Interesting case of GI bleed

Dr Charles Panackel MD DM, Dr Sunil K Mathai MD, DMDepartment of Gastroenterology, Medical Trust Hospital, KochiPresenting Author – Dr Sunil K Mathai, HOD Gastroenterology

History

•56 year old female•Admitted with

▫Hematemesis - 2 episodes▫Malena - 3 episodes▫Generalized weakness▫Giddiness

Admitted to ICU

•Hemodynamically stable•PR – 80 / min., BP – 140/70 mm Hg•RT inserted – no fresh blood, coffee

ground aspirate•General examination – mild pallor +•Systemic examination – no s/o liver

disease▫No contributory findings

Urgent Endoscopy

Ulceration with Adherent Clot in Mid Esophagus

? Aortoesophageal fistula

Flash Back

Fish bone in mid esophagus in 2005. Active oozing ++ -Referred to MTH

Flash Back

•CT Chest- Fish bone in mid esophagus piercing aorta

•Emergency Thoracotomy with aortic repair on 21/03/2005

•Uneventful till date…. When she presented with GI bleed on 15/o6/2012

Back to case

CT chest with aortogram

Diagnosis

Upper GI BleedAortoesophageal Fistula

How to Manage ?

How to Manage ( what literature says?)• High mortality

•Common cause of death – ▫ Exsanguinating Bleed ▫ Infection

How to Manage ( what literature says?)•2 main options for Aortic Pseudo

aneurysm▫Open surgery

Aortic repair using – Synthetic material Pedicle graft

Thoracic esophagectomy + cervical esophagostomy + gastrostomy

▫Endovascular repair

How to Manage ( what literature says?)•Esophageal defect ??

• Leave it alone ??

• Esophagostomy/Esophagectomy ??

• Stenting ??

Plan •Endovascular repair

•Esophageal Stenting

•PEG for Feeding

•Antibiotics

Esophageal stenting done

PEG tube for feeding

Follow up aortogram

•Both stents well in situ

•No obvious leak seen.

•Antibiotics

•PEG feed

CT Chest after 2 weeks

Follow up

•Six weeks

•Patient eating well

•No infection or leak

•Planned for removal of esophageal stent

At Six weeks

•At six weeks

Granulation tissue in growth at both ends of esophageal stent. Unable to remove

APC done to ablate the granulation

Still stent could not be dislodged.

Six Months

•Both Stents in situ

•In growth of Granulation tissue at both ends. Planned for APC

Thank you.