Mind the fistula

Abstract

Thoracic aortic dissection (TAD) with aortooesophageal fi stula formation is an uncommon but fatal cause of haematemesis. A case is presented of a previously healthy 63-yearold man who presented to the emergency department with syncope and haematemesis. He had no history of heavy alcohol intake and was previously well. Bedside portable chest x ray revealed a widened mediastinum and, while awaiting a CT angiogram, he had a further large haematemesis which led to him undergoing resuscitation and rapid sequence intubation. CT angiography of his thoracic aorta revealed a large thoracic aortic aneurysm with dissection from the arch of the aorta down to the left iliac artery. The dissection had formed an aorto-oesophageal fi stula in the proximal oesophagus. He was transferred to a tertiary referral centre for repair of the dissection and aorto-oesophageal fi stula.A 63-year-old man presented to the emergency department complaining of a sudden onset of feeling unwell, followed by a syncopal episode while seated and an episode of vomiting bright red blood. In addition, he complained of a 15 week history of interscapular back pain which was being managed in the community with Co-codamol 30/500. Despite this, the pain had persisted. He gave no history of alcohol abuse or upper gastrointestinal symptoms. He denied any abdominal pain or any history of melaena. Review of his systems revealed only that he had experienced a recent history of dysphagia to solids. His past medical history was significant for hypertension and hypercholesterolaemia and he was a smoker of one or two cigarettes per day and denied any illicit drug use.On physical examination, the patient was pale, diaphoretic and clinically shocked. Despite this, his vital signs remained within normal limits. He received 500 ml of 0.9% saline by the ambulance crew as his initial blood pressure on scene was noted to be 96/54 mm Hg. Subsequent blood pressure checks in his left and right arms revealed a blood pressure of 127/87 and 115/74 mm Hg, respectively. The cardiovascular examination revealed no murmurs, rubs or gallops and his lung sounds were clear to auscultation. His abdominal examination revealed a soft, non-tender abdomen. His neurological examination was grossly intact.A venous blood gas, obtained while the patient was breathing room air, revealed a pH of 7.13, pCO 2 8.23 kPa, pO 2 4.37 kPa, HCO 3 20.1 mmol/l, BE −9.0 mmol/l, haemoglobin 9.4 g/dl and haematocrit 31.7%. An ECG revealed normal sinus rhythm only. His portable chest x ray revealed a widened mediastinum. While awaiting CT aortogram, the patient had a large haematemesis, 800 ml of fresh blood, and became increasingly pale, diaphoretic and agitated. He was resuscitated and underwent rapid sequence intubation with etomidate and suxamethonium and was given type O negative blood and intravenous omeprazole. He was transferred for CT aortic angiography which revealed a large thoracic aortic aneurysm measuring approximately 8 cm in AP diameter. There was a prominent Stanford type B dissection within it...