Case Presentation: A 79-year-old patient with a history of esophageal cancer status post esophagectomy six years prior with neo-esophagus creation and chemotherapy currently in remission, was admitted for upper tract gastrointestinal (GI) bleeding. An esophagogastroduodenoscopy (EGD) demonstrated several non-bleeding gastric ulcers. Given stability and resolution of the bleeding, the patient was discharged home. Later that evening the patient described feeling fatigued and dizzy, along with symptoms of a cough and gastric reflux. Within a few hours the patient collapsed and was immediately brought back to the hospital. The patient was somnolent, febrile, tachycardic and hypotensive. The patient was intubated for airway protection and admitted to the intensive care unit on pressors and antibiotics. Computed tomography (CT) chest/abdomen with intravenous (IV) contrast showed a dilated neo-esophagus with copious internal debris and no pneumomediastinum. The patient developed acute kidney injury, intermittent dark bloody output from the naso-gastric tube, and melena. Blood cultures grew Bacillus and Candida Glabrata, and CT imaging of the head showed multifocal watershed and embolic infarcts thought to be due to the bacteremia and fungemia. A transthoracic echocardiogram demonstrated a left atrial echogenicity. The patient’s condition did not improve, and the patient was transitioned to comfort care. A post-mortem examination demonstrated an unexpected finding of gastric-left atrium fistula (GAF) at the site of prior esophagectomy and associated systemic embolization of gastric contents to the brain, lungs, liver, and spleen.
Discussion: Gastro-atrial fistulas can occur after trauma or radiofrequency ablation to treat atrial fibrillation, but can also develop as a rare complication of esophagectomy with gastric pull-through [1,2]. The most common presenting findings from gastro-atrial fistulization are hematemesis or melena, acute neurologic symptoms from cerebral emboli, dysphagia and/or chest pain [1]. GAFs are often challenging to diagnose, and diagnosis is often missed or delayed given the rarity of the condition and non-specific presenting symptoms. The best diagnostic modalities are CT chest with IV and oral contrast or magnetic resonance imaging (MRI). In patients with known or suspected GAFs, endoscopy is not advised because insufflation of the esophagus can result in air embolus with risk for stroke [3]. The condition is associated with a high rate of mortality and morbidity unless detected early. Treatment options include surgery or stent placement [4].
Conclusions: Gastro-atrial fistulas are a very rare but almost always fatal complication of esophagectomy with gastric-pull through. Although diagnosis can be difficult, the condition should be considered for patients with a history of esophagectomy and present with GIB, embolic stroke, dysphagia and/or chest pain. A MRI or CT scan of the chest with IV and oral contrast can assist with early detection and possible treatment.