Thoracic aortic aneurysm rupture into the esophagus
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Thoracic aortic aneurysm rupture into the esophagus Ita Hadzˇisejdic´ • Elvira Mustac´ • Mira Krstulja Neven Franjic´ • Davor Sˇtimac
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Accepted: 8 September 2011 / Published online: 11 October 2011 Ó Springer Science+Business Media, LLC 2011
Case report A 73-year-old female with a history of mild hematemesis was transported to the hospital emergency department. Although she was under the influence of alcohol, the patient remained alert. She had hypotension (100/60 mmHg) and anemia (red cell count 2.80 9 1012/L; hemoglobin 86 g/L; hematocrit 0.265 L/L). A digital rectal examination performed after admission revealed black, formed stool. She had medical comorbidities of choleithiasis and a history of alcohol abuse. An emergency upper digestive endoscopy was performed immediately, which showed blood clots and fresh blood in the stomach. There was a protrusion near the gastro-esophageal junction but, despite intensive examination, the immediate place of bleeding could not be identified. As the exact site of bleeding was undeterminable diluted adrenaline was injected into the suspected area of hemorrhage at the fundus of the stomach. The patient was transferred to the intensive care unit where intravenous fluids and a blood transfusion were administered. The patient became stable upon aggressive fluid administration and a surgeon was requested for consultation. The surgeon advised the hospital staff caring for the patient to continue with the conservative therapy course (that included frequent monitoring of hemodynamic parameters) until the exact bleeding site could be identified. However, a few hours after I. Hadzˇisejdic´ E. Mustac´ (&) M. Krstulja Department of Pathology, School of Medicine, University of Rijeka, B. Branchetta 20, 51000 Rijeka, Croatia e-mail: [email protected] N. Franjic´ D. Sˇtimac Department of Internal Medicine, School of Medicine, University of Rijeka, Kresˇimirova 42, 51000 Rijeka, Croatia
admission the patient started to vomit blood vigorously and became hypotensive. A diagnosis of thoracic aortic aneurysm (TAA) with esophageal fistula was made. Emergency surgical treatment was ordered. The patient was transferred to the operating room, where she collapsed and became unconscious and asystolic. She died one hour later despite critical life support measures. Although a complaint of medical negligence was not raised in this case, an autopsy was performed in accordance with Croatian law, which requires that all patients who die within 24 h of hospital admission have to be examined by a certified pathologist. The autopsy revealed a large spherical aneurysm, 5 cm in diameter, of the descending thoracic aorta; 1.5 cm below the tracheal bifurcation (Fig. 1). Rupture into the esophagus was observed, with an aorto-esophageal fistula (AEF) around 2 cm in diameter (Fig. 1). On the aortic side of the fistula, the opening was covered with laminated thrombus that was firm on palpation. The rest of the intima of the thoracic and abdominal aorta did not exhibit severe atheros
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