Hospital: University Hospital Santa Lucía, University Hospital Morales Meseguer.
Aut@r o Autores: C. Botía González, B. Márquez Argente Del Castillo, L. Martínez Encarnación, Y. Martínez Paredes, V. Algara Soriano, M. Gutiérrez Fuente.
A 71-year-old female attended to the Emergency Department for hematemesis and chest pain. She had an aortic prosthesis because of a contained ruptured of the descending aorta three months ago. A gastroscopy first revealed a compressive lesion at the second third of the esophagus which lead to erosion and oozing bleeding into the esophageal lumen. An hemostatic clip was placed at the point of bleeding. A contrast-enhanced chest computed tomography (CECT) in arterial and venous phases was then performed. On it, a lineal high-density focus between the anterior aspect of the descending aorta and the esophagus in the arterial and venous phases, as well as a high-density air-fluid level in the esophagus in the venous phase were depicted, findings compatible with a low-flow aorto-esophageal fistula (AEF). The patient was operated and had a new aortic prosthesis placed distally to the previous one. Her inpatient evolution was good but she died two months later due to an aortitis.
Aortoesophageal fistulas are rare but usually fatal complications that can cause massive bleeding and sepsis , and in which Chiari´s classic triad of mid-thoracic pain, sentinel hematemesis and exanguination after a symptom-free interval is present in only 45% of patients, which often leads to a late diagnosis . In AEF secondary to thoracic endovascular aortic repair (TEVAR) (1,7-1,9 % of procedures), the cause of the fistula remains unclear, even though graft infection, which would perforate into the esophagus wall, is the most likely hypothesis . Gastroscopy is the first procedure to perform in ongoing hematemesis, and in AEF, it may detect the fistula and exclude other causes of gastrointestinal bleeding . After endoscopy, contrast-enhanced computed tomography (CECT) is the modality of choice in patients without significant active bleeding . CT findings include air bubbles within the aortic lumen, loss of the fat plane between the aorta and the esophagus, and contrast extravasation from the aorta to the esophageal lumen, which is the most specific but less sensitive finding . Treatment strategies include bleeding control by TEVAR in the urgent phase, and esophageal and aortic surgery in the semiurgent phase .
Upper gastroingestinal bleeding in a patient with previous history of aortic surgery must raise suspicion of an aortoesophageal fistula, and uncommon entity with fatal outcome.
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