Abstract
A 28-year old was admitted to intensive care for treatment of massive hematemesis. The patient suffered from mitochondria disorders (MELAS), and had recently been treated by long term nasogastric intubation because of difficulties related to an oral diet and medication. Despite vigorous resuscitation, including a rapid transfusion, she did not recover. A post-mortem examination revealed an esophageal ulcer that perforated to the left subclavian artery. Her aortic arch was normal, as was the Subclavian artery. The circumference of the esophageal ulcer was thickened, suggesting chronic inflammation. We considered that long term compression by the naso-gastric tube had caused pressure necrosis of the esophageal and arterial wall, finally resulting in an arterio-esophageal fistula. An arterio-esophageal fistula (AEF) is a rare entity, but is usually present with fatal gastrointestinal bleeding. In the majority of reported cases, an AEF results from an aneurysmal formation of an aberrant right subclavian artery in elderly patients, or from naso-gastric tube intubation in young patients with an aberrant right subclavian artery. While an AEF might occur in patients who have a normal aortic arch, it usually is found as a complication of foreign body ingestion. Our case appears unique as it occurred as a result of naso-gastric intubation. We concluded that very careful management of naso-gastric tubes is required, especially in cases of long-term intubation.
