Primary Aortoesophageal Fistula: Great Masquerader of Esophageal Variceal Bleeding.

SESSION TITLE: Pulmonary Vascular Case Report PostersSESSION TYPE: Affiliate Case Report PosterPRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PMINTRODUCTION: Aortoesophageal fistula are common after instrumentation of thoracic aorta. Spontaneous cases, also called primary aortaesophageal fistula are rare, and can present as relentless upper GI bleeding and can be confused with variceal bleedingCASE PRESENTATION: 69 year old man with history of alcohol abuse but no known liver disease presented with sudden onset hematemesis, melena and hematochezia. At a community hospital, upper endoscopy showed grade I lower esophageal varices without any active signs of bleeding. Even though he was hemodynamically stable, he continued to require continuous PRBC transfusion to maintain his hemoglobin and hence was transferred to UAMS. Repeat upper endoscopy showed a healing MW tear, no varices and no signs of active bleeding. Colonoscopy revealed massive amounts of blood but no abnormality noted. He continued to require frequent PRBC transfusions to maintain hemoglobin and had received 6 in two days. His INR and platelets were normal and no serological or radiological evidence of liver cirrhosis was noted. On the evening of admission, he suddenly developed massive hematemesis and hematochezia pushing him to hemorrhagic shock and required emergent intubation along with aggressive fluid resuscitation and initiation of massive transfusion protocol. Emergent CT Angiogram showed type B aortic dissection with active extravasation of blood into esophagus in arterial phase and communication between the two structures suggestive of primary aortoesophageal fistula (AEF). Patient underwent emergent thoracic endovascular aortic repair (TEVAR) which stabilized the patient with complete cessation of the GI bleeding. Patient later underwent staged surgical repair for his esophageal defect.DISCUSSION: Primary aortooesophageal fistula is a rare and often unrecognized cause of upper GI bleeding. Dissection is the commenest cause followed by infections (Tuberculosis and Syphilis) . Other reported causes include trauma, malignancy and foreign body ingestion. Even though Esophagogastroduodenoscopy is the standard of care in upper GI bleeding, it has only a sensitivity of upto 30% in diagnosing these casesCONCLUSIONS: Physicians should consider aortoeosophageal fistula in cases of refractory gastrointestinal bleeding .Prompt suspicion and step wise approach with CT angiogram as in our case will differentiate this from with variceal bleedingReference #1: Primary aortoesophageal fistula: A rare but fatal cause of upper gastrointestinal bleeding.Wei Fan HSU: Jou of Dige Dise 2013; 14; 676-678DISCLOSURE: The following authors have nothing to disclose: Mohan Rudrappa, Deepak Chandra, Clinton Colaco, Brendon Colaco, Mohammad Siddiqui, Penchala MittadodlaNo Product/Research Disclosure Information.