SHM Converge Scientific Abstract ePoster Gallery-Gastro-Atrial Fistula: It's a Matter of the Heart, Head and Gut, a Rare Connection

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This case describes a rare and often fatal complication of prior esophagectomy with gastric pull-through: a gastro-atrial fistula (GAF), an abnormal connection between the stomach/neo-esophagus and the left atrium. A 79-year-old patient with remote esophageal cancer in remission was admitted for upper GI bleeding. Endoscopy showed non-bleeding gastric ulcers, and the patient was discharged. That evening, the patient developed fatigue, dizziness, cough, and reflux, then rapidly deteriorated with collapse, fever, shock, and altered mental status.<br /><br />In the ICU, the patient required intubation, pressors, and antibiotics. CT imaging showed a dilated neo-esophagus with debris but no clear mediastinal air. The patient then developed kidney injury, recurrent bloody NG output, and melena. Blood cultures grew Bacillus and Candida glabrata, and brain imaging revealed multiple watershed and embolic strokes, likely from septic emboli. Echocardiography showed a left atrial echogenicity. Despite treatment, the patient worsened and was transitioned to comfort care. Autopsy revealed an unexpected gastric-left atrium fistula at the prior esophagectomy site, with widespread embolization of gastric contents to the brain, lungs, liver, and spleen.<br /><br />The discussion emphasizes that GAF can occur after trauma, atrial fibrillation ablation, or rarely after esophagectomy with gastric pull-through. Common presentations include hematemesis/melena, neurologic symptoms from emboli, dysphagia, and chest pain. Diagnosis is frequently delayed because symptoms are nonspecific and the condition is rare. Recommended diagnostic tests are CT chest with IV and oral contrast or MRI; endoscopy should be avoided when GAF is suspected because insufflation may cause air embolism and stroke. Early recognition is critical, as mortality is high. Treatment options include surgery or stent placement.

Asset Subtitle

Maya Narayanan

Meta Tag

Author List Andrew D. Auerbach, Christopher Kim, Maya Narayanan

Category Clinical Vignettes

Concept Gastro-atrial fistula

Concept Computed Tomography

Concept Systemic Embolism

Concept Gastrointestinal Bleeding

Concept Magnetic Resonance Imaging

Distinguished Non-Finalist

Presenter Organization University of Washington School of Medicine

Presenting Author Maya Narayanan

Track Adult

Keywords

gastro-atrial fistula

esophagectomy

gastric pull-through

upper gastrointestinal bleeding

septic emboli

left atrium

hematemesis

melena

stroke

computed tomography

Gastro-atrial fistula

Computed Tomography

Systemic Embolism

Gastrointestinal Bleeding

Magnetic Resonance Imaging