Abstract Introduction Atrio-esophageal fistulas are rare but can occur after radiofrequency ablation as a treatment for atrial fibrillation. An atrio-gastric (neo-esophagus) fistula can be a life-threatening delayed complication after esophagectomy for esophageal cancer, especially in patients with prior chemoradiation. We present a case of a patient presenting with mixed distributive, cardiogenic and hemorrhagic shock found to have left atrio-gastric fistula. Case Description A 63-year-old woman with esophageal adenocarcinoma status-post neoadjuvant chemoradiation, esophagectomy with esophageal-gastric anastomosis two year ago, and adjuvant nivolumab presented with acute chest pain, encephalopathy and melena. She was found to be in shock and was intubated for airway protection and started on vasopressors after resuscitation with intravenous fluids. Workup was significant for a hemoglobin of 8.3g/dL (from a baseline of 10.7g/dL) and ST-elevation myocardial infarction on EKG with a high-sensitivity troponin I of 4,017 pg/mL which later peaked at 18,280 pg/mL. Cardiac catheterization was deferred due to concern for hemorrhagic shock. The patient was transfused 2 units of packed red blood cells and started on broad-spectrum antibiotics. Blood cultures were positive for Streptococcus viridans, Klebsiella pneumoniae, and Candida glabrata. Transthoracic echocardiography showed a severely reduced ejection fraction (20-25%) with regional wall motion abnormalities correlating with the EKG changes. Esophageal gastroendoscopy revealed a large 3 cm bleeding ulcer in the neo-esophagus at the anastomosis site with a pulsating vessel. While clipping the ulcer to assist interventional radiology in localizing the ulcer for possible embolization, the patient started briskly bleeding from the ulcer. This raised concern for left atrio-gastric conduit fistula, which was confirmed on computed tomography angiography of the chest (Image 1). Given her poor prognosis and comorbidities, the patient was transitioned to comfort care per the family’s wishes. Discussion Atrio-gastric fistula is a rare but catastrophic complication that can occur after esophagectomy. Pre-operative chemotherapy and radiation are factors that may increase the risk of fistula formation. In addition, nivolumab can also increase the risk as it has been associated with tracheo- and broncho-esophageal fistula formation. Fistulas typically form due to erosion of the gastric conduit into the left atrium, leading to life-threatening gastrointestinal blood loss. Our case was especially challenging as patient also suffered a myocardial infarction, further complicating her presentation. This case highlights the importance of early recognition of atrio-gastric fistula bleeding, especially following high-risk esophagectomy procedure. Due to its rarity and high mortality, prompt multidisciplinary involvement is essential. This abstract is funded by: none
Salem et al. (Fri,) studied this question.