Traumatic Oesophageal-aortic fistula - Erler Zimmer

Traumatic Oesophageal-aortic fistula - Erler Zimmer

Clinical History

A woman who ingested a chop bone during lunch experienced a sudden collapse later in the afternoon, followed by a severe episode of haematemesis. During laparotomy, the stomach was found to be filled with fresh blood, but the specific cause remained unidentified. Unfortunately, she passed away one day later, and a postmortem examination revealed a communication between the aorta and the oesophagus. The stomach was distended with blood, containing a few bone fragments.

Pathology

The specimen comprises a block dissection of the distal trachea (posterolateral on the right margin), aortic arch (opened in the coronal plane and viewed from the anterior aspect), and oesophagus (opened longitudinally posteriorly). The oesophageal mucosa shows signs of ulceration and hemorrhage. A small blue probe indicates the presence of a fistula between the oesophagus and the posterior wall of the thoracic descending aorta.

Further Information

While this case involved a traumatic cause of oesophageal-aortic fistula, it's essential to recognize that non-traumatic causes exist as well. These fistulas can result from aortic compression due to an aneurysm, advanced gastrointestinal malignancies, or erosion of an aortic graft into the adjacent gastrointestinal tract, occurring along any segment of the aorta.

Aorto-enteric fistulas pose a life-threatening risk, commonly presenting with gastrointestinal bleeding, ranging from minor to severe, leading to hemodynamic compromise. Symptoms may include melaena (dark, sticky feces containing partly digested blood) or visible bleeding in stools. Smaller fistulas with slow, minor bleeds can manifest as malaise or lower limb ischemia due to reduced blood flow from the aortic bleed. Other presentations may involve haematemesis, as observed in this case.

Diagnosing these fistulas can be challenging, depending on factors such as cause, size, and location. In stable patients, endoscopic exploration or CT angiography may be initial diagnostic options. However, for hemodynamically unstable patients, a more time-critical approach, including laparotomy and blood transfusions for stabilization, may be necessary.