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A Disheartening Bleed: An Uncommon Cause of Massive Gastrointestinal Hemorrhage FREE TO VIEW

Jonathan Wiesen, MD; Ari Wiesen, MD; Bradley Confer, DO; Adam Wilberger, DO; Carmela Tan, MD; Jihane Faress, MD
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Cleveland Clinic Foundation, Cleveland, OH

Chest. 2014;146(4_MeetingAbstracts):276A. doi:10.1378/chest.1991429
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SESSION TITLE: Critical Care Cases II

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Tuesday, October 28, 2014 at 07:30 AM - 08:30 AM

INTRODUCTION: Gastrointestinal bleeding (GIB) is a common cause of admission to the intensive care unit (ICU).

CASE PRESENTATION: A 73-year-old man with a remote history of Barrett’s esophagus treated with an esophagectomy and gastric pull through 15 years prior, and significant daily alcohol and ibuprofen use, presented with a massive upper gastrointestinal (UGI) bleed. An esophagogastroduodenoscopy (EGD) eight months earlier showed an intact anastomosis and a clean based gastric ulcer in the gastric fundus with no stigmata of recent bleeding. While he was hemodynamically stable, his hemoglobin (Hb) dropped 2g from baseline. An emergent EGD showed a large clot in the gastric body which was not disturbed. He continued to have repeated episodes of large volume hematemesis, became hypotensive requiring vasopressors and experienced a 5g drop in his Hb. He was intubated for airway protection and aggressively resuscitated requiring a total of 9 units of packed red blood cells (PRBC) and increasing doses of vasopressors. An emergent aortogram was negative for evidence of aorto-enteric fistula or other source of bleeding. Despite our aggressive resuscitative efforts, he became rapidly and progressively hypotensive, and subsequently suffered a cardiac arrest. His autopsy revealed the source of bleeding to be a gastrocardiac fistula between a benign peptic ulcer in the gastric conduit and the posterior wall of the left ventricle (LV) as well as an acute transmural myocardial infarct in the said area of the LV.

DISCUSSION: Although most commonly due to gastric or duodenal ulcers, esophageal varices or mechanical defects, the list of rare causes of GIB is extensive and the instensivist must keep an open mind when the patient's history or presentation suggest something other than the most common etiologies. In hindsight, only an emergent ventriculogram would have diagnosed the gastrocardiac fistula.

CONCLUSIONS: Gastrocardiac fistula is a rare complication of thoracic surgery. It must be suspected when patients with a history of thoracic surgery present with massive, otherwise unexplained, UGI bleeding. A high index of suspicion is necessary to provide patients with the urgent management of this acutely life threatening event.

Reference #1: Finelli et al. Esophageal rupture complicated by gastrocardiac fistula. Ann Thor Surg 1989;48:582-3.

Reference #2: Pentiak et al. Benign post esophagectomy gastrocardiac fistula. Interactive cardiovascular and thoracic surgery 2011;13:447-9.

DISCLOSURE: The following authors have nothing to disclose: Jonathan Wiesen, Ari Wiesen, Bradley Confer, Adam Wilberger, Carmela Tan, Jihane Faress

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