upper gastrointestinal bleeding ( ugib ) is a major cause of mortality and morbidity accounting for about 56.5/100,000 hospitalization with a mortality rate of 8.2% . aorto - esophageal fistula ( aef ) , an abnormal anatomical communication between the aorta and esophagus is a rare cause of ugib . as the thoracic aneurysm grows in size , the increasing tension on its wall will erode the aorta and rupture into the surrounding esophagus leading to uncontrolled bleeding . as ulcer related or variceal bleeding constitutes for most of the ugib bleeding , even in elderly who are at risk of aef and the inability of the esophagogastroduodenoscopy ( egd ) to detect most cases , aef is often not diagnosed timely . all these factors make the timely diagnosis of aef challenging , and at times missed altogether leading to catastrophic consequences . we present a case of aef which was initially treated as variceal bleeding and later promptly diagnosed with computed tomography ( ct ) . a 70-year - old male patient with hypertension with regular ethanol use , presented to a local hospital with complaints of hematemesis and melena from the past 1-day . he was hemodynamically stable on presentation with initial hemoglobin level of 7.2 g / dl . he underwent timely egd , which showed grade 1 mid and distal esophageal varices without any active bleeding . subsequently , his condition deteriorated with the development of hypotension and transferred to our medical center for further management . weiss tear without active bleeding along with the presence of large blood clots in the gastric fundus . as the source of bleeding was not clear despite two egd and clinical evidence of gi bleeding , he underwent emergent colonoscopy which once again failed to detect any source lower gi bleeding . however , later in the day , he developed massive hematemesis and hematochezia leading to persistent hemorrhagic shock . emergent intubation was done for airway protection , massive transfusion protocol was initiated , and a ct angiogram was performed . it revealed type b aortic dissection with rupture and the active extravasation of blood into the esophagus , confirming the diagnosis of aef [ figure 1 ] . he underwent emergency percutaneous thoracic endovascular aortic repair with aortic stent placement [ figure 2 ] . his shock resolved hemoglobin stabilized and did not have any more episodes of bleeding thereafter . repeat egd showed a 3-cm opening in the midesophagus with ragged and irregular borders , not seen earlier egds . his hospital course was complicated by the infection of the endograft which was replaced and fortified with an omental flap and being is presently being , followed by for reconstruction surgeries . ( a ) communication and extravasation between aortia and esophagus ( blue arrow head ) in the arterial phase . ( b ) accumulation of blood in lower esophagus in venous phase ( yellow arrow head ) . ( c ) significant accumulation of blood in the stomach in the kidney delay images ( red arrow head ) . ( d ) sagittal reconstruction images shows commination ( blue arrow ) and extravasation ( yellow arrow ) of blood between aorta and esophagus endovascular graft in the thoracic aorta aorto - esophageal fistula is an abnormal anatomical communication between the aorta and esophagus . in 1818 , dubrueil described this condition for the 1 time in a french soldier who ingested a beef rib , leading to massive hematemesis . almost a century later , chiari described the triad of midthoracic pain , herald hemorrhage , and fatal hematemesis seen in these patients . the exact incidence of this condition is not known , as the vast majority of these patients die before a definitive diagnosis can be made . in the past , infections such as tuberculosis and syphilis , leading to aortitis were the common cause of this condition . in this antibiotics era , thoracic aortic aneurysm constitutes for more than half of these cases . other causes described in the literature are cancer , acid reflux disease , trauma , caustic ingestion , and esophageal biopsies . aefs are classified as primary if they are caused by the spontaneous erosion of the aortic wall into the esophagus and as secondary if they occur as a complication following aortic or esophageal surgeries . owing to the increasing number of interventions of the aorta , secondary aef is 10 times more common than primary . the herald bleeding described by chiari is only seen in half of these patients . once the bleeding starts , rapid extravasation from aorta will cause a sudden drop in blood pressure . , the blood pressure will raise again dislodging the fresh and loose clot around the aef leading to terminal bleeding . commonly used resuscitation fluids including pseudo random binary sequence lack adequate clotting factors add to the compromise of clot integrity . unlike in other structures , the lax mediastinum around the aorta and esophagus prevent autotamponade , to prevent persistent extravasation of blood . these factors can contribute to torrential bleeding , the final hematemesis as described by chiari . the risk of aortic aneurysm increases with age , with an incidence of 12.5% in elderly americans . the sensitivity of egd to identify the source of bleeding in other causes of ugib is 90% , but for aef it is < 10% . it may show pulsatile mass , bluish discoloration , or simply blood clotting in the esophagus in one - third of cases . a ct arteriogram is diagnostic in most cases , which show active extravasation of blood from the aorta to esophagus . once diagnosed , aef should be treated with emergent aortic stenting to control the bleeding . owing to contamination from the gi tract , one - quarter of stents become infected . apart from broad - spectrum antibiotics and antifungals , once the infection is controlled , the complex aortic and esophageal reconstruction is done in multiples stages . aef , once considered to be uniformly fatal , is now a treatable condition with timely intervention . aorto - esophageal fistula is a rare , but life - threatening condition presenting as ugib . a high level of suspicion is needed , as routine tests performed for ugib typically only detect one - third of cases . avoiding over - resuscitation can be helpful in preventing subsequent hemorrhages .
aorto - esophageal fistula is a rare cause of upper gastrointestinal bleeding . 
 thoracic aneurysm , the most common cause of this condition , will slowly increase over time and can erode the wall of the aorta creating a fistula and leading to torrential bleeding . 
 high clinical suspicion is required for timely diagnosis as common investigations routinely done for gastrointestinal ( gi ) bleeding , including esophagogastroduodenoscopy , fails to detect most cases . 
 the classical triad of midthoracic pain , herald bleeding and fatal hematemesis described in this condition is seen in only one - third of cases . 
 physician should be wary of this condition , especially in elderly patients with uncontrolled gi bleeding and who are also at risk of thoracic aneurysm . 
 computed tomography angiogram detects most cases and emergent endovascular repair with stents controls the initial bleeding . 
 later , both the aorta and the esophagus are repaired and reconstructed in staged procedures .