Korean J Gastroenterol.  2019 Jan;73(1):35-38. 10.4166/kjg.2019.73.1.35.

Endoscopic Diagnosis of Aortoesophageal Fistula Not Presenting Hematemesis

• Lee JY
• Jang JS
• Kim DK
• Cha JH
• Choi WJ

• KMID: 2432434
• DOI: http://doi.org/10.4166/kjg.2019.73.1.35

Abstract

Aortoesophageal fistula (AEF) is an extremely rare but lethal cause of massive gastrointestinal hemorrhage. Characteristic symptoms are mid-thoracic pain, sentinel minor hemorrhage, and massive hemorrhage after a symptom-free interval. Prompt diagnosis and immediate treatments are necessary to reduce mortality. However, AEF is difficult to diagnose because it is uncommon and often leads to death with massive bleeding before proper evaluation. We report a case of endoscopic diagnosis of AEF that did not present with hematemesis; it was treated with thoracic endovascular aortic repair (TEVAR) and surgery. A 71-year-old female presented to the emergency department with epigastric discomfort. Endoscopy demonstrated a submucosal tumor-like protrusion and pulsating mass with blood clots. Contrast-enhanced chest CT confirmed AEF due to descending thoracic aortic aneurysm. The patient immediately underwent TEVAR to prevent massive bleeding and subsequently underwent surgery. Endoscopists should consider AEF if they see a submucosal tumor-like mass with a central ulcerative lesion or a pulsating protrusion covered with blood clots in mid-esophagus during an endoscopy.

Keyword

Aortoesophageal fistula; Gastrointestinal hemorrhage; Aortic aneurysm; Endoscopy

MeSH Terms

Aged
Aortic Aneurysm
Aortic Aneurysm, Thoracic
Diagnosis*
Emergency Service, Hospital
Endoscopy
Female
Fistula*
Gastrointestinal Hemorrhage
Hematemesis*
Hemorrhage
Humans
Mortality
Tomography, X-Ray Computed
Ulcer

Figure

• 

  Fig. 1 Endoscopic finding. Submucosal mass-like protrusion and pulsating mass with blood clots is found at 30 cm below the incisors.

• 

  Fig. 2 Contrast-enhanced chest CT. (A) Esophageal lumen is narrow and esophageal wall is thickening (arrow). (B) Peripheral enhancing loculated cavity filled with fluid and multiple air-bubbles in posterior mediastinum (arrow).

• 

  Fig. 3 Thoracic endovascular aortic repair (TEVAR). (A) Saccular aneurysm is visible. (B) TEVAR was performed in thoracic descending aorta.

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  Fig. 4 Endoscopic findings after thoracic endovascular aortic repair. Ulcerative lesion covered with exudate is found at 30 cm below the incisors.

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  Fig. 5 Esophagography. Outpouching typed contrast leakage in esophagus is observed.

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