Teaching Case

A 74 year old male patient was admitted to our hospital for hematemesis evaluation. On clinical examination the patient was hypotensive with tachypnea. The patient underwent CT, esophageal endoscopy and surgical repair.

On clinical examination of the abdomen there was not any abdominal tenderness or pain, while the patient was mild hypotensive (80mmHg) with tachypnea.
The patient underwent CT examination. At non-contrast enhanced CT (Fig 1), at subcardinal level, a linear hyperdense lesion was demonstrated between the oesophagus and descending aorta, with a lucency within it. Gas effusion and increased density of the adipose tissue at the interval between oesophagus and descending aorta were also visualized (Fig 2). The presence of blood and gas effusion was compatible with oesophageal rupture whereas the lucency within the hyperdense lesion was similar to that of bone marrow. The probable diagnosis was that of oesophageal rupture due to bone swallowing. The patient was asked and confirmed our suspicion. At contrast enhanced CT (Fig 3), in addition to the bone lesion an abnormal active contrast leakage was observed due to aortoesophageal fistula.
Thereafter an endoscopic examination of oesophagus was performed and the diagnosis was confirmed (Fig 4). An operation was performed and the foreign body was removed and the aorta and the oesophagus were sutured. The patient was admitted to the intensive care unit and discharged several days later.

Aortoesophageal fistula (AEF) is a rare condition that can cause upper gastrointestinal tract haemorrhage. Rupture of an aneurysm of the descending aorta into the oesophagus is the most common cause of AEF. Less frequent causes with decreasing frequency are foreign body ingestion, mid oesophagus carcinoma, bronchogenic carcinoma, Barrett’s ulcer. Secondary AEF occurs following an aortic or oesophageal surgery.
Chiari was the first one to describe the clinical presentation of an AEF consisting of mid-thoracic pain, sentinel haemorrhage followed by a symptom free interval leading finally to exsanguination. AEF is rarely being diagnosed before massive hematemesis.
A chest radiograph may show mediastinal widening due to an aortic aneurysm. Oesophageal contrast series can be useful in some cases either by showing contrast material around the aortic prosthesis in patients with oesophagoparaprosthetic fistula or by demonstrating oesophageal perforation. Angiography has been used in diagnosis with partial success, but can provide useful information for the surgical planning. Oesophagoscopy is a very important tool in the diagnosis and evaluation of AEF, but CT scanning is the most valuable diagnostic method.
In our case AEF was caused by the ingestion of chicken bone. The CT scanning revealed the lesion and oesophagoscopy confirmed the diagnosis. The false aneurysm between the oesophagus and the descending aorta as well as the presence of gas effusion are typical findings of AEF in CT scanning.
A foreign body impaction usually occurs at the places where oesophagus normally narrows. Because of the close proximity of the aorta, foreign bodies can cause perforation of the aortic wall. The most commonly used treatment for AEF repair is left thoracotomy.
As a conclusion we can say that AEF caused by a foreign body is a very rare condition that could be fatal. AEF should be suspected in a patient who presents with the characteristic symptoms of Chiari’s syndrome and a history of foreign body ingestion. CT scanning and endoscopy will confirm the fistula, but the most important factor for the proper diagnosis is the awareness of the clinician.