- Email: [email protected]
A Case of Secondary Aortoesophageal Fistula
The Journal of Emergency Medicine, Vol. 49, No. 6, pp. e193–e194, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.06.008
Visual Diagnosis in Emergency Medicine
A CASE OF SECONDARY AORTOESOPHAGEAL FISTULA Emerson D. Genuis, MD* and Daniel J. Kim, MD*† *Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada and †Department of Emergency Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada Reprint Address: Daniel J. Kim, MD, Department of Emergency Medicine, Vancouver General Hospital, 920 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada
CASE REPORT
DISCUSSION
A 65-year-old male presented to the emergency department by ambulance with several hours of hematemesis. His medical history was significant for hypertension, diabetes, and previous endovascular repair of a thoracic aortic aneurysm. He had several episodes of smallvolume hematemesis in the months before this presentation. He appeared pale and unwell at triage, with an initial set of concerning vital signs: temperature 37.8 C, blood pressure 122/89 mm Hg, heart rate 120 beats/min, respiratory rate 40 breaths/min, and oxygen saturation 93% on room air. He was brought to the resuscitation bay where he had ongoing hematemesis and then developed hypotension. He was intubated and resuscitated with packed red blood cells, then underwent a computed tomography (CT) scan. The CT scan revealed extensive gas around the thoracic aortic stent graft, worrisome for infected aortoesophageal fistula (AEF) (Figures 1–3). At this time, both the thoracic surgery and gastroenterology teams were consulted, and he was treated with broadspectrum antibiotics. He underwent upper endoscopy, which revealed an opening consistent with a fistula in the distal esophagus. He was admitted to the intensive care unit, where he died shortly after from massive hemorrhage.
Secondary AEF can occur anytime after aortic surgery, with the longest documented time period between surgery and presentation being 26 years (1). Although
Figure 1. Transverse section from a computed tomography scan demonstrates gas locules (arrowhead) at the interface of the thoracic aortic stent graft and the esophagus, seen with a nasogastric tube (arrow) in place. This suggests the presence of an aortoesophageal fistula.
RECEIVED: 11 May 2015; ACCEPTED: 1 June 2015 e193
e194
E. D. Genuis and D. J. Kim
Figure 2. Coronal section from a computed tomography scan demonstrates extensive gas (arrowheads) around the thoracic aortic stent graft, consistent with graft infection.
this is an uncommon diagnosis, it is important to consider in patients with previous aortic surgery presenting with gastrointestinal bleeding. The classic presentation of AEF is midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free period (Chiari’s triad) (2). Endoscopy is the most sensitive and specific test for the detection of an AEF and is the initial study of choice in the setting of ongoing hematemesis. Endoscopic findings include direct visualization of pulsatile blood, pulsatile submucosal mass with adherent clot, submucosal hematoma, and direct visualization of aortic prosthesis through the site of esophageal perforation (3). Contrast-enhanced CT scan is an integral part of the work-up and is the diagnostic test of choice in patients without significant active bleeding. CT findings strongly associated with fistula formation include the presence of air within the aortic lumen, excluded aneurysm sac, or around the stent, as well as loss of the normal fat plane between the aorta and esophagus (4). Contrast extravasation into the enteric lumen is the most specific finding, but this is rarely visualized (5). Management of AEF requires surgical intervention, as nonsurgical management invariably results in death. In a patient with a known
Figure 3. Sagittal section from a computed tomography scan demonstrates extensive gas (arrowheads) around the thoracic aortic stent graft, consistent with graft infection.
history of thoracic aortic aneurysm, upper gastrointestinal bleeding must be treated as an AEF until proven otherwise, as it requires prompt operative management to prevent mortality.
REFERENCES 1. Bergqvist D, Bjo¨rck M. Secondary arterioenteric fistulation—a systematic literature analysis. Eur J Vasc Endovasc Surg 2009;37:31–42. 2. Hollander JE, Quick G. Aortoesophageal fistula: a comprehensive review of the literature. Am J Med 1991;91:279–87. 3. Heckstall RL, Hollander JE. Aortoesophageal fistula: recognition and diagnosis in the emergency department. Ann Emerg Med 1998;32:502–5. 4. Christensen JD, Heyneman LE. Case of the season: aortoesophageal fistula complicating thoracic aortic aneurysm stent graft repair. Semin Roentgenol 2009;44:4–7. 5. Hagspiel KD, Turba UC, Bozlar U, et al. Diagnosis of aortoenteric fistulas with CT angiography. J Vasc Interv Radiol 2007;18:497–504.
http://dx.doi.org/10.1016/j.jemermed.2015.06.008
Visual Diagnosis in Emergency Medicine
A CASE OF SECONDARY AORTOESOPHAGEAL FISTULA Emerson D. Genuis, MD* and Daniel J. Kim, MD*† *Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada and †Department of Emergency Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada Reprint Address: Daniel J. Kim, MD, Department of Emergency Medicine, Vancouver General Hospital, 920 West 10th Avenue, Vancouver, British Columbia V5Z 1M9, Canada
CASE REPORT
DISCUSSION
A 65-year-old male presented to the emergency department by ambulance with several hours of hematemesis. His medical history was significant for hypertension, diabetes, and previous endovascular repair of a thoracic aortic aneurysm. He had several episodes of smallvolume hematemesis in the months before this presentation. He appeared pale and unwell at triage, with an initial set of concerning vital signs: temperature 37.8 C, blood pressure 122/89 mm Hg, heart rate 120 beats/min, respiratory rate 40 breaths/min, and oxygen saturation 93% on room air. He was brought to the resuscitation bay where he had ongoing hematemesis and then developed hypotension. He was intubated and resuscitated with packed red blood cells, then underwent a computed tomography (CT) scan. The CT scan revealed extensive gas around the thoracic aortic stent graft, worrisome for infected aortoesophageal fistula (AEF) (Figures 1–3). At this time, both the thoracic surgery and gastroenterology teams were consulted, and he was treated with broadspectrum antibiotics. He underwent upper endoscopy, which revealed an opening consistent with a fistula in the distal esophagus. He was admitted to the intensive care unit, where he died shortly after from massive hemorrhage.
Secondary AEF can occur anytime after aortic surgery, with the longest documented time period between surgery and presentation being 26 years (1). Although
Figure 1. Transverse section from a computed tomography scan demonstrates gas locules (arrowhead) at the interface of the thoracic aortic stent graft and the esophagus, seen with a nasogastric tube (arrow) in place. This suggests the presence of an aortoesophageal fistula.
RECEIVED: 11 May 2015; ACCEPTED: 1 June 2015 e193
e194
E. D. Genuis and D. J. Kim
Figure 2. Coronal section from a computed tomography scan demonstrates extensive gas (arrowheads) around the thoracic aortic stent graft, consistent with graft infection.
this is an uncommon diagnosis, it is important to consider in patients with previous aortic surgery presenting with gastrointestinal bleeding. The classic presentation of AEF is midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free period (Chiari’s triad) (2). Endoscopy is the most sensitive and specific test for the detection of an AEF and is the initial study of choice in the setting of ongoing hematemesis. Endoscopic findings include direct visualization of pulsatile blood, pulsatile submucosal mass with adherent clot, submucosal hematoma, and direct visualization of aortic prosthesis through the site of esophageal perforation (3). Contrast-enhanced CT scan is an integral part of the work-up and is the diagnostic test of choice in patients without significant active bleeding. CT findings strongly associated with fistula formation include the presence of air within the aortic lumen, excluded aneurysm sac, or around the stent, as well as loss of the normal fat plane between the aorta and esophagus (4). Contrast extravasation into the enteric lumen is the most specific finding, but this is rarely visualized (5). Management of AEF requires surgical intervention, as nonsurgical management invariably results in death. In a patient with a known
Figure 3. Sagittal section from a computed tomography scan demonstrates extensive gas (arrowheads) around the thoracic aortic stent graft, consistent with graft infection.
history of thoracic aortic aneurysm, upper gastrointestinal bleeding must be treated as an AEF until proven otherwise, as it requires prompt operative management to prevent mortality.
REFERENCES 1. Bergqvist D, Bjo¨rck M. Secondary arterioenteric fistulation—a systematic literature analysis. Eur J Vasc Endovasc Surg 2009;37:31–42. 2. Hollander JE, Quick G. Aortoesophageal fistula: a comprehensive review of the literature. Am J Med 1991;91:279–87. 3. Heckstall RL, Hollander JE. Aortoesophageal fistula: recognition and diagnosis in the emergency department. Ann Emerg Med 1998;32:502–5. 4. Christensen JD, Heyneman LE. Case of the season: aortoesophageal fistula complicating thoracic aortic aneurysm stent graft repair. Semin Roentgenol 2009;44:4–7. 5. Hagspiel KD, Turba UC, Bozlar U, et al. Diagnosis of aortoenteric fistulas with CT angiography. J Vasc Interv Radiol 2007;18:497–504.