Aortoesophageal fistula: A rare and dreaded cause of gastrointestinal haemorrhage

Abstract

Aortoesophageal fistula (AEF) is an uncommon cause of gastrointestinal bleeding. Most cases are identified post-mortem after an exsanguinating haemorrhage. Common causes include rupture of thoracic aortic aneurysm, oesophageal foreign bodies and thoracic surgery. AEF following previous aortic or oesophageal surgery are termed as secondary AEF, whereas fistulas that are the result of a ruptured aortic aneurysm, aortic dissection, foreign bodies, oesophageal cancer etc. are termed as primary AEF. The presentation is with the classic Chiari's triad, however, not all components might be present. Endoscopy, computed tomography scan and aortography are useful for diagnosis and for identifying the site of the fistula. Emergency surgery is the treatment of choice, although isolated reports of aortic stenting are available. Aortic repair, restoration of circulation and delayed oesophageal reconstruction are essential principles in the management of aortoesophageal fistula. With early recognition and proper management, more survivors are being reported in literature.

Perspectives of a Hong Kong surgeon on aortoesophageal fistula

“…In a review article on aortoesophageal fistula (AEF) in the August 2005 issue of Surgical Practice , Kapoor and associates summarized the clinical aspects of this potentially lethal condition and reiterated that only vigilance and timely surgical intervention could be life‐saving 1 . The authors also cautioned that, although AEF used to be rare, because of a recent increase in thoracic aortic/oesophageal surgery and intervention, this potentially lethal entity is expected to be on the increase.…”

Primary aortoesophageal fistula: a rare cause of acute upper gastrointestinal bleeding

“…These are represented by aortoesophageal fistula (AEF) and aortoenteric fistula, respectively 6. These uncommon causes of acute UGIB are typically identified post-mortem after an exsanguinating hemorrhage 7. The first report of AEF was in 1818 by Dubrueil, who described the case of a soldier dying from massive upper gastrointestinal hemorrhage 5 days after esophageal impaction of a bone fragment, which had penetrated the thoracic aorta 7 , 8.…”

“…These uncommon causes of acute UGIB are typically identified post-mortem after an exsanguinating hemorrhage 7. The first report of AEF was in 1818 by Dubrueil, who described the case of a soldier dying from massive upper gastrointestinal hemorrhage 5 days after esophageal impaction of a bone fragment, which had penetrated the thoracic aorta 7 , 8. Since then, numerous cases of AEF, attributed to various causes, have been reported in literature.…”

Secondary aorto‐esophageal fistula managed with endoluminal stenting

“…Secondary thoracic aorto‐oesophageal fistula is a rare form of AEF (5%) that typically occurs after surgery. Less than 17% of them were a result of oesophageal malignancy . Formation of AEF may be attributed to the effects of chemo‐radiotherapy on normal tissues, direct invasion and ulcerative process of tumours in the adventitia, thrombosis of the vasa vasorum and bacterial infection…”