A 69-YEAR-OLD MAN WITH

GASTROINTESTINAL EXSANGUINATION

Authors: Lindsey Mills, BSN, RN, CEN, Melissa Stevens, BSN, RN, CEN, Brian J. Tollefson, MD, andMelissa Watkins, RN, Jackson, MS

Section Editor: Laura M. Criddle, PhD, RN, CEN, CCNS, FAEN

Earn Up to 8.5 CE Hours. See page 424.

A69-year-old man with suspected gastrointestinalbleeding was airlifted to our emergency departmentfrom an outlying facility. He had a history of hyper-

tension and lung and esophageal cancer (which was in remis-sion) and a distant history of occasional alcohol use. Theman had an esophageal stent placed 2 weeks prior to presen-tation. He arrived at the transferring facility with a systolicblood pressure in the 70s (mmHg). He was given 3 units ofpacked red blood cells and 2 L of normal saline solution.Upon arrival at our emergency department, the man’s bloodpressure had improved to 100/56 mmHg. He was alert andoriented and complained of moderate, cramping pain in themid-abdominal region. His stool tested positive for blood,but no gross bleeding was observed.

While preparing the patient for transport to the com-puted tomography scanner, he had 2 large bowel move-ments, the second of which was largely blood. Shortlythereafter, the patient vomited copious amounts of brightred blood, his blood pressure dropped to 58/24 mm Hg,and he became unresponsive. He was endotracheally intu-bated and an infusion of norepinephrine (Levophed) wasbegun. Immediately after intubation, an orogastric tubewas inserted, but blood continued to pour uncontrollably

from the patient’s mouth and nose. An arterial line and 2venous central lines were placed for rapid infusion of crystal-loids and blood products. During the subsequent 2 hours thepatient received a total of 9 units of packed red blood cells, 8units of fresh frozen plasma, 6 units of platelets, 2 ampules ofcalcium gluconate, and 6 L of normal saline solution. A totalof 10 L of bright red blood was suctioned from the patient’soral and nasal cavities.

The gastrointestinal service was consulted, and itwas determined that the patient was too unstable forendoscopy. The interventional radiology service was con-sulted regarding potential embolization of the bleedingvessel, but it was not possible to perform the procedureimmediately. A general surgeon also was consulted. Ulti-mately it was decided that a Minnesota esophagogastricballoon tamponade was the best available option forcontrolling the hemorrhage. The tube was placed inthe esophagus and both the proximal and distal balloonswere inflated to the recommended pressures. After inser-tion of the tube, no further oral or nasal blood wasnoted. The patient’s blood pressure quickly improvedto 133/64 mm Hg, and the norepinephrine infusionwas discontinued.

The patient was then transported to the interventionalradiology suite for visceral angiography. The Figure showshis actively bleeding aortoesophageal fistula. The patientwas taken directly to the operating room, where a 26mm × 10 cm stent was successfully placed in the aorta,with no evidence of a leak. The patient remained in criticalcondition in the intensive care unit for 5 days until hisfamily eventually made the decision to withdraw all life-sustaining support. The patient subsequently died.

An aortoesophageal fistula is a life-threatening cause ofgastrointestinal bleeding in which abnormal communica-tion between the esophagus and the aorta causes high-pres-sure aortic blood to enter the esophagus. Etiologies includethoracic aortic aneurysm, foreign body ingestion, esopha-geal malignancy, and postoperative complications.1 Ourpatient’s history of esophageal malignancy and esophagealstent placement 2 weeks earlier put him at high risk for thislife-threatening condition. Chiari’s triad describes classic

Lindsey Mills is Charge Nurse, Adult Emergency Department, University ofMississippi Medical Center, Jackson, MS.

Melissa Stevens is Staff Nurse, Adult Emergency Department, University ofMississippi Medical Center, Jackson, MS.

Brian J. Tollefson is Assistant Professor, Emergency Medicine, Adult Emer-gency Department, University of Mississippi Medical Center, Jackson, MS.

Melissa Watkins is Staff Nurse, Adult Emergency Department, University ofMississippi Medical Center, Jackson, MS.

For correspondence, write: Lindsey Mills, BSN, RN, CEN, Adult EmergencyDepartment, University of Mississippi Medical Center, 2500 N State St,Jackson, MS 39216; E-mail: lmills@nursing.umsmed.edu.

J Emerg Nurs 2011;37:363-4.

Available online 5 August 2010.

0099-1767/$36.00

Copyright © 2011 Emergency Nurses Association. Published by Elsevier Inc.All rights reserved.

doi: 10.1016/j.jen.2010.07.002

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findings in the patient with aortoesophageal fistula: (1)mid-thoracic pain, (2) sentinel arterial bleeding, and (3)massive hemorrhage and exsanguination after a symptom-free interval.1 A 30-year review of all reported cases of aor-toesophageal fistula identified mid-thoracic pain in 59%,dysphagia in 45%, and a sentinel hemorrhage in 65% ofcases. Only 45% of patients in the review met all 3 criteriaof Chiari’s triad.1 Our patient exhibited abdominal pain,sentinel hemorrhage, and exsanguination after a symp-tom-free interval.

Given the amount of blood loss associated with aortoe-sophageal fistula, it is obvious that volume replacementtherapy is imperative. Correction of coagulopathies andelectrolyte abnormalities also is indicated. Esophagogastricballoon tube insertion is recommended to control bleeding,and immediate endovascular stenting is required to repairthe aorta. Stenting can be either a permanent solution ora bridge to definitive therapy with vascular grafts.2 In ourpatient’s case, direct pressure was applied to the bleedingfistula with use of a Minnesota tube. This technique pro-vided temporary control of the hemorrhage until the patientcould be transported to undergo interventional radiology.

Nurses with many years of experience will recall eso-phagogastric tamponade tubes, which were frequently used2 decades ago to control bleeding esophageal varices. Withthe advent of better medical, endoscopic, and surgicaltherapies to prevent and manage gastrointestinal bleeding,these tubes have largely become a thing of the past. The3-lumen Sengstaken-Blakemore tube has an esophageallumen that inflates a long, sausage-shaped balloon designedto fill the esophagus and tamponade varices. A secondlumen inflates a large gastric balloon. The inflated gastricballoon anchors the tube in the stomach and prevents dis-placement of the esophageal balloon into the upper airwaywhen traction is applied. The third lumen is for gastric suc-tioning. A Minnesota tube is a later modification of theSengstaken-Blakemore tube. It provides a fourth port, situ-ated in the esophagus, for esophageal suctioning, whicheliminates the need for Salem sump tube placement inthe esophagus.3 Continuous low suction must be availablefor both the gastric and esophageal ports. A manometer isrequired to regulate pressure in the balloons. A 60-mLsyringe is used to inflate the balloons.

This case emphasizes the importance of early recogni-tion and emergent intervention in the patient suspected ofhaving an aortoesophageal fistula. Although it is rarely usedtoday, theMinnesota tube can be lifesaving in these patients.Emergency nurses need to be aware of these tubes and have abasic knowledge of how they are inserted, along with post-insertion care. Immediate surgical intervention is not alwaysan option, and a Minnesota tube can be lifesaving in apatient with intractable esophageal bleeding.

REFERENCES1. Heckstall RL, Hollander JE. Aortoesophageal fistula: recognition and

diagnosis in the emergency department. Ann Emerg Med. 1998;32:502-5.

2. Zuber-Jerger I, Hempel U, Rockmann F, Klebl F. Temporary stentplacement in 2 cases of aortoesophageal fistula. Gastrointest Endosc.2008;68:599-602.

3. Greenwald B. The Minnesota tube: its use and care in bleeding esopha-geal and gastric varices. Gastroenterol Nurs. 2003;27:212-7.

This section features actual emergency situations with particular edu-cational value for the emergency nurse. Contributions (3 to 5 typed,double-spaced pages) should include a case summary focused on theemergency care phase, accompanied by pertinent case commentary.Submissions to this column are encouraged and may be sent toLaura M. Criddle, PhD, RN, CEN, CCNS, FAENhttp://ees.elsevier.com/jen

FIGURE

Visceral angiography demonstrating an aortoesophageal fistula and a Minnesotatube balloon that has been inflated.

CASE REVIEW/Mills et al

364 JOURNAL OF EMERGENCY NURSING VOLUME 37 • ISSUE 4 July 2011