Upper Gastrointestinal Bleed with an Unusual Etiology: A Difficult Case with Unclear Imaging Findings.




0009-0008-0397-1482 (Wazir, Ali)

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Background: Atrial fibrillation (AF) is a cardiac arrhythmia which can be managed with AF ablations, used to control aberrant electrical activity. A serious complication of ablations includes atrioesophageal fistulas (AEF), with clinical manifestations of hematemesis, fever, neurological deficits, and mental status changes. A majority of documented cases utilize computed tomography (CT) scans which demonstrate the presence of a fistula, but there remains a paucity of AEF cases with unclear imaging findings. Case Presentation: A 63-year-old Caucasian male with symptomatic persistent AF underwent radiofrequency ablation with PVs and left atrial posterior wall isolation on December 12, 2016. The patient tolerated the procedure well. On January 11, 2017, the patient returned to the emergency department with hematemesis one day prior. The patient reported chills, nausea, mild headache and a temperature of 103.2F. Patient reported taking ibuprofen with no relief. Vital signs at admission: T 98.5 F, BP 107/57, HR 62 bpm, and oxygen saturation of 100% on room air. PE: normal with no neurologic deficits. Labs: CBC indicated leukocytosis with neutrophilic shift and bandemia, thrombocytopenia, and low hemoglobin. CMP: low serum albumin and total protein. Coagulation studies: elevated aPTT and INR. Serum troponin I: minimally elevated. ECG: nonspecific T wave changes. CXR: no evidence of cardiopulmonary disease. Cranial CT scan: nonspecific bilateral subcortical frontal lobe white matter changes. Chest CTA with contrast was recommended by the EP to assess for an AEF and revealed no atrial wall defects. Gastroenterology was consulted for an upper GI bleed (UGIB) caused by NSAID usage based on imaging findings. Patient further experienced vision changes, confusion, chills, and myalgias. Blood Gram stain was positive for gram-positive cocci. Patient was started on a course of piperacillin-tazobactam and vancomycin. Magnetic Resonance Imaging illustrated bihemispheric ischemic infarctions. EGD revealed a protuberance with a small opening thirty centimeters from the incisors. Patient continued to deteriorate, and a repeat CT angiogram displayed a possible atrial wall defect but no overt fistula, pneumomediastinum, or contrast media within the esophagus. Based on high clinical suspicion of an AEF, a cardiothoracic surgery consult was requested. A cardiothoracic surgery was performed with repair of the left atrium and esophageal fistula. A 2-3 millimeter punctate defect was present between the left and right inferior pulmonary veins. Fibrinous adhesions were present on the anterior esophagus at the level of the left atrium. A punctate mucosal perforation was present in the esophageal wall measuring 2-3 millimeters in diameter. A pericardial patch was placed. The patient tolerated the procedure well and was transferred to the cardiovascular ICU. Post-operatively, the patient developed sepsis, delirium, and difficulty swallowing and was placed on tube feeding. Over the following days, mental status improved. Final culture results on postoperative day seven confirmed Streptococcus oralis, Streptococcus mitis, and Granulicatella adiacens and were treated with IV ceftriaxone outpatient. On postoperative day nine, the patient was discharged with no neurological deficits. Conclusion: This case highlights the importance of including AEFs within differential diagnoses of UGIB given recent AF ablations when imaging results are inconclusive.