P4233 - A Subtle Presentation of Aortoesophageal Fistula

Mary Parianos, MD¹, Natasha Mederos Rocha, MD², John Coleman, MD^2
1Holy Cross Hospital, Fort Lauderdale, FL; ²University of Miami Miller School of Medicine at Holy Cross Hospital, Fort Lauderdale, FL

Introduction: Aortoenteric fistulas (AEF) are a rare etiology for a gastrointestinal bleed and typically occur in individuals with histories of malignancy, surgical intervention, or thoracic aortic disease. This is a subtle presentation of an AEF in a patient without obvious risk factors, suggesting primary fistula formation.

Case Description/Methods: An 83 year old gentleman with history of iron deficiency anemia, hiatal hernia, heart failure with preserved ejection fraction, atrial fibrillation on anticoagulation, chronic renal insufficiency presented to the hospital with nausea and non-bloody emesis. On arrival, he was hypotensive to 51/43 with leukocytosis, lactic acidosis, and normocytic anemia decreased from baseline. A CT abdomen and pelvis was notable for a distended stomach with mixed and high attenuation material extending into his hiatal hernia and esophagus. He was admitted to the intensive care unit with NG tube placed for decompression with findings of largely bloody output. Despite this, he responded well to supportive care. Endoscopic evaluation was notable for distal esophageal stenosis, sloughing esophagitis, and a large amount of red blood in stomach. CT angiography indicated contained rupture of distal aorta with fistulization to the gastrointestinal tract. The patient underwent endovascular repair of the aortoesophageal fistula, as well as arterectomy of the left femoral artery and left iliac artery. No leak was noted on subsequent gastrografin study. In the following days, the patient had worsening respiratory distress with concern for intrathoracic infection, potentially extending to the graft site, as a result of his previous fistula. After multidisciplinary discussion, prolonged IV antibiotics were opted for in consideration of high risk of additional surgery. Over the next few weeks, the patient developed worsening renal insufficiency and anemia in the context of melanotic stool. A repeat EGD found severe esophageal necrosis and pale and discolored stomach mucosa, suspected due to ischemia. Despite best efforts, the patient deteriorated and passed away.

Discussion: This was an initially subtle presentation of an AEF, which on first impression appeared more concerning for malignant gastric outlet obstruction. There were no obvious risk factors for an AEF, as even imaging a few months prior did not show evidence of obvious aortic aneurysmal disease. As such, this suggests primary fistulization. Overall, this was a unique case in both its presentation and primary nature of the fistula.


Disclosures:


Mary Parianos, MD¹, Natasha Mederos Rocha, MD², John Coleman, MD². P4233 - A Subtle Presentation of Aortoesophageal Fistula, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.