Aortoesophageal Fistula Mimicking Dieulafoy Disease: A Case Report

Introduction: Aortoesophageal fistula (AEF) is a rare and potentially fatal cause of upper gastrointestinal bleeding. The classic Chiari’s triad of symptoms and typical endoscopic findings are not present in all patients, making diagnosis challenging. Case Presentation: An 86-year-old man was admitted to the emergency room for melena and hematemesis with hemodynamic instability. He had a previous hospitalization for cardioembolic stroke complicated by hematemesis of unknown etiology after initiation of anticoagulation (which was suspended), being discharged on aspirin. His medical history also included hypertension, diabetes, ischemic heart disease, and prostate cancer. On upper endoscopy, no lesions were found, despite the presence of a large non-mobilizable clot in the gastric fundus. He was admitted to the intensive care unit, and, on the next day, reassessment esophagogastroduodenoscopy was normal. On the eighth day of hospitalization, the patient presented with hemorrhagic shock due to new-onset hematemesis. Upper endoscopy revealed an esophageal 10-mm non-ulcerated mucosal depression with a visible vessel at 20 cm from the incisors, closed with 3 hemoclips. Thoracic CT angiography showed a brachiocephalic trunk aneurysm with aortoesophageal fistulization. He was deemed unsuitable for endovascular or surgical treatment. About 2 months later, the patient was admitted to the emergency room in cardiorespiratory arrest following an episode of hematemesis at home. Discussion: This report highlights the diagnostic and therapeutic complexity of AEF. Endoscopic treatment can be the main therapy in patients without indication for vascular intervention. The purpose was to palliate new bleeding episodes, maintaining a very poor prognosis.