SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aorto-gastric/esophageal fistula is an abnormal communication between the gastrointestinal tract and the aorta. A high level of suspicion is required to diagnose it, as routine tests to diagnose upper gastrointestinal bleeding (UGIB) only detect one-third of the cases. We present a fatal case of aorto-gastric fistula. CASE PRESENTATION: A 60-year-old male presented to the hospital with multiple episodes of hematemesis with epigastric pain lasting for a day. He has a past medical history of esophageal adenocarcinoma treated with esophagectomy and adjuvant radiation twenty years back. The patient reported that since the last four weeks, he started taking an escalating dose of ibuprofen for new-onset lower back pain. On presentation, he was hemodynamically stable with a blood pressure of 120/70 mm Hg and a heart rate of 80 beats/minute. Physical examination was notable for epigastric tenderness. Labs revealed hemoglobin of 13gm/dl, normal electrolytes, liver, and renal function tests. He was started on intravenous fluids and intravenous pantoprazole. While we were planning for an upper endoscopy, he had an episode of large volume hematemesis leading to profound hypotension. He underwent an urgent computerized tomography scan of the chest that revealed an aorto-gastric fistula to the descending thoracic aorta. He was emergently taken to the operating room for an endovascular repair with successful repair of the fistula; however, the patient suffered a massive ischemic stroke post-procedure. Upon discussion with his family, his goals of care were transitioned to comfort. DISCUSSION: Aorto-gastric/esophageal fistula is a rare but catastrophic cause of UGIB. It can be secondary to foreign body ingestion, descending thoracic aneurysm, or malignancy. It is also seen as an early complication of esophagectomy and often presents 2-3 weeks after esophagectomy (1). The exact incidence is unknown, as a vast majority of people die before a definitive diagnosis is made. The patients present with the usual triad of symptoms called the Chiari’s triad that is characterized by midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval. Initial bleeding causes a drop in blood pressure that leads to a temporary cessation of bleeding due to clot formation (2). However, once the fluid resuscitation begins, there is clot dislodgment and rebleeding. CT arteriogram can show active extravasation from the aorta. Once the fistula is diagnosed, it should be treated emergently with aortic stenting and repair to control the bleeding. CONCLUSIONS: Gastrointestinal bleeding due to aorto-gastric fistula is a devastating and life-threatening complication of esophagectomy. It should be kept in mind that this often presents as a herald bleed, and causes massive bleeding after a symptom-free interval. Hence, timely intervention is essential. Reference #1: Molina-Navarro C, Hosking SW, Hayward SJ, Flowerdew AD. Gastroaortic fistula as an early complication of esophagectomy. Ann Thorac Surg. 2001;72(5):1783-8. Reference #2: Kokatnur L, Rudrappa M. Primary aorto-esophageal fistula: Great masquerader of esophageal variceal bleeding. Indian J Crit Care Med. 2015;19(2):119-21. DISCLOSURES: No relevant relationships by Ayesha Azmeen, source=Web Response No relevant relationships by Dimitrios Drekolias, source=Web Response No relevant relationships by Raymond Foley, source=Web Response No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Anantha Sriharsha Madgula, source=Web Response No relevant relationships by Mahati Paravathaneni, source=Web Response