AORTOESOPHAGEAL FISTULA - RECOGNITION AND DIAGNOSIS IN THE EMERGENCY DEPARTMENT

An aortoesophageal fistula is a life-threatening cause of gastrointest inal bleeding where an abnormal communication between the esophagus an d the aorta may result from a thoracic aortic aneurysm, foreign body i ngestion, esophageal malignancy, or postoperative complications. The d iagnosis can be made on the basis of clinical findings alone. Classic patients present with the triad of midthoracic pain, sentinel arterial hemorrhage, and exsanguination after a symptom-free interval (Chiari' s triad). The identification of massive upper gastrointestinal hemorrh age that is bright red and arterial in nature is characteristic. Most diagnostic tests have significant individual limitations. Endoscopy of the upper gastrointestinal tract should exclude alternative bleeding sources and may show a submucosal hematoma. Aortography may be useful during active hemorrhage to demonstrate the fistula, but results of ao rtography may be negative during the symptom-free interval. Dynamic co mputed tomography may be a more rapid alternative. For patients who ar e in stable condition after the sentinel hemorrhage, a confirmatory te st is reasonable. Patients in unstable condition should undergo immedi ate surgery. Survival is now possible with rapid surgical intervention .