oesophageal fistulae and aorto-oesophageal fistulae

see also:

• upper GIT bleeding

• fistulae may form from the oesophagus to adjacent anatomic organs such as:
  • aorta (aorto-oesophageal fistula)
  • pericardium (oesophageal–pericardial fistula)
  • mediastinum causing mediastinitis
  • pleural space (oeophageal pleural fistula)
  • trachea (tracheoesophageal fistula)
• they may be caused by inflammation or trauma:
  • within the oesophagus:
    • Boorhaave's syndrome (15% of oesophageal perforations)
    • severe ulcerative oesophagitis such as:
      • ingested, retained button batteries
      • radiotherapy
    • foreign bodies causing oesophageal perforation
    • complication of balloon tamponade for Rx of oesophageal varices or dilatation for Rx of stricture
    • complication of gastroscopy/oesophagoscopy (causes 45% of oesophageal perforations)
    • oesophageal cancer - second most common cause
    • post-operative following oesophagectomy
  • external to the oesophagus:
    • thoracic aortic aneurysm - accounts for 90% of aorto-oesophageal fistulae
    • penetrating aortic ulcers
    • following thoracic endovascular aortic repair
    • double arch aorta ¹⁾
    • penetrating trauma
    • pressure necrosis from intercostal drain tubes

• these are often classified as either:
  • Primary - occurring in native aortae
  • Secondary - occurring in surgically repaired aortae
    • can occur after endovascular AAA repair despite the absence of endoleak or AAA diameter increase on follow-up computed tomographic scan.²⁾
• they often have an initial herald transient GIT bleed which may not be visible on gastroscopy once it has stopped and this may precede the final, usually fatal bleed by hours or even months.
• one third have the classical triad of:
  • mid-thoracic pain
  • herald bleeding
  • delayed onset of rapidly fatal haematemesis

• rare
• has been reported following catheter ablation using radiofrequency or cryothermal energy for Rx of arrythmias
  • 2nd most common fatal complication of the procedure and usually happens 3-35 days after the procedure and presents with sudden onset chest pain and fever ³⁾