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A3418 - Primary Aortogastric Fistula Caused by Ulcerated Gastric Carcinoma Occurring 23 Years After Surgical Treatment for Esophageal Carcinoma
Author Block: M. Li, S. Chen, W. Xie; Department of Respiratory Medicine, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, China.
Introduction Aortogastric fistula (AGF) is a very rare condition, commonly results in rapid exsanguination and a high mortality rate. Here, we describe a patient presented with a fatal hematemesis due to a primary AGF caused by ulcerated intrathoracic gastric carcinoma. Case report A 76-year-old man presented with hematemesis, chest pain, and melena. The patient had undergone esophagectomy, gastroesophagoplasty and chemotherapy for esophageal carcinoma 23 years ago. He had been disease-free but discontinued follow-up 13 years postoperatively. Physical examination was unremarkable. Initial emergent chest CT demonstrated the stomach was mobilized through the posterior mediastinum. Endoscopy revealed that a non-pulsatile mass with overlying mucosal ulceration but no active bleeding and no blood clot were seen. The definitive diagnosis was low-differentiated gastric adenocarcinoma. He achieved initial hemostasis after administration of PPI medications, antibiotics, and blood transfusion. For further evaluation, contrast chest CT was performed and revealed contrast extravasation into the gastric lumen from descending thoracic aorta. Massive hematemesis occurred suddenly during CT scan. Surgery could not be performed because of patient’s rapid and profound shock, and the patient died of exsanguinations. Discussion The presentation of AGF can be highly variable. In our patient, sentinel arterial bleeding may have occurred initially. However, it was not easy to make an early accurate diagnosis in this patient, who was initially diagnosed as ulcerated gastric carcinoma, and achieved initial hemostasis after medical treatment when the cause of bleeding was considered as a peptic ulcer proved by endoscopy. Causes of AGF include fistula include foreign bodies, tumor, peptic ulcer etiologies, esophageal hiatus hernia and anastomotic leakage. To our knowledge, this is the first report of a primary aortogastric fistula due to gastric adenocarcinoma occurring 23 years after esophagectomy for esophageal carcinoma. The mechanism of formation of an AGF might be perforation of a gastric ulcer, advanced gastric adenocarcinoma eroding thoracic aorta, the change in the normal anatomical structure caused by esophagectomy but no evidence of anastomotic leak. The fact that an earlier chest contrast-enhanced CT might aid to the early diagnosis was also indicated in this study. However, initial emergent chest CT did not demonstrate the fistula probably because of a clot plugging the fistulous tract, or lack of vigorous bleeding at the time of CT scan. Therefore, CT findings will be influenced by the timing of the examination in relation to bleeding.