Primary Aortoesophageal Fistula: Is a High Level of Suspicion Enough?

Abstract

Aortoenteric fistula (AEF) is a rare condition with a high mortality rate. AEFs are classified according to their primary and secondary causes, the former being less frequent. Primary AEFs occur in a native aorta and their causes include aneurysms, foreign bodies, tumours, radiotherapy and infection. The classic triad of aortoesophageal fistulas, a subtype of AEFs, are mid-thoracic pain and sentinel haemorrhage, followed by massive bleeding after a symptom-free interval. We present the case of a 41-year-old male patient who presented in the emergency room after successive episodes of abundant haematemesis. He was hypovolemic, hypothermic and acidotic at presentation. His medical history included an emergency room visit the week before with chest pain but no relevant anomalies on work-up, active intravenous drug use and chronic hepatitis. Esophagogastroduodenoscopy (EGD) showed a bulging ulcerated lesion suspicious for aortoesophageal fistula, confirmed by computed tomography (CT) angiography, which revealed a saccular aortic aneurysm with a bleeding aortoesophageal fistula. The patient underwent urgent thoracic endovascular aortic repair. The sentinel chest pain, leucocytosis and CT findings hinted at the presence of a mycotic aneurysm, despite the negative blood cultures. It was most likely caused by a septic embolus due to the patient's risk factors. While a high level of suspicion for aortoesophageal fistula is needed to prompt a fast diagnosis, EGD and CT findings were crucial to establish it and allow a life-saving intervention. We conclude that chest pain cannot be disregarded in a patient aged 41 years with multiple comorbidities, despite normal work-up, to prevent a fatal outcome.

Learning points: Aortoesophageal fistula is a rare cause of severe upper gastrointestinal haemorrhage with a high mortality rate.Computed tomography angiography is diagnostic in most cases but a high level of suspicion is essential.Chest pain, a characteristic clinical symptom of aortoesophageal fistula, cannot be disregarded in a patient with multiple comorbidities, even in the presence of a normal electrocardiogram and chest x-ray.

Keywords: Aortoesophageal fistula; computed tomography angiography; mycotic aneurysm.

Figure 1

Esophagogastroduodenoscopy performed in the setting of massive upper gastrointestinal bleeding, revealed a bulging ulcerated lesion, with an adherent clot 28 cm below the incisors (arrow)

Figure 2

Coronal (A) and oblique sagittal (B) maximum intensity projection reconstructions of aortic computed tomography (CT) angiography, revealing a communication between a saccular aortic aneurism and the oesophagus (red arrow). The oesophageal lumen filled with vascular contrast (asterisk). (C) Enhanced axial thoracic CT showing effacement of the periaortic fat and ectopic gas adjacent (yellow arrow) to the aortic lumen (a). (D) Abdominal axial CT before contrast with spontaneously dense content inside the stomach (asterisk)