Timely Endoscopic Recognition of Aortoesophageal Fistula With Successful Treatment
Brotherton, Tim MD; Numan, Laith MD; Al-Kaade, Samer MD.
ACG Case Rep J. 10(8):p e01123, August 2023.
Medicine is ever-evolving with new challenges and mysteries that require out-of-the-box thinking. In this edition, we delve into a particularly interesting case that shows the importance of multidisciplinary care and utilizing unconventional but effective methods of controlling gastrointestinal bleeding. Brotherton et al present a case of a 52-year-old man with a past medical history of non-small cell lung cancer status post chemoradiation therapy complicated by mid-esophagus stricture treated with multiple dilations who presented to the hospital with syncope and hematochezia. The patient left the hospital against medical advice and underwent esophagogastroduodenoscopy the next day which showed a visible vessel around the mid-esophageal scar area without any active bleeding. During the procedure, the patient started coughing and developed profuse bleeding, which was not controlled despite the application of epinephrine, thermal therapy, hemostatic clip, and hemospray. Bleeding was finally controlled with a 20 mm esophageal dilation balloon tamponade, however, bleeding recurred every time on deflation of the balloon. Bleeding was not controlled despite placing 2 fully covered metal stents. The balloon was re-inserted, and the patient was transferred to the interventional radiology suite with an angiogram showing aortoesophageal fistula. An endovascular aortic stent graft was emergently placed by vascular surgery with successful control of bleeding and deflation of balloon post-surgery. The patient recovered and was discharged home without any complications. Gastrointestinal bleeding is one of the most common reasons for inpatient consultation with a gastroenterologist. While assessing the patient, the focus of the teams should be on rapid resuscitation, timely endoscopic intervention, and having a broad differential for the cause of bleeding. The ACG provides guidelines for the management of upper and lower gastrointestinal bleeding. In this case, the authors used different tools, came up with an unconventional method for control of bleeding, and involved other teams in a timely manner resulting in great outcome for the patient.
Banreet Dhindsa, MD
New York University Langone Health
ACG Case Reports Journal