IMAGES IN FORENSICS

Thoracic aortic aneurysm rupture into the esophagus

Ita Hadzisejdic • Elvira Mustac • Mira Krstulja •

Neven Franjic • Davor Stimac

Accepted: 8 September 2011 / Published online: 11 October 2011

� 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 per-

formed 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 examina-

tion, the immediate place of bleeding could not be identi-

fied. 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

admission the patient started to vomit blood vigorously and

became hypotensive. A diagnosis of thoracic aortic aneu-

rysm (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 ath-

erosclerotic changes. The stomach was completely filled

with blood and clots (about 800 mL); with bloody and tarry

contents in the intestines. Tissue histology around the fistula

(the aortic and esophageal wall) showed hemorrhage,

inflammation and fibrosis. The aortic wall was severely

infiltrated with neutrophils around the rupture site (Fig. 2).

The laminated thrombus appeared to have acted as a lid

covering the fistula opening. There was no histological

evidence of cystic medial degeneration in the aortic wall.

No significant pathology was observed in any other organs.

Discussion

Thoracic aneurysms may cause a wide range of symptoms

depending upon their location, including dysphagia and

I. Hadzisejdic � E. Mustac (&) � M. Krstulja

Department of Pathology, School of Medicine,

University of Rijeka, B. Branchetta 20, 51000 Rijeka,

Croatia

e-mail: elviram@mamed.medri.hr

N. Franjic � D. Stimac

Department of Internal Medicine, School of Medicine,

University of Rijeka, Kresimirova 42, 51000 Rijeka, Croatia

123

Forensic Sci Med Pathol (2012) 8:327–329

DOI 10.1007/s12024-011-9281-2

hematemesis as esophageal manifestations. The presence

of hematemesis is indicative of an aorto-esophageal fistula,

where the earliest occurrence of hematemesis is recognized

as a sentinel hemorrhage [1]. The patient may then become

stable until the next hemorrhage, which is usually a fatal

exsanguination. In fact, about 60% of patients die within

6 h of the onset of hemorrhage [1, 2]. TAA accounts for

about two-thirds of all AEFs with an incidence of rupture

into the esophagus of 6.2–22.1% [3–5]. In our case, a

retrospective investigation found only mild hematemesis

which, according to the patient, preceded admission by a

few hours. However, rectal examination on admission was

positive for melena. Thus, it is more probable that the

bleeding had occurred a few days prior. It is possible that

the patient neglected the bleeding due to her alcoholism.

This would have reduced the time for investigation, diag-

nosis and definitive treatment. Reviews of the clinical lit-

erature show that a diagnosis of AEF is made ante-mortem

in most cases [5]. This is due to the fact that most cases of

TAA are asymptomatic until the aneurysm expands,

therefore these patients go undiagnosed. Although various

non-invasive and invasive imaging techniques are available

to detect potential sources of upper gastrointestinal bleed-

ing, it is important to stress the fact that a routine chest

X-ray can provide significant information, even for patients

with gastrointestinal bleeding, as it can detect saccular

aneurysm of the thoracic aorta [5]. In the majority of cases,

the prognosis of AEF is poor because of acute massive

hemorrhage. Thus, AEF is fatal in most cases without

surgical treatment [5].

In our case, histology of the aortic and esophageal wall

at the rupture site showed signs of early inflammatory

response with heavy infiltration of neutrophils, indicating

that the rupture was around 2–3 days old. We believe that

atherosclerosis is the primary contributor in the etiology of

the aneurysm in this patient. Aortic wall thinning and

medial destruction was secondary to plaques which origi-

nated in the intima. Alcohol is also considered to be one of

the risk factors in developing abdominal aortic aneurysm in

men [6]; therefore, it is plausible to think that excessive

alcohol drinking might have contributed to this patient

developing TAA, since it is known that high alcohol intake

can increase blood pressure (high blood pressure is one of

the risk factors of TAA). In our case, the initial bleeding

into the esophagus and melena on DRE was slow due to a

large laminated thrombus that was covering the orifice of

the fistula, controlling the volume of bleeding.

In conclusion, it must be emphasized that patients with

AEF can suddenly, and unexpectedly, die once massive

bleeding occurs. Therefore, it is important to stress that this

Fig. 1 Thoracic aortic aneurysm with esophageal fistula (a) and large

thrombus within the aortic wall acting like a valve that was

controlling the hemorrhage (b)

Fig. 2 The aortic and esophageal wall around the fistula showed

diffuse neutrophil infiltration with hemorrhage (H&E a. 1009,

b. 2009)

328 Forensic Sci Med Pathol (2012) 8:327–329

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rare but fatal condition should be considered in any patient

with recurring gastrointestinal bleeding, because prompt

surgical treatment is crucial for survival.

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