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KEY WORDS: aortic aneurysm; aortoente ric (R) stula; aortoesophage al (R) stula; gastrointestinal bleed.
Dubrue il (1) described the (R) rst case of aortoe sophageal (R) stula in 1818. Chiari (2) in 1914 de scribed the syndrome of aortoe sophage al (R) stula as a triad of: midthoracic pain or dysphagia followe d by a [feminine ordinal] herald[masculine ordinal] hemorrhage and fatal hematemesis. Carte r et al (3) , in an autopsy review of 24 cases of aortoe sophage al (R) stula, found that 80% had a sentinal hemorrhage prior to fatal exsanguination. We report a case of an aortoe sophage al (R) stula due to a saccular aneurysm of the descending aorta and review the cause s, clinical manife stations, diagnostic modalitie s, and treatment options of this uncommon but often fatal cause of uppe r gastrointe stinal hemorrhage .
CASE REPORT
A 76-ye ar-old man was transfe rred from another hospital for work-up of a second episode of massive hemate mesis. A few minutes afte r eating lunch, the patient e xpe rienced nausea and vomited bright red blood seve ral times. The re was no associate d abdominal pain, me lena, or hematoche zia. On initial e xamination, the patient had orthostatic hypotension and his hematocrit decreased to 21% from a base line of 38% . Physical examination included a soft, nontende r abdomen with normal bowel sounds and brown heme-positive stool. Nasogastric intubation revealed a modest amount of coffee-ground mate rial that rapidly cleared with lavage . Additional studies included a blood urea nitrogen of 16 mg/dl, creatinine of 1.4 mg/dl, normal prothrombin and partial thromboplastin times, and normal plate lets. Chest x-ray showed only mild cardiomegaly.
The patient reported having had a similar episode of hemateme sis two weeks previously and had undergone endoscopy, which showed [feminine ordinal] severe gastritis[masculine ordinal] with a positive CLOtest for Helicobacter pylori. He was discharged at that time on omeprazole 20 mg twice daily and clarithromycin 500 mg three times daily for two weeks. Signi(R) cant past medical history included noninsulin-dependent diabetes me llitus,myocardial infarction followed by three-ve ssel coronary arte ry bypass surgery, chronic atrial (R) brillation, and laser ablation of a benign epiglottal cyst. He stopped smoking 15 years previously...