrolled hypertension and abdominal aortic aneurysm presented with large volume hematemesis resulting in two episodes of PEA arrests. ROSC was achieved with aggressive hemodynamic support. Gastroenterology was consulted, but the patient was deemed too unstable for endoscopy. Octreotide and pantoprazole drips were initiated. Placement of a Blakemore tube was attempted. POCUS demonstrated descending aortic intraluminal flap consistent with aortic dissection. After stabilization, CTA was pursued which showed descending thoracic aortic aneurysm with penetrating ulcer and active extravasation into the subcarinal mediastinum. Vascular surgery was urgently consulted but the patient became increasingly unstable and ultimately expired. Discussion: AEF is a rare cause of UGIB that should be suspected in patients with large volume hematemesis, chest pain, hemodynamic compromise. Index of suspicion should be high in patients with a history of aortic aneurysm, esophageal malignancy, ingestion of foreign body or recent esophageal surgery. Temporization, rapid diagnosis, and surgical intervention are critical, but guideline directed diagnostic modalities are limited in hemodynamically unstable patients. Here, POCUS allowed prompt diagnosis several hours before the patient was stable enough for CTA. This case demonstrates that POCUS has a diagnostic role in massive UGIB in patients with a high pretest probability of vascular pathology and may limit unnecessary invasive testing in select patients who are unlikely to benefit from endoscopy. Further research is needed to determine the diagnostic role of POCUS in UGIB, but it should be considered in patients with high suspicion for AEF (Figure).Figure 1.: (A) POCUS showing descending aortic intraluminal flap consistent with aortic dissection. (B) CTA showing descending aortic aneurysm with penetrating ulcer resulting in hematoma of the subcarinal mediastinum.