Aortoesophageal Fistula Is no Ordinary Ulcer

A 33-year-old man admitted for renal failure had an episode of hematemesis. His history was significant for endovascular repair of the descending aorta 12 years prior, owing to a transection after a motor vehicle accident. Esophagogastroduodenoscopy revealed a 2- to 3-cm nonbleeding ulcer in the proximal esophagus (Figure A). A week later, the patient had another episode of hematemesis. The chest x-ray showed widening of the aortic knob, suggesting a change in location of the thoracic stent (Figure B, arrow). A computed tomography angiogram revealed an aortoesophageal fistula (AEF), with a leaking pseudoaneurysm at the proximal aspect of the thoracic aortic endovascular stent (Figure C, arrow). The patient was planned for repair; however, he died after deterioration from an arrest secondary to a bleed. AEF is a life-threatening cause of bleeding that can present as a triad of midthoracic pain, herald hemorrhage, and fatal hematemesis. This is a rare case of AEF in a young patient who had a benign-appearing esophageal ulcer. Endoscopy plays a role in the evaluation; however, it has a poor rate of detection for AEFs, prompting the need of computed tomography imaging with high clinical suspicion. Management requires a multidisciplinary approach; however, there are reports of esophageal stents as an alternative to surgery.