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A rare cause of upper gastrointestinal bleed: Bulge in lower esophagus is the clue
Journal Pre-proof A rare cause of upper gastrointestinal bleed: Bulge in lower esophagus is the clue Zaheer Nabi, Shujaath Asif, D.Nageshwar Reddy
PII: DOI: Reference:
S0016-5085(20)30086-X https://doi.org/10.1053/j.gastro.2019.12.039 YGAST 63137
To appear in: Gastroenterology Accepted Date: 30 December 2019 Please cite this article as: Nabi Z, Asif S, Reddy DN, A rare cause of upper gastrointestinal bleed: Bulge in lower esophagus is the clue, Gastroenterology (2020), doi: https://doi.org/10.1053/ j.gastro.2019.12.039. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by the AGA Institute
A rare cause of upper gastrointestinal bleed: Bulge in lower esophagus is the clue Zaheer Nabi, Shujaath Asif, D.Nageshwar Reddy Authors 1. Zaheer Nabi M.D, D.N.B. Consultant gastroenterologist, Asian institute of Gastroenterology, Hyderabad ([email protected]) 2. Shujaath Asif M.D, D.N.B. Consultant gastroenterologist, Asian institute of Gastroenterology, Hyderabad ([email protected]) 3. D. Nageshwar Reddy M.D. D.M, Chairman and Chief Gastroenterologist, Asian institute of Gastroenterology, Hyderabad ([email protected])
Address for correspondence: Zaheer Nabi; M.D., D.N.B. Consultant Gastroenterologist, Asian institute of Gastroenterology Asian Institute of Gastroenterology 6-3-661, Somajiguda, Hyderabad - 500 082 India Phone: +91-40-2337 8888 Fax: +91-40-2332 4255 e-mail: [email protected]
Author Contributions Zaheer Nabi and Shujaath Asif were involved in collection of data and drafting of manuscript D. Nageshwar Reddy was involved in providing critical inputs to the manuscript All the three authors agreed to the final version of the manuscript Financial disclosures: None Conflict of interest: None for all the authors (Zaheer Nabi, Shujaath Asif, D.Nageshwar Reddy)
A rare cause of upper gastrointestinal bleed: Bulge in lower esophagus is the clue A 20-year old young male presented to the emergency department with massive hematemesis and transient loss of consciousness. There was no history of NSAID or substance abuse. He never experienced a similar episode in past. On physical examination, his heart rate was 110 beats/min, respiratory rate was 24/min and blood pressure 80/60 mm Hg. Laboratory data showed haemoglobin (Hb) 5 gm/dl, leukocyte count 6.8 x 109/ L (4 -11 X 109), alanine transaminase 32 U/L (0-40 U/L), blood urea 24 mg/dl, serum creatinine 1.1 mg/dl. There was no coagulopathy and international normalized ratio was within normal limits. He was resuscitated with intravenous fluids. In addition, three units of blood transfusion was given in view of severe anaemia (Hb 6.5 gm%). After initial resuscitation and stabilization of vital parameters, esophagogastroduodenoscopy was performed which revealed an extrinsic bulge and a small fistulous opening in distal esophagus (Fig. A and B). A contrast enhanced computed tomography (CT) of thorax and abdomen was performed (Figure C). Subsequently a CT aortogram was done which confirmed the diagnosis in this case (Figure D and E). Question: What is the etiology of upper gastrointestinal (GI) bleeding in this case?. 1. Mallory Weiss tear 2. Dieulafoy’s lesion 3. Aortoesophageal fistula 4. Esophageal submucosal tumor
Answer to the Question Contrast CT of chest revealed a large saccular descending thoracic and abdominal aortic aneurysm (Fig C). CT aortogram showed an irregular saccular dilatation of the descending thoracic and suprarenal abdominal aorta with partial luminal thrombosis and eccentric mural calcification of the aorta (Fig D and E). There was no active extravasation of contrast on CT aortogram. The findings on CT and esophagogastroduodenoscopy were suggestive of aortoesophageal fistula (AEF). The patient was immediately referred to cardiothoracic and vascular surgeon for subsequent management. AEF are rare but fatal cause of upper gastrointestinal bleeding. The common aetiologies for AEF include aneurysm involving thoracic aorta, post-endovascular aortic repair, foreign body ingestion, and esophageal malignancies.1 In our case, the aetiology of AEF was primary aortic aneurysm as other causes were ruled out based on history and imaging. The clinical symptoms include chest pain, dysphagia, herald bleeding followed by a variable symptom free interval. It is important to recognize this condition in the initial phase as subsequent bleeding can be massive, exsanguinating and fatal. The classical presentation with chest pain, herald bleeding followed by exsanguinating haemorrhage constitutes the Chiari’s triad. Early diagnosis and management are crucial for this rare but life threatening condition. Of note, active bleeding or contrast extravasation on CT may not be seen in cases with a small fistulous opening and insulation due to thrombus in the aneurysm.2 The management of AEF constitutes of emergent endovascular aortic repair or stenting. More recently, covered esophageal stents have been utilized for the management of esophageal defect in these cases.3
References 1.
Heckstall RL, Hollander JE. Aortoesophageal fistula: recognition and diagnosis in the emergency department. Ann Emerg Med 1998;32:502-5.
2.
Karb DB, Mansoor E, Sullivan J, et al. Atypical Presentation of Aortoesophageal Fistula Without Hemorrhage. ACG Case Rep J 2019;6:e00004.
3.
Rodrigues-Pinto E, Pereira P, Vilas-Boas F, et al. Esophageal Stents in Aortoesophageal Fistulas-Anecdotal Experiences or New Armamentarium? Am J Gastroenterol 2017;112:1343-1345.
PII: DOI: Reference:
S0016-5085(20)30086-X https://doi.org/10.1053/j.gastro.2019.12.039 YGAST 63137
To appear in: Gastroenterology Accepted Date: 30 December 2019 Please cite this article as: Nabi Z, Asif S, Reddy DN, A rare cause of upper gastrointestinal bleed: Bulge in lower esophagus is the clue, Gastroenterology (2020), doi: https://doi.org/10.1053/ j.gastro.2019.12.039. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by the AGA Institute
A rare cause of upper gastrointestinal bleed: Bulge in lower esophagus is the clue Zaheer Nabi, Shujaath Asif, D.Nageshwar Reddy Authors 1. Zaheer Nabi M.D, D.N.B. Consultant gastroenterologist, Asian institute of Gastroenterology, Hyderabad ([email protected]) 2. Shujaath Asif M.D, D.N.B. Consultant gastroenterologist, Asian institute of Gastroenterology, Hyderabad ([email protected]) 3. D. Nageshwar Reddy M.D. D.M, Chairman and Chief Gastroenterologist, Asian institute of Gastroenterology, Hyderabad ([email protected])
Address for correspondence: Zaheer Nabi; M.D., D.N.B. Consultant Gastroenterologist, Asian institute of Gastroenterology Asian Institute of Gastroenterology 6-3-661, Somajiguda, Hyderabad - 500 082 India Phone: +91-40-2337 8888 Fax: +91-40-2332 4255 e-mail: [email protected]
Author Contributions Zaheer Nabi and Shujaath Asif were involved in collection of data and drafting of manuscript D. Nageshwar Reddy was involved in providing critical inputs to the manuscript All the three authors agreed to the final version of the manuscript Financial disclosures: None Conflict of interest: None for all the authors (Zaheer Nabi, Shujaath Asif, D.Nageshwar Reddy)
A rare cause of upper gastrointestinal bleed: Bulge in lower esophagus is the clue A 20-year old young male presented to the emergency department with massive hematemesis and transient loss of consciousness. There was no history of NSAID or substance abuse. He never experienced a similar episode in past. On physical examination, his heart rate was 110 beats/min, respiratory rate was 24/min and blood pressure 80/60 mm Hg. Laboratory data showed haemoglobin (Hb) 5 gm/dl, leukocyte count 6.8 x 109/ L (4 -11 X 109), alanine transaminase 32 U/L (0-40 U/L), blood urea 24 mg/dl, serum creatinine 1.1 mg/dl. There was no coagulopathy and international normalized ratio was within normal limits. He was resuscitated with intravenous fluids. In addition, three units of blood transfusion was given in view of severe anaemia (Hb 6.5 gm%). After initial resuscitation and stabilization of vital parameters, esophagogastroduodenoscopy was performed which revealed an extrinsic bulge and a small fistulous opening in distal esophagus (Fig. A and B). A contrast enhanced computed tomography (CT) of thorax and abdomen was performed (Figure C). Subsequently a CT aortogram was done which confirmed the diagnosis in this case (Figure D and E). Question: What is the etiology of upper gastrointestinal (GI) bleeding in this case?. 1. Mallory Weiss tear 2. Dieulafoy’s lesion 3. Aortoesophageal fistula 4. Esophageal submucosal tumor
Answer to the Question Contrast CT of chest revealed a large saccular descending thoracic and abdominal aortic aneurysm (Fig C). CT aortogram showed an irregular saccular dilatation of the descending thoracic and suprarenal abdominal aorta with partial luminal thrombosis and eccentric mural calcification of the aorta (Fig D and E). There was no active extravasation of contrast on CT aortogram. The findings on CT and esophagogastroduodenoscopy were suggestive of aortoesophageal fistula (AEF). The patient was immediately referred to cardiothoracic and vascular surgeon for subsequent management. AEF are rare but fatal cause of upper gastrointestinal bleeding. The common aetiologies for AEF include aneurysm involving thoracic aorta, post-endovascular aortic repair, foreign body ingestion, and esophageal malignancies.1 In our case, the aetiology of AEF was primary aortic aneurysm as other causes were ruled out based on history and imaging. The clinical symptoms include chest pain, dysphagia, herald bleeding followed by a variable symptom free interval. It is important to recognize this condition in the initial phase as subsequent bleeding can be massive, exsanguinating and fatal. The classical presentation with chest pain, herald bleeding followed by exsanguinating haemorrhage constitutes the Chiari’s triad. Early diagnosis and management are crucial for this rare but life threatening condition. Of note, active bleeding or contrast extravasation on CT may not be seen in cases with a small fistulous opening and insulation due to thrombus in the aneurysm.2 The management of AEF constitutes of emergent endovascular aortic repair or stenting. More recently, covered esophageal stents have been utilized for the management of esophageal defect in these cases.3
References 1.
Heckstall RL, Hollander JE. Aortoesophageal fistula: recognition and diagnosis in the emergency department. Ann Emerg Med 1998;32:502-5.
2.
Karb DB, Mansoor E, Sullivan J, et al. Atypical Presentation of Aortoesophageal Fistula Without Hemorrhage. ACG Case Rep J 2019;6:e00004.
3.
Rodrigues-Pinto E, Pereira P, Vilas-Boas F, et al. Esophageal Stents in Aortoesophageal Fistulas-Anecdotal Experiences or New Armamentarium? Am J Gastroenterol 2017;112:1343-1345.