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Atrioesophageal Fistula

A Catastrophic Complication of a Benign Esophageal Ulcer

Moraveji, Shayan BS1; Mesa, Hector MD2; Siddiqui, Ali A. MD3

doi: 10.14309/crj.0000000000000258

1University of California, Merced, Bakersfield, CA

2Department of Pathology, Minneapolis Veteran's Affairs Medical Center, Minneapolis, MN

3Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA

Correspondence: Ali A. Siddiqui, MD, Division of Gastroenterology, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354 (

Received May 01, 2019

Accepted September 23, 2019

Online date: October 22, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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An 83-year-old man with a diagnosis of locally metastatic squamous cell carcinoma of the right tonsil was admitted to the hospital to undergo a course of radiation therapy for curative intent. The patient tolerated the radiation therapy well, and his only complaints were intermittent episodes of chronic heartburn for which he was on no medications. The patient had no previous endoscopic evaluation of his chronic heartburn.

On the evening after his radiation therapy, the patient was found to be unresponsive in his room without a pulse. Resuscitation was started with chest compressions and medical management, but the patient remained pulseless and cardiopulmonary resuscitation was stopped after 25 minutes. The autopsy revealed that the cause of death was due to an acute massive hemorrhage because of a left atrial-esophageal fistula caused by a benign ulcer in the distal esophagus (Figure 1). The ulcer had penetrated through the esophageal wall, through the adherent pericardial sac, and through the posterior wall of the left atrium. The opening into the atrium was round and measured 4 mm in diameter. Microscopic findings revealed an atrial-esophageal fistulous tract lined by a thin layer of granulation tissue and covered by debris, inflammatory cells, and fibrin that resulted as a complication of a penetrating chronic esophageal ulcer in the setting of incidental Barrett's esophagitis (Figure 2).

Figure 1

Figure 1

Figure 2

Figure 2

Atrioesophageal fistula is an extremely rare complication of a benign esophageal ulcer with only 2 cases described in the literature.1–3 These fistulas usually arise from esophageal injury due to a complication of atrial ablative therapy, foreign body ingestion, esophageal malignancy, or postoperative complications rather than a benign peptic ulcer.4 This case report describes an extremely rare yet fatal complication of a benign esophageal ulcer.

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Author contributions: All the authors contributed equally to this manuscript. AA Siddiqui is the article guarantor.

Financial disclosures: None to report.

Informed consent could not be obtained for this case report. All identifying information has been removed.

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1. Brynjolfsson G, Kania R, Bekeris L. Gastroesophageal cardiac fistula due to perforation of an esophagogastric anastomotic ulcer into the left atrium. Hum Pathol. 1980;11(6):677–9.
2. Zeiderman MR, O'Grady JT. Fatal haematemesis arising from benign oesophagoatrial fistula. Thorax. 1988;43(9):733–4.
3. Prolla JC, Taebel DW, Kirsner JB. Perforation of an esophagogastric anastomotic ulcer into the left atrium. Case report and review of the literature. Gastroenterology. 1967;52(5):871–4.
4. Jehaludi A, Heist EK, Giveans MR, Anand R. Retrospective review of 65 atrioesophageal fistulas post atrial fibrillation ablation. Indian Pacing Electrophysiol J. 2018;18(3):100–7.
© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.