Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Oct 16, 2021; 9(29): 8938-8945
Published online Oct 16, 2021. doi: 10.12998/wjcc.v9.i29.8938
Secondary aortoesophageal fistula initially presented with empyema after thoracic aortic stent grafting: A case report
De-Qiong Wang, Mei Liu, Wen-Juan Fan
De-Qiong Wang, Mei Liu, Wen-Juan Fan, Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
Author contributions: Wang DQ reviewed the literature and contributed to manuscript drafting; Liu M analyzed and interpreted the imaging findings and endoscopic images; Fan WJ reviewed the literature, drafted the manuscript, and was responsible for revising the manuscript for important intellectual content; all authors issued final approval for the version to be submitted.
Informed consent statement: Informed written consent was obtained from family members of the patient for publication of this report and any accompanying images.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Wen-Juan Fan, Chief Doctor, Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Avenue, Wuhan 430030, Hubei Province, China. juanwenfan1989@163.com
Received: June 21, 2021
Peer-review started: June 21, 2021
First decision: July 5, 2021
Revised: July 7, 2021
Accepted: September 2, 2021
Article in press: September 2, 2021
Published online: October 16, 2021
Processing time: 115 Days and 19.2 Hours
Abstract
BACKGROUND

Massive upper gastrointestinal (GI) bleeding is usually urgent and severe, and is mostly caused by GI diseases. Aortoesophageal fistula (AEF) after thoracic aortic stent grafting is a rare cause of this condition, and has a poor prognosis with a high mortality rate. The clinical symptoms of AEF are usually nonspecific, and the diagnosis is often difficult, especially when upper GI bleeding is absent. Early identification, early diagnosis, and early treatment are very important for improving prognosis.

CASE SUMMARY

A 74-year-old man was admitted to the infectious disease department with > 10-d fever and 10-mo prior history of thoracic aortic stent grafting for thoracic aortic penetrating ulcers. Blood tests revealed elevated inflammatory indicators and anemia. Chest computed tomography (CT) showed postoperative changes of the aorta after endovascular stent graft implantation, pulmonary infection and pleural effusion. Pleural effusion tests showed empyema. After 1 wk of anti-infective treatment, temperature returned to normal and chest CT indicated improvement in pulmonary infection and reduction of pleural effusion. Esophageal endoscopy was performed because of epigastric discomfort, and showed a large ulcer with blood clot in the middle esophagus. However, on day 11, hematemesis and melena developed suddenly. Bleeding stopped temporarily after hemostatic treatment and bedside endoscopic hemostasis. Thoracic and abdominal aortic CT angiography confirmed AEF. Later that day, he suffered massive hemorrhage and hemorrhagic shock. Eventually, his family elected to discontinue treatment.

CONCLUSION

AEF should be strongly considered in patients with a history of aortic intervention who present with fever, especially with empyema.

Keywords: Gastrointestinal hemorrhage; Esophageal fistula; Esophageal perforation; Thoracic aorta; Empyema; Case report

Core Tip: Aortoesophageal fistula (AEF) is a rare cause of upper gastrointestinal (GI) bleeding. We present a case of massive upper GI bleeding caused by AEF after thoracic aortic stent grafting. Fever was the main clinical manifestation in the early stage accompanied by later epigastric discomfort. Chest computed tomography showed pulmonary infection and pleural effusion; pleural effusion tests showed empyema. Esophageal endoscopy revealed a large esophageal ulcer. Pulmonary infection and empyema were controlled by antibiotics and symptomatic treatment. However, the patient developed hematemesis and melena (conservative treatment and emergency endoscopic hemostasis were ineffective), subsequently suffering hemorrhagic shock, and discontinued further treatment.