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Background: Fistulous tracts within the thorax are best exemplified aorto-esophageal fistulas (AEFs), which are rare exsanguinations of the upper gastrointestinal tract. Most of them are diagnosed at autopsy., Aim: This is an autopsy-based study of fatal cases of AEFs gathered over a period of 20 years., Materials and Methods: Cases of AEFs were retrieved from the autopsy records of the cardiovascular pathology sub-specialty at a tertiary care center and were studied with reference to demographic details, modes of clinical presentation, and pathological features., Results: Ten cases of AEFs (10 males and 8 females, mean age of 46.9 years) were identified in a span of 20 years. A clinical diagnosis of AEF was made in only one patient, while the rest were identified at autopsy. All the patients had a bout of massive and fatal hematemesis. The fistulous connections, involving the middle-third of the esophagus, were caused by a fishbone, esophageal ulceration and aneurismal aortic diseases of varied etiology., Conclusions: AEFs are often missed or misdiagnosed. Early recognition of this rapidly fatal condition is essential as these fistulas require quick and aggressive management.

Two patients with locally advanced squamous cell carcinoma of the mid-esophagus, with esophageal stents in situ, suffered sudden onset of massive hematemesis and hemodynamic instability due to an aortoesophageal fistula. Although their esophageal neoplasms were deemed inoperable and treatment was palliative, the bleeding was successfully stopped with an endovascular aortic stent-graft. They both remained stable with no septic or hemorrhagic complications, and survived for 14 and 16 weeks after the operation. We emphasize that even if esophageal tumors are locally advanced, emergency endovascular management of aortoesophageal fistula is worthwhile for prolongation of survival.

Tuberculosis remains a serious public health problem worldwide, especially in Korea. Although tuberculosis is generally considered a non-fatal chronic disease, deaths have occurred. In this case study, a 68-year-old man was admitted to the hospital with dyspepsia, vomiting, and abdominal pain. Nine hours later, he suffered severe hematemesis and died despite cardiopulmonary resuscitation. A medico-legal autopsy was performed and an external examination revealed no external injuries. However, an internal examination revealed an aortoesophageal fistula and a large amount of blood in the stomach. A histologic examination confirmed tuberculous mediastinitis with disseminated tuberculosis involving multiple organs, including the heart, lungs, liver, kidneys, and spleen. Both an aortoesophageal fistula and sudden death due to tuberculosis infection are rare. This paper reports the case of a fatal aortoesophageal fistula associated with disseminated tuberculosis.

Traumatic pseudoaneurysms are relatively frequently mentioned in textbooks of pathology and forensic medicine but their incidence in pathological reports is seldom documented. Our described case presented a patient who suffered from chronic alcoholism and who was repeatedly hospitalised because of various injuries including epidural and subdural hematomas. We present a case of a 69-year-old man who was hospitalised after nonspecific blunt chest injury with chest pain and dysphagia. By computed tomography the traumatic pseudoaneurysm of the descendent thoracic aorta was diagnosed pressing the oesophageal wall which was solved by implantation of aortal stent graft (TEVAR - thoracic endovascular aortic/aneurysm repair). Since after the implantation there was no blood leak, no progression of the lesion, he was soon discharged from hospital. The patient was hospitalised again after two months for newly developed haemoptysis. On suspicion of bleeding from aortal arch a carotid-carotid bypass from right to left side was performed and then re-TEVAR was implanted proximally to the first one. The man died two days following the implantation after a massive bleeding from oesophagus due to aortoesophageal fistula. The presented case deals with the etiology of the development of pseudoaneurysms, histomorphological picture of pseudoaneurysm resembling not only an isolated thoracic aortitis but slightly also the Takayashu disease. We suppose that in this case the most probable cause of necrosis and perforation of aortal wall was a decubital necrosis caused by stent graft which led to the fatal aortoesophageal necrosis. Aortoesophageal fistula belongs to the most common lethal complications of the TEVAR.

Esophageal foreign body ingestion is especially frequent in childhood and may cause fatal complications in case of late diagnosis and delayed treatment. We present a case of 2-year old girl who was admitted to emergency department with massive bleeding. However, she died due to an unrecognized foreign body resulted an aorto-esophageal fistula. At autopsy an aorto-esophageal fistula was detected by gross examination. Tissue samples were obtained from the organs and fistula region. In histopathological examination, a calcified body with multinucleated giant cell and surrounding granulation tissue was detected at the bleeding site. An ulcerated fistula tract ran from the intima to the adventitia, passing through layers of esophageal wall was also noticed. The mortality rate for foreign body ingestion is less than 1%, except in cases of perforation. Therefore the presented case is among rare examples of fatal foreign body ingestions., (Copyright © 2014 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Delayed presentation of coarctation of the aorta can be associated with severe complications. A challenging case of aortoenteric fistula secondary to an aneurysm from coartation of the aorta presented with massive gastrointestinal hemorrhage. The clinical management of this patient and a review of the literature are presented.

Objective: An aorto-oesophageal fistula is a rare clinical entity, leading to life-threatening gastrointestinal bleeding. Thoracic aortic aneurysms are the most common cause of aorto-oesophageal fistulae; further causes involve foreign body ingestion, trauma (in most cases iatrogenic), carcinoma or, very rarely, aortitis tuberculotica., Methods: Due to its rarity, there are no large multicentre studies present to evaluate the efficacy of different therapeutic management options. Since it is associated with significant morbidity and mortality, we give a short summary of various treatment approaches performed in our clinical practice in the past three years. The most straightforward therapeutic option may be an endovascular aortic repair and subtotal oesophageal resection followed by gastro-oesophageal reconstruction, but other alternative treatment possibilities are also present, although with probable higher morbidity., Conclusions: Eliminating the source of bleeding as an emergency, resecting the oesophagus urgently to prevent sepsis and reconstructing the gastrointestinal continuity as an elective case after having the inflammatory processes settled seems to justify the endovascular aortic repair and subtotal oesophageal resection, followed by a gastro-oesophageal reconstruction, as an effective surgical approach.

Aorto-oesophageal fistula refers to a rarely encountered communication between the aorta and the oesophagus that results in massive and lethal haemorrhage into the upper gastrointestinal tract. Although the time between the initial haemorrhage and the terminal event may be days, a clinical diagnosis may not be established by the time of autopsy. A fistulous tract develops between the aorta and the oesophagus most commonly due to expansion of a thoracic aortic aneurysm or from an ingested foreign body. Less common causes include infiltrating neoplasms, oesophageal ulceration, vascular rings and iatrogenic lesions. Three cases are presented to illustrate the features of such cases due to aortic dissection, bronchial carcinoma and tuberculosis. Cases should be suspected if there has been a history of midthoracic pain or dysphagia, a 'herald' haemorrhage and then massive fatal haematemesis with bright red blood. Careful dissection at autopsy is required to demonstrate the site of the fistulous tract., (Copyright © 2012 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

Aortoesophageal fistula (AEF) formation nearly always results in catastrophic consequences. As a result of its development being extremely rare, many may never consider it in their differential. Although prognosis is extremely grim, early diagnosis and intervention is considered the optimal means to enhance one's prognosis. We present a case of AEF formation secondary to a Stanford B aortic dissection, along with a review of literature and terminology involved in describing such pathology.

A 69-year-old woman with a history of graft replacement of descending aortic aneurysm was referred to our hospital due to massive hematemesis with shock status. Additionally, the deterioration of respiratory status made us start the management under mechanical ventilation. The emergent gastrointestinal endoscopy by a general practitioner showed ulcer-like lesion of the upper esophagus and arterial bleeding. A contrast-enhanced computed tomography showed thoracic aortic aneurysm surrounded by low density mass and contrast medium protruding from the aneurysm. The findings suggested that thoracic aortic aneurysm perforated into esophagus and made an aortoesophageal fistula. Hemodynamic deterioration rapidly progressed and she passed away 4 days after her hospitalization. Autopsy showed that a new thoracic aortic aneurysm arose from the proximal site of the graft. The aneurysm ruptured to esophagus with 6.0 cm x 5.0 cm sized fistula. The fistula was filled with a large thrombus. The large thrombus filling with the fistula worked as the tamponade and prevented her from the fatal exsanguinations and sudden death. The mechanism of the sentinel bleeding and the fatal exsanguinations known as Chiari's triad was revealed in our report.

Aortoesophageal fistula secondary to thoracic aneurysm is rare, but is usually lethal, and few survivors have been reported. We report successful surgery for aortoesophageal fistula in a one-stage operation. Repair involved in situ replacement of the thoracic aneurysm using a rifampicin-soaked graft, primary repair of the esophagus, omental wrap and tube jejunostomy. This is the original report of the surgical repair of aortoesophageal fistula using a rifampicin-soaked graft.

Purpose: Caustic agent ingestion may produce corrosive lesions that can extend beyond adjacent organs. We report three cases of aortoesophageal fistulas (AEF) after caustic ingestion that were diagnosed by autopsy., Results: AEF is a fatal complication that should be suspected in any patient with caustic ingestion who presents with gastrointestinal bleeding. A high index of suspicion, early recognition by gastrointestinal endoscopy, computed tomography scan, and aortography are important to improve the outcome.

Background: Aneurysmal dilatation in Takayasu's arteritis is a recognized complication; however, fistula formation, especially to the esophagus, is very rare., Methods: A 22-year-old male presented with severe hematemesis. Investigation by means of esophagogastroscopy and CT scan revealed a saccular aneurysm in the proximal descending aorta with communication to the esophagus. The patient was taken to theater, the aneurysm excised and replaced by a graft., Results: Gross examination of the aneurysm showed multiple points of outpouching from the aneurysm. Histopathological examination of the showed marked intimal fibromyxoid thickening, loss of outer medial muscle and elastic fibers and marked fibrosis of the adventitial layer. The histological features were in keeping with Takayasu's arteritis. No evidence of tuberculosis was noted., Conclusions: This case illustrates an unusual complication of Takayasu's arteritis, in the form of a fistula between the aorta and the esophagus, which resulted in massive hematemesis and the ultimate demise of the patient., (Copyright 2003 Elsevier Inc.)

Aortoesophageal fistula is a rare and lethal disorder that may result from primary diseases of aorta or esophagus, aortic bypass graft, ingestion of foreign body, trauma, surgical procedure or instrumentation. Tuberculous fistula is extremely rare. We present a 27-yr-old female patient with aortoesophageal fistula associated with tuberculous mediastinitis. The patient experienced massive hematemesis and esophagoscopy revealed a small mucosal defect with exudate-coated blood vessel like Dieulafoy 's lesion on about 25 cm from the incisor teeth. Despite two sessions of endoscopic hemostatic procedures, active massive hemorrhage recurred and was controlled effectively with a prompt insertion of Sengstaken-Blakemore tube. The patient underwent open thoracotomy, which revealed aortoesophageal fistula. Numerous white-yellowish, millet seed-like tubercles were scattered in pleural and abdominal cavity. Division of fistular tract and esophageal resection with Ivor-Lewis anastomosis were performed. Histopathologic study confirmed tuberculous pleuritis and peritonitis. The patient died of postoperative pulmonary complication.

Self-expanding metal stents are an established option in the palliative treatment of malignant stenoses of the esophagus. Herein, we report on a 60-year-old man with a recurrent stenosis that developed 2 months after radiochemotherapy for a squamous cell carcinoma in the middle part of the esophagus. To relieve progressive dysphagia, a Gianturco-Rösch stent (Cook-Z stent, 10 cm, PE-covered, manufactured by William Cook Europe) was implanted. Six weeks later, precipitous massive hemoptysis leading to the collapse and death of the patient occurred. Autopsy showed that a barb in the middle of the stent had perforated the aortic arch, resulting in massive bleeding into the gastrointestinal tract, and aspiration. Although hemorrhage and esophageal perforation are known late complications of all types of metal stents, our case is the first description of a perforation involving a fixation barb. These barbs are a particular feature of the European version of the Cook-Z stent, and are intended to prevent stent migration. In future, any hemorrhage observed after stent implantation should prompt a search for perforation by a barb (autopsy!). If necessary, the European version of the Gianturco Z stent should be modified.

A 78-year-old man was admitted because of haematemesis. A week before, the patient was admitted for prostate resection. During that admission he ingested an analgesic tablet complete with foil packaging. Since then, he suffered from dysphagia. Endoscopic examination revealed the foil packaging, but during the procedure massive bleeding in the oesophagus occurred. Despite initial haemodynamic stabilisation, fatal bleeding occurred a short while later. Post mortem examination revealed an aortic-oesophageal fistula which was ascribed to the foil packaging. One other oesophageal rupture was thought to be due to the packaging and a third rupture was ascribed to the inserted Sengstaken-Blakemore tube. Ingestion of a foil packaging warrants active medical intervention, as is stated elsewhere in the literature.

A rare and potentially fatal cause of hematemesis is fistula formation between the esophagus and the vascular system. A case report of a 39-year-old woman with congenital aortic arch anomalies hospitalized for treatment of head injuries demonstrates the potential for iatrogenic esophageal trauma to initiate fistula formation between the esophagus and an anomalous arterial system. A literature review revealed 6 other cases of vascular-esophageal fistulae caused by nasogastric esophageal intubation. It is concluded that aortic arch anomalies increase the risk of esophageal injury and subsequent fistula formation from nasogastric esophageal intubation. In addition, the clinical features and pathologic findings of vascular-esophageal fistulae are reviewed.

Aortoesophageal fistula is a rare cause of upper gastrointestinal bleeding, ranging from 0 to 2.3% in literature. The authors studied a group of 266 patients with upper gastrointestinal bleeding during the period of three years (1996-1998). According to two patient cases and the data from literature diagnostic methods, causes of aortoesophageal fistulas are analysed and the necessity of urgent closure of the fistulas is stressed. (Tab. 2, Fig. 2, Ref. 15.)

We present the case of a 45-year-old man who underwent surgical repair of a dissecting aneurysm of the descending thoracic aorta. 25 days postoperatively, the patient unexpectedly developed hematemesis and hypovolemic shock. Emergency gastroscopy was performed and a suspected aortoesophageal fistula was diagnosed. Unfortunately, the patient died prior to emergency surgery. Aneurysms of the aorta or of aortic grafts occasionally lead to the development of fistulae to the upper gastrointestinal tract. Once this rare, but life-threatening complication is suspected, endoscopy must be performed immediately. Emergency surgery is associated with a high risk, but represents the only possibly chance of survival for the patient.

We report herein the case of a patient with an aortoesophageal fistula (AEF) who was managed successfully by surgery. A 5-mm oval, well circumscribed aortic perforation just above the orifice of the celiac axis and a 4-mm defect in the esophagus were primarily closed, and an omental flap was placed between the aorta and the esophagus. No definite etiology could be determined. Our experience of this case suggests that primary closure for defects in both the aorta and the esophagus is the best option when the defects are small, and that the possibility of an AEF must be considered in patients with midthoracic pain or hematemesis, even if there is no history of thoracic aortic aneurysm, foreign body ingestion, trauma, or esophageal disease.

Aorto-esophageal fistula is a very rare disease and few cases are reported. The most frequent ethiological factors are foreign body ingestion primary disease of esophagus or aorta and iatrogenic damages in particular endoscopical investigations. In this report a new case is described and a pathogenic explanation for the development of the disease is proposed.

The development of a fistula between the aorta and the oesophagus after graft replacement of the thoracic aorta is extremely rare. We report a case which occurred 3 years and 7 months after repair of an aneurysm of the descending thoracic aorta and review the previous reports of this uniformly fatal condition.

An 81-year-old female patient with an 8-year history of Parkinson's disease was hospitalized because of aspiration pneumonia. The clinical course of her pneumonia was prolonged because of dysphagia with a short period of remission, and she required a long period of bed rest. She received supportive nutrition via a nasogastric tube and many peroral medications that consisted of 3 anti-Parkinsonian drugs and 5 anti-bacterial or anti-tussive agents. Six months after admission, she vomited fresh blood through the nasogastric tube, then went into hypovolemic shock. Hemodynamic stability was temporarily achieved by blood transfusion. Gastroduodenal endoscopic examination could not reveal the exact bleeding site because of massive blood clots. Five days later, the patient died of a massive hematemesis. Autopsy revealed 2 chronic longitudinal ulcers, each 1.7 x 0.4 cm in size, in the upper portion of the esophagus. One of them had developed a fistula to the aorta. Neither esophageal carcinoma nor a foreign body was detected around the fistula. Atherosclerosis of the aorta was mild and the perforation channel was covered with the esophageal epithelium. The fistula was assumed to be a product of local esophageal injury due to drug retention.

A 61 year old man died after presenting with a 24 h history of haematemesis and haemoptysis, and one year history of hoarseness of voice. Post-mortem examination showed a dental plate eroding through the mid-oesophagus into a bronchus and into the descending arch of the aorta, with scarring suggestive of old perforation. An organized haematoma also involved the left recurrent laryngeal nerve. Vocal cord paralysis may be a manifestation of foreign body-induced oesophageal perforation, which can lead to death from an oesophago-broncho-aortic fistula. Both complications of oesophageal perforation from a foreign body have not to our knowledge been previously reported.

A 29 year old patient with artificial respiration because of a severe trauma was fed by tube. 23 days after his admission to a hospital an uncontrollable bleeding arised out of the oesophagus. The autopsy revealed an aortic-oesophageal fistula, caused by the feeding tube, which owing to the (unrecognised) arteria lusoria had lead to a pressure sore of the oesophagus.

We report a case of traumatically induced false aneurysm with secondary bacterial aortitis of the descending aorta and fistula formation between the aorta and esophagus. This lesion was diagnosed at autopsy and caused death in a 68-year-old female 19 years after an automobile accident. Aortoesophageal fistula (AEF) formation as a result of any cause is rare. To our knowledge, this is the second reported case of traumatic aortic aneurysm as a result of an automobile accident with subsequent AEF formation.

A 25-year-old man suffering from lymphogranuloma malignum received mediastinal radiotherapy in a dose of 3,380 R (827 mC/1 kg). About 2,5 years later fatal gastro-intestinal haemorrhage occurred from a aortooesophageal fistula. Aortic necrosis of media and intima with G+ cocci was found, as well as adventitial fibrosis with radiation fibroblasts. Assisting mechanisms of aortic damage by therapeutic doses of radiation were discussed.

Exsanguination in a case of esophageal carcinoma resulted from an aortoesophageal fistula. The squamous carcinoma was undiagnosed clinically and was untreated. Ulceration of the carcinoma gave rise to mediastinitis and an abscess containing necrotic tumor and bacteria. Infection spread from the abscess to the adjacent aorta, producing focal bacterial aortitis, necrosis of the aortic media, and aortic perforation. A fistula was thus established between the aorta, the abscess cavity, and the esophagus. Terminally, the patient had a large hematemesis, and massive hemorrhage acutely distended the stomach which ruptured to produce a large hemoperitoneum.

After massive hematemesis esophageal varices were found by radiography and endoscopy in a 79-year-old woman. Two episodes of bleeding could be stopped with the Sengstaken-Blakemore-tube. The patient, however, died after heavy vomitting of arterial blood, although the tube was in the proper position. Atopsy shows a fistula between a tractiondiverticulum of the esophagus and the aorta. A flaringup of an old tuberculosis, demonstrated by histology, caused the colliquating of the wall of the diverticulum and also the arrosion of the aorta.

Endoscopic photographs were obtained in a patient with back pain and hematemesis. External compression of the mid-esophagus and small esophageal diverticula was noted, as well as a small erosion oozing bright red blood in otherwise normal mucosa. Angiography revealed an aneurysm of the thoracic aorta without leak. Surgical closure of the aneurysm was initially successful; however, the patient developed recurrent bleeding one month later. Repeat endoscopy revealed a recurrent fistula with an intramural mass in the mid-esophagus, oozing blood with adherent clot. These findings are the earliest endoscopic features of aortoesophageal fistula described, and this is the only case with subsequent reendoscopy, demonstrating previously reported findings in an advanced stage of fistula formation. Flexible endoscopy is a safe, valuable diagnostic study in suspected aortoesophageal fistula. The literature on endoscopy in aortoesophageal fistula is reviewed.

Two cases of aortoesophageal fistula are presented. The etiology, symptoms, and diagnosis of aortoesophageal fistula are reviewed. Signs and symptoms of gastrointestinal hemorrhage followed by sudden collapse hours to days later should prompt consideration of an aortoesophageal fistula. Accidental ingestion of foreign bodies, particularly by children, is a frequent etiology.

Aortoesophageal fistula is a rare disorder that may result from many causes. In this report, we describe the unique case of a 71-year-old woman who developed an aortoesophageal fistula following prolonged placement of a nasogastric tube. The presence of dense fibrous adhesions between the aorta and esophagus may have facilitated the development of aortoesophageal fistula in this patient.

A 56-year-old, otherwise healthy man died in operative room from a massive esophageal hemorrhage, one week after a single episode of postprandial odynophagia. Surgical specimen of the esophagus and the aorta showed a fistulous tract extending from an esophageal tumoral mass to the aorta. Histological examination disclosed the microscopic finding of the so-called inflammatory pseudotumor of the esophagus (IPT). To our knowledge, this is the first reported case of such unusual complication of IPT, resulting in fatal gastrointestinal bleeding.

An 87-year-old woman with a known atherosclerotic thoracic aneurysm died suddenly from a massive esophageal hemorrhage. Prior to death, tuberculous esophagitis was diagnosed by biopsy. At autopsy, a fistulous tract was found extending from the esophagus to the aortic aneurysm; this fistula proved to be the site of fatal hemorrhage. The tract was surrounded by a granulomatous inflammatory reaction, in which acid-fast bacilli were found. To our knowledge, this is the first reported case of tuberculous esophagitis extending to an aortic aneurysm resulting in hemorrhage and death.

Though secondary aortoesophageal fistula and subsequent hemorrhage is rare, the clinician must have a high index of suspicion to establish the correct diagnosis and institute appropriate treatment. We have proposed an algorithm to help prevent a massive hemorrhage such as the one that proved fatal in our patient. In the case of massive upper gastrointestinal hemorrhage, a Sengstaken-Blakemore tube should be done expeditiously. In the case of sentinel hemorrhage, aortography is the initial diagnostic procedure of choice, followed by flexible esophagogastroscopy if necessary.