Amol S. Koldhekar, MD1, Dharma Sunjaya, MD2, Emad S. Qayed, MD, MPH1, Anand S. Shah, MD3; 1Emory University School of Medicine, Atlanta, GA; 2Emory University, Atlanta, GA; 3Emory University, Decatur, GA
Introduction: Arterial-enteric fistula is a rare and often fatal cause of upper GI bleeding requiring prompt intervention. The most common cause stems from slowly growing atherosclerotic aneurysms that erode the thoracic aortic wall and create a fistula with the esophagus, leading to life-threatening bleeding. However, pathology in the esophageal lumen may also lead to anomalous connections with arterial systems.
Methods: A 36-year-old African-American male was admitted to the hospital for bright red blood output from his gastrostomy tube. His prior medical history was notable for AIDS (CD4+< 10) complicated by non-resolving HIV-related aphthous ulcers involving the distal esophagus, cecum, and rectum. Upper endoscopy revealed persistent, large, circumferential esophageal ulcer extending from the gastroesophageal junction into the mid-esophagus with a visible, pulsatile vessel and slow blood extravasation. Radiopaque hemostatic clip was placed adjacent to the visible vessel to localize the source of bleeding and serve as a target for embolization. Transcatheter arterial angiogram of the thoracic aorta was performed showing a normal caliber aorta with active extravasation from the aortic-esophageal arteries adjacent to the recently placed hemostatic clip. Coil-embolization was subsequently performed with hemostasis. Discussion: The likely etiology of the anomalous connection was persistent HIV-related, non-healing esophageal ulcer eroding through the superficial layers of the esophagus. Although rare, persistent esophageal ulceration or severe reflux esophagitis can predispose to the development of arterial-enteric fistulas. Endoscopic therapy for hemostasis is not recommended and placement of covered esophageal stents has been previously purposed as a bridge for treatment of bleeding AEF. Placement of radiopaque clip should be performed to help readily identify and target the correct vessel for embolization and minimize risk of recurrent, life-threatening bleeding.
Endoscopic image showing large circumferential esophageal ulcer
Endoscopic image showing aortic-esophageal artery with active bleeding
Radiopaque hemoclip transcatheter arterial angiogram showing active extravasation from the aortic-esophageal arteries
Disclosures: Amol Koldhekar indicated no relevant financial relationships. Dharma Sunjaya indicated no relevant financial relationships. Emad Qayed indicated no relevant financial relationships. Anand Shah indicated no relevant financial relationships.