Postmortem diagnosis of massive gastrointestinal bleeding in a patient with aberrant right subclavian artery–esophageal fistula

Abstract

Case: Aberrant right subclavian artery-esophageal fistula is a rare, but fatal, complication. A 55-year-old febrile man with a nasogastric feeding tube developed sudden massive hematemesis and shock.Outcome: Upper endoscopy revealed an intragastric hematoma with no active bleeding observed except for oozing from an esophageal tear. Enhanced computed tomography scan detected aberrant right subclavian artery but was unable to determine the bleeding source. Repeat endoscopy carried out on day 2 confirmed hemostasis and the disappearance of the intragastric hematoma. However, the patient suddenly developed recurrent massive hematemesis with refractory shock on day 4 and died. Postmortem computed tomography revealed endoscopic clips in contiguity with aberrant right subclavian artery; a final diagnosis of aberrant right subclavian artery-esophageal fistula was made. Conclusion:Our case demonstrates aberrant right subclavian artery-esophageal fistula may present with transient spontaneous hematemesis in a state of shock, possibly related to fever of unknown origin, and is challenging to diagnose by repeated endoscopy once hematemesis develops.

Aberrant Left Subclavian Artery-Esophageal Fistula in a Patient with a Prolonged Use of Nasogastric Tube: A Case Report and Literature Review

“…Esophageal compression may be aggravated in older individuals with progressed ectasia, tortuosity, and atherosclerotic change of the artery. The vascular pressure on the esophagus can create a fistula [ 8 , 9 ].…”

Upper Gastrointestinal Bleeding From Aberrant Right Subclavian Artery-Esophageal Fistula

“…The most common etiology for development of ARSA-esophageal fistula appeared to be secondary to compression, friction, or pressure necrosis from recent instrumentation with an endotracheal tube, nasogastric tube, or tracheostomy tube, seen in 14 of the 33 summarized cases. 14,15,17,19,21,22,24,27,29,31,[38][39][40][41] Fistula development from prior placement of esophageal stent was noted in 5 cases. 34,36,42,43 Other reported causes for fistula formation included placement of a salivary bypass tube and a possible consequence of gastric pull-up surgery.…”