[Severe upper gastrointestinal hemorrhage of a rare cause: aorto-esophageal fistula successfully treated].

Aorto-esophageal fistula is a rare entity, determining huge digestive bleeding with a very poor prognostic most often. We present the case of a patient with aorto-esophageal fistula of unknown origin, treated successfully in the Center of Surgery and Liver Transplantation from Fundeni Clinical Institute. A young man, 21 years old, was admitted in our clinic from another hospital for repetitive severe upper gastrointestinal bleeding, with hematemesis and melena, pale, asthenia, without any pain; the bleeding stopped when he was admitted. The upper digestive endoscopy and esophago-gastro-duodenal radioscopy with barium did not show any lesion. During the 7th day the patient presents sudden massive hematemesis with hemodynamic instability; during the surgery we found two subcardial ulcers (stress ulcers?) for which we have done excision and suture which temporary stopped the bleeding. After 14 days, the patient had another massive bleeding; the upper endoscopy shows 28 cm far from the dental arch a protrusive formation of 6-7 mm with a telangiectasis aspect and with a white spot (possibly a central ulceration); 1 ml pure alcohol was injected inside it with temporary bleeding ceasing. After 3 days the patient is bleeding again, with marked decrease in blood pressure; a Blakemore tube stopped the bleeding until surgery was performed. During the intervention an aorto-oesophageal fistula is detected; we made the excision of the fistula with simple suture of the aorta, subtotal esophagectomy, cervico-stoma and gastrostomy, with good postoperative evolution. After 4 months the digestive transit is restored by esophagoplasty with tubulized stomach placed behind the sternum. The diagnostic and treatment difficulties encountered in these kind of cases need to consider also an aorto-esophageal fistula diagnosis, especially for the cases with Chiari triad (mild thoracic pain, sentinel digestive bleeding and exsanguination). The Blakemore tube can save patient's life by ensuring temporary hemostasis and allowing the time for a definitive surgical intervention. The subtotal esophagectomy with cervicostoma and feeding gastrostomy, followed after few months by a esophageal reconstruction , is a solution for this extreme severe cases.