Clinical Challenges

Clinical Challenges - March 2017
What's Your Diagnosis?

Publish date: March 1, 2017

By Chih-Ming Lin, PhD, Yang-Yuan Chen, MD, and Hsin-Yuan Fang, MD.

Published previously in Gastroenterology (2013;144:31,251-2).

A 72-year-old man was admitted to our hospital presenting with hematemesis and tarry stool for 1 day. Approximately 1 year before this admission, he received a diagnosis of T3N0M0 lower esophageal squamous cell carcinoma and underwent subtotal esophagectomy and reconstruction with gastric conduit interposition by the retrosternal root. In addition, 1 month before his admission, he received a diagnosis of constrictive pericarditis and underwent pericardiectomy. During this period of hospitalization, the patient developed persistent hematemesis followed by hypovolemic shock. Emergent esophagogastroduodenoscopy failed to identify the bleeder because numerous blood clots were present in the gastric tube. A contrast-enhanced chest computed tomography revealed a bleeder over the posterior wall of the reconstructed gastric conduit (Figure A, black arrow).


 

The Diagnosis

Answer: Gastrocardiac fistula with active bleeding

Active bleeding from a fistula between the right ventricle and reconstructed gastric conduit was identified after opening the gastric conduit (Figure B, black arrow). The surgeon decided to resect the gastric tube, create an esophagotomy and

feeding jejunostomy, and perform a cardiorrhaphy with primary suture closure and peritoneal patch repair. The bleeding stopped after the operation, and the patient was discharged without incident 3 weeks later.

Only seven cases of fistula between postesophagectomy gastric conduits and cardiac chambers, including this case, have been reported in English literature. The disease mortality rate is as high as 60%. 1 Several predisposing risk factors exist for gastrocardiac fistula, including malignancy, radiation, ischemia, and peptic ulcer disease. 1 We surmised that the previous pericardiectomy was the predisposing factor in this case.

Fistula rarely develops between the upper gastrointestinal tract and adjacent structures, including the trachea, bronchi, pleura, aorta, pericardium, and heart. 2,3 The symptoms differ depending on the location of the fistula, and recurrent bronchopneumonia, pleuritis, mediastinitis, pericarditis, and upper gastrointestinal bleeding may be present. Because of the high mortality rate, physicians should be alert to these fatal fistula. If fistula is suspected, a contrast radiological study and direct endoscopic visualization can be employed to establish a diagnosis.
Gastrocardiac fistula is a rare cause of upper gastrointestinal bleeding. The majority of diagnoses were made at autopsy. Only aggressive and emergent operative intervention can offer patients a chance of survival because they tend to deteriorate rapidly. 1 This case of gastrocardiac fistula occurred after esophagectomy with gastric conduit reconstruction and a pericardiectomy. Immediate surgery is required for life-threatening upper gastrointestinal bleeding if gastrocardiac fistula is suspected. Patient survival is likely after immediate operation.

References

1. Pentiak, P., Seder, C.W., Chmielewski, G.W., et al. Benign post-esophagectomy gastrocardiac fistula. Interact Cardiovasc Thorac Surg. 2011;13(4):447-9.
2. Schouten van der Velden, A.P., Ruers, T.J., Bonenkamp, J.J. A cardiogastric fistula after gastric tube interposition (A case report and review of literature). J Surg Oncol. 2007;95(1):79-82.
3. Rana, Z.A., Hosmane, V.R., Rana, N.R., et al. Gastro-right ventricular fistula: a deadly complication of a gastric pull-through. Ann Thorac Surg. 2010;90(1):297-9.

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