Published online Oct 16, 2021. doi: 10.12998/wjcc.v9.i29.8938
Peer-review started: June 21, 2021
First decision: July 5, 2021
Revised: July 7, 2021
Accepted: September 2, 2021
Article in press: September 2, 2021
Published online: October 16, 2021
Massive upper gastrointestinal (GI) bleeding is usually urgent and severe, and is mostly caused by GI diseases. Aortoesophageal fistula (AEF) after thoracic aortic stent grafting is a rare cause of this condition, and has a poor prognosis with a high mortality rate. The clinical symptoms of AEF are usually nonspecific, and the diagnosis is often difficult, especially when upper GI bleeding is absent. Early identification, early diagnosis, and early treatment are very important for improving prognosis.
A 74-year-old man was admitted to the infectious disease department with > 10-d fever and 10-mo prior history of thoracic aortic stent grafting for thoracic aortic penetrating ulcers. Blood tests revealed elevated inflammatory indicators and anemia. Chest computed tomography (CT) showed postoperative changes of the aorta after endovascular stent graft implantation, pulmonary infection and pleural effusion. Pleural effusion tests showed empyema. After 1 wk of anti-infective treatment, temperature returned to normal and chest CT indicated improvement in pulmonary infection and reduction of pleural effusion. Esophageal endoscopy was performed because of epigastric discomfort, and showed a large ulcer with blood clot in the middle esophagus. However, on day 11, hematemesis and melena developed suddenly. Bleeding stopped temporarily after hemostatic treatment and bedside endoscopic hemostasis. Thoracic and abdominal aortic CT angiography confirmed AEF. Later that day, he suffered massive hemorrhage and hemorrhagic shock. Eventually, his family elected to discontinue treatment.
AEF should be strongly considered in patients with a history of aortic intervention who present with fever, especially with empyema.
Core Tip: Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal (GI) bleeding. We present a case of massive upper GI bleeding caused by AEF after thoracic aortic stent grafting. Fever was the main clinical manifestation in the early stage accompanied by later epigastric discomfort. Chest computed tomography showed pulmonary infection and pleural effusion; pleural effusion tests showed empyema. Esophageal endoscopy revealed a large esophageal ulcer. Pulmonary infection and empyema were controlled by antibiotics and symptomatic treatment. However, the patient developed hematemesis and melena (conservative treatment and emergency endoscopic hemostasis were ineffective), subsequently suffering hemorrhagic shock, and discontinued further treatment.