Aortoesophageal fistula is a rare but life‐threatening complication after surgical aortic repair and should be considered in patients with history of aortic graft placement who complains of unexplained gastrointestinal bleeding. The mortality rate of an unrecognized fistula is 100%. A 51‐year‐old African American woman with a history of uncontrolled hypertension, iron deficiency anemia and aneurysmal aortic dissection came to ER complaining of passing black, tarry stool and lightheadedness for 1 day. She also complained of upper back pain for the last couple of days, for which she took ibuprofen. She denied chest pain, shortness of breath, nausea, vomiting or abdominal pain. She was hospitalized 2 years prior for chest pain and discharged after a negative stress test. One month later, she presented with severe chest discomfort and a chest CT showed a DeBakey type 1 dissection of the aorta, extending from the aortic valve to the lower descending thoracic aorta. She underwent an emergent thoracotomy with ascending aortic replacement using a graft. Her medications included lisinopril, atenolol, and aspirin 81 mg. She smoked 1 pack of cigarettes a day for the last 35 years and denied any alcohol or illicit drug use. On physical exam, the patient's blood pressure was 91/47 mm Hg, HR 124, and RR 20. The patient appeared in moderate distress. Cardiovascular exam showed regular rate and rhythm with no murmurs, gallops, or rubs. Lab revealed hemoglobin 7.9 g/dL, MCV 80 fL, BUN 61 mg/dL, Creatinine 1.12 mg/dL, and lactic acid 11 mmol/L Cardiac enzymes and coagulation profile were unremarkable. EKG showed evidences of left ventricular hypertrophy. Chest x‐ray was unremarkable. Emergent upper endoscopy revealed a punctate, 8‐mm ulceration and protruding organized clot in lower esophagus, suggestive of an aortoesophageal fistula due to the previous emergent aortic repair. An hour after the procedure, she had a large hematemesis with fresh red blood, her blood pressure dropped and she went into cardiac arrest. The patient was taken to the OR as a last resort of intervention by vascular surgeon, where she died secondary to hemorrhagic shock.
High index of clinical suspicion and prompt imaging are critical in risk stratification, management, and prevention of complications from acute aortic dissection. Our patient had a history of misdiagnosed cardiac chest pain, underwent emergent acute aortic repair, developed aortoesophageal fistula, complained of some herald gastrointestinal bleeding and back pain, and expired secondary to hemorrhagic shock.
A meticulous approach should be done for the prompt diagnosis and management of an aortoesophageal fistula, as this is an aggressive condition with high mortality if undiagnosed.
To cite this abstract:Raeissi S, Rashid N, Farooq S, Bajwa M, Pourpaki M. An Unfortunate Case of Aortoesophageal Fistula with Herald Symptoms. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 477. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/an-unfortunate-case-of-aortoesophageal-fistula-with-herald-symptoms/. Accessed March 29, 2020.