Shiva Dindyal

Aorto-esophageal fistula is often a terminal event in many patients. The commonest causes are thoracic aortic aneurysm and esophageal malignancy. To achieve a good outcome in this condition, a MDT approach is required that combines the expertize of vascular surgeons, radiologists, and emergency physicians. A 50-year-old man presented to the Emergency Department (ED) with hematemesis and epigastric pain. This was on a background of a 1-week history of progressive chest and upper abdominal pain and he had been taking regular ibuprofen for analgesia. Seven months previously, he had been diagnosed with a lower esophageal adenocar-cinoma, for which he underwent esophageal stenting and neoadjuvant chemoradiotherapy. One week prior to his presentation, he had undergone a restaging CT and was awaiting multidisciplinary team (MDT) discussion later that week. On arrival, he was in hypovolemic shock, with a heart rate of 110 bpm and blood pressure of 90/41 mmHg. The emergency department team resuscitated him successfully, but further large volume hematemesis resulted in profound refractory hypotension. The anesthetic team, medical registrar, and emergency endoscopy registrar were called at this point. Initial blood gas results showed a hemoglobin of 8.8 g/dL. Once stabilized, the patient was prepared for an urgent esophagogastroduodenoscopy (OGD) under general anesthetic in the operating theater. The OGD identified frank bleeding originating from the lower esophagus. A bleeding point could not be identified but appeared to originate from the same region as the tumor. The hemorrhage was unresponsive to endo-scopic coagulation attempts and the interventional radiol-ogists and vascular surgeons were therefore contacted, with a view to performing embolization of the culprit vessel. However, the patient's past medical history of esopha-geal adenocarcinoma and briskness of the bleeding encountered on OGD also raised a possibility of an aorto-esophageal fistula. Hence, as the patient was being prepped for angiography, a contingency plan to place an aortic endograft was also made, if a fistula was identified. The patient was too unstable to undergo CT imaging to determine the aortic dimensions for potential stent graft placement. However, liaison with the radiologists at the ter-tiary center managing his esophageal cancer allowed for axial measurements of the aorta to be made from his recent staging CT scan and this information was relayed verbally