Aortoesophageal fistula in a child
A 10-year-old boy presented to the pediatric emergency with bouts of massive hematemesis, passage of fresh blood per rectum, and melena for 2 h. There was a previous history of massive hematemesis 2 weeks back, which resolved spontaneously after 2 units of blood transfusion. He had a history of anorexia and weight loss over the last 1 month. There was no history of trauma, foreign body, or corrosive ingestion. On examination, the child was restless and irritable. He had marked pallor, a low volume pulse, and a pulse rate of 140 per minute and blood pressure of 100/60 mmHg. Systemic examination was unremarkable. The child was resuscitated with fluids and packed red blood cells (PRBCs). However, massive hematemesis and melena continued resulting in progressive worsening of hemodynamic status over the next few hours. Resuscitation was stepped up with transfusion of multiple PRBC units to make up for the ongoing blood loss, and the child was intubated for prevention of aspiration and put on support. The preliminary reports revealed hemoglobin of 2.5 g/dl, platelet count of 200,000/mm3, and a normal prothrombin time. Upper GI endoscopy showed active esophageal bleeding and a pale esophageal mucosa with an ulcerated lesion of around 1 cm in diameter with overturned margins and a clot over it, in mid-esophagus at 25 cm from the incisors. Rest of the esophagus was unremarkable. Hemostatic procedures in the form of sclerotherapy around the lesion were tried, but re-bleeding occurred during the procedure. Child was shifted to pediatric intensive care unit, where resuscitative measures were continued and ionotropes were started. Imaging with contrast enhanced computed tomography (CT) scan thorax showed multifocal parenchymal consolidation and marked soft tissue thickening in mediastinal planes with esophageal mural and periesophageal thickening. The intravenously administered contrast was seen filling the esophageal lumen with a linear track extending from medial aortic border to the esophagus []. Based on clinical, endoscopic, and imaging findings, a diagnosis of AEF was made and the child was taken up for emergency thoracotomy. On exploration by left thoracotomy, mediastinum was studded with multiple necrotic nodes and inflammatory soft tissue. Mid esophagus and the aorta were encased in dense inflammatory tissue preventing separation of the esophagus from the aorta. Therefore, the aorta was transected between clamps to approach the AEF [], which was then dissected off the posterior wall of the aorta. Damaged segment of the aorta was resected and continuity restored using Dacron graft within 20 minutes without cardiopulmonary bypass. A partial esophagectomy of the densely inflamed esophagus, closure of distal esophageal stump, and cervical esophagostomy was performed. A gastrostomy and feeding jejunostomy were also placed. In the post-operative period, the inotropes were gradually tapered and stopped, and the child was weaned of the ventilator over the next few days. The histopathological examination of lymph nodes, aortic wall, and esophagus showed presence of necrotizing epithelioid cell granulomas compatible with tuberculosis []. The Mantoux test done in postoperative period was strongly positive (18-mm induration). There was global neurological impairment with poor recovery secondary to neurological injury as a result of massive preoperative blood loss and hypoxemia. However, the child could be discharged home on anti-tubercular drugs and enteral nutrition through the feeding jejunostomy, pending an esophageal replacement.