Haemoptysis or haematemesis? The not so bleeding obvious.

An aortobronchial fistula is a rare but important diagnosis, which if missed is potentially fatal. We describe a case of a man who presented with severe, spontaneous per oral bleeding. The patient believed the bleeding occurred on coughing not vomiting. Despite denying haematemesis, initial investigations were focused on excluding an upper gastrointestinal bleed because of multiple risk factors (previous alcohol dependence, recent gastritis and heavy smoking). Two urgent oesophagogastroduodenoscopys were unremarkable. A plain chest film demonstrated left-sided perihilar shadowing of possible neoplastic origin. Two days later following sudden torrential haemoptysis, an emergency CT angiogram demonstrated a descending aortic aneurysm and associated aorto-bronchial fistula. The case helps reaffirm the old aphorism that "the patient is telling you the diagnosis"--this was indeed haemoptysis not haematemesis. Despite the power of hindsight, it is a reminder that accurate history-taking is essential in selecting the best first-line investigation, particularly in cases of diagnostic uncertainty.