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Ann Thorac Surg 1996;61:1843-1845
© 1996 The Society of Thoracic Surgeons

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Case Report

Successful Salvage of Aortoesophageal Fistula Caused by a Fish Bone

Departments of Surgery and Internal Medicine, Ishikawa Prefectural Central Hospital, Kanazawa, Japan

Accepted for publication December 11, 1995.

	Abstract

Top Footnotes Abstract Introduction Comment References

 
We report saving the life of a 66-year-old woman with an aortoesophageal fistula caused by a fish bone. In this case, a hemostastic clip, which was applied to the lesion during emergency endoscopy, facilitated the subsequent diagnosis of this fistula by diagnostic imaging. Compressive hemostasis was effective in controlling preoperative bleeding.

	Introduction

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An aortoesophageal fistula (AEF) is a relatively rare esophageal disorder, which has a very high fatality rate [1–3]. This fistula has been attributed to trauma, infection, malignant tumor, aneurysm, and foreign bodies. Although a fish bone is the most common foreign body in the esophagus, it is quite rare that an AEF is caused by a fish bone. Therefore, the optimal timing for operation on this fistula may be lost unless the physician bears in mind that it is a possible cause when examining patients with esophageal abnormalities.

We recently encountered a case of AEF caused by a fish bone. Early detection and surgical treatment saved the life of this patient. Prior to this case, only a few cases of AEF caused by a foreign body had been treated successfully in the world [4–6]. In our case, various imaging modalities were used for diagnosis.

A 66-year-old woman complained of chest pain after she ate a fish in mid-March 1992. The pain in the retrosternal region persisted for several days. The patient left it untreated. From about 4:00 PM on April 15, she repeatedly vomited small amounts of blood. She visited our hospital at 7:20 PM on the same day. On examination, she was anemic, but her blood pressure was normal. However, her skin was moist, suggesting a preshock condition.

We performed emergency endoscopy. A protruding lesion was detected about 25 cm from the incisors. Clots were seen at the top, but no pulsatile bleeding was noted. A hemostastic clip was applied to the top of the lesion, and the patient was hospitalized. Massive blood vomiting occurred at 10:00 PM. At that time, a Sengstaken-Blakemore tube was inserted and bleeding stopped. A plain chest roentgenogram revealed no dilatation of the aorta and no pleural effusion. Chest computed tomography disclosed a low-density area identical to the clipped area as well as an interruption of the aortic tunica intima (Fig 1A). Aortography revealed no aortic aneurysm. Although no leakage of the contrast medium from the aorta into the esophagus (compressed by the Sengstaken-Blakemore tube) was observed, the clip was located very close to the lumen of the descending aorta (Fig 1B). Based on these findings, the patient was diagnosed as having AEF.

View larger version (176K): [in this window] [in a new window]   Fig 1. . (A) Chest computed tomogram of descending aorta. The hemostatic clip is very close to the aorta. The aortic wall is interrupted at the clip. (B) Aortogram of the descending aorta. The hemostatic clip is very close to the aortic wall.

The removed tissue, viewed from the side of the aortic tunica intima, had a 0.2 x 0.3-cm hole in the aortic wall, forming a fistula involving the aorta and esophagus. Histopathologic examination revealed granulomatous inflammation, accompanied by foreign body reaction in a region from the esophageal mucous to the aortic wall.

	Comment

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Until now, more than 100 cases of AEF caused by a foreign body have been reported [7]. It is very rare that the life of patients with this fistula caused by a foreign body can be saved, and only a few patients have survived [4–6]. In most of the past cases, diagnosis of this fistula was made during postmortem examination. Emergency operation based on a diagnosis of this fistula was performed in only a small number of cases, and the life of patients could rarely be saved.

In the present case, preoperative diagnostic imaging was possible and disclosed interruption in the aortic tunica intima and proximity of the esophageal mucosa and the aortic wall. If a patient vomiting blood visits a hospital, the patient usually undergoes emergency endoscopy to identify the site and cause of bleeding. Our experience with the present case indicates that what is most important during emergency endoscopy is to look for a minimal lesion within the esophagus and to mark the lesion with a hemostatic clip. In the present case, the hemostatic clip did not effect hemostasis, but it provided information useful for identifying the side of the lesion during subsequent computed tomography and aortography. We therefore emphasize the usefulness of a hemostatic clip.

The symptoms of aortoesophageal fistula are known as Chiari's three signs [8]. According to past reports, the time from the preceding bleeding to the massive bleeding ranged from 2 hours to 18 days (mean, 2 to 3 days). This period was shorter in cases where a sharp foreign body directly penetrated the aortic wall. In cases where mediastinal bleeding and inflammation due to a foreign body involved the aorta, there was some lag period. Our case seems to be one of the latter cases.

The only means of treating this fistula is operation. All patients who survived underwent operation. In the present case, emergency operation was performed while hemorrhage was controlled with a Sengstaken-Blakemore tube. Preoperative compressive hemostasis of the esophagus using this tube was quite effective.

	Footnotes

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Address reprint requests to Dr Yamada, Department of Surgery, Ishikawa Prefectural Central Hospital, 153-Nu Minamishinbo, Kanazawa, 920-02 Japan.

Address reprint requests to Dr McGrath, Department of Surgery, Deborah Heart and Lung Center, 200 Trenton Rd, Browns Mills, NJ 08015.

	References

Top Footnotes Abstract Introduction Comment References

 

1. Sloop RD, Thompson JC. Aorto-esophageal fistula: report of a case and review of literature. Gastroentelogy 1967;53:768–77.
2. Wilson RT, Dean PK, Lewis M. Aortoesophageal fistula due to a foreign body. Gastrointest Endosc 1987;33:448–50.[Medline]
3. Khawaja FI, Varindani MK. Aortoesophageal fistula. J Clin Gastroenterol 1987;9:342–4.[Medline]
4. Ctercteko G, Mok CK. Aorto-esophageal fistula induced by a foreign body: the first recorded survival. J Thorac Cardiovasc Surg 1980;80:233–5.[Abstract]
5. Bruce CM, Paul VM, Ben EK. Successful salvage of an 8-month-old child with an aortoesophageal fistula. J Pediatr Surg 1991;26:1394–5.[Medline]
6. Wu M, Lai W. Aortoesophageal fistula induced by foreign bodies. Ann Thorac Surg 1992;54:152–4.[Abstract]
7. Nandi P, Ong GB. Foreign body in the oesophagus: review of 2394 cases. Br J Surg 1978;65:5–9.[Medline]
8. Chiari H. Uber Fremdkorperverletznung des Oesophagus mit Aorten-perforation. Berlin Klin Wochenschr 1914;51:5–7.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yamada, T. Articles by Shimazaki, H. Search for Related Content PubMed PubMed Citation Articles by Yamada, T. Articles by Shimazaki, H.