West Virginia University Hospital, Ruby Memorial Hospital Morgantown, WV, United States
Salman Khan, MD, Kareem Diab, MD, Megan Willard, MD West Virginia University Hospital, Ruby Memorial Hospital, Morgantown, WV
Introduction: An aorto-esophageal fistula (AEF) is a rare cause of GI bleeding associated with high mortality. Primary AEF is seen in patients with untreated aortic aneurysms, thoracic trauma, or malignancies. In contrast, secondary AEF, rarely seen and is a postoperative complication presenting on average 3-7 years post-surgery, has an incidence of 1.9% (1,2,3). This case is a patient found to have an AEF only 20 days after a type A aortic dissection repair.
Case Description/Methods: The patient had a history of retrograde propagation of a Type B aortic dissection into a Type A dissection. She had emergent reconstruction of the aortic root and ascending aorta with an aortic arch replacement. Twenty days post-operatively, she had melena and was admitted to the hospital with profound hypotension. CTA of the chest, abdomen, and pelvis did not show any abnormality, and there was no acute bleeding. Soon after, she had massive hematemesis. An emergent upper endoscopy revealed a fistulous tract with a sizeable overlying clot in the esophagus 20 cm from the incisors. She was taken to the operating room for repair of the AEF and did well.
Discussion: This case is of a patient found to have an acute secondary AEF just 20 days after aortic dissection repair. Secondary AEFs, which are post-surgical complications, are exceedingly rare, accounting for only 1.9% of all AEFs. When secondary AEFs occur, they usually appear 3-7 years post-surgery. This condition is highly fatal, and early diagnosis is paramount to survival. However, its diagnosis is notoriously difficult. A clinician must maintain a high index of suspicion to allow for early diagnosis and lifesaving intervention. This case is unique in that the AEF developed only days after the inciting surgery. Although rare, AEFs always need consideration in patients with upper GI bleeding and a history of thoracic surgery, no matter how recent the surgery.
1-Amin, Shirish, James Luketich, and Arnold Wald. "Case Report: Aortoesophageal Fistula Case Report and Review of the Literature." Digestive diseases and sciences 43.8 (1998): 1665-1671.
2-Heckstall, Robert L., and Judd E. Hollander. "Aortoesophageal fistula: recognition and diagnosis in the emergency department." Annals of emergency medicine 32.4 (1998): 502-505.
3-Kapoor, Sorabh, Rajneesh K. Singh, and Tushar K. Chattopadhyay. "Aortoesophageal fistula: A rare and dreaded cause of gastrointestinal haemorrhage." Surgical Practice 9.3 (2005): 68-74.
Figure: Endoscopic images that show the Aortic Esophageal Fistula with adherent clot.
Disclosures: Salman Khan indicated no relevant financial relationships. Kareem Diab indicated no relevant financial relationships. Megan Willard indicated no relevant financial relationships.
Salman Khan, MD, Kareem Diab, MD, Megan Willard, MD. P2595 - An Uncommon Case of an Acute Aorto-Esophageal Fistula, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.