Arterioesophageal fistula secondary to rupture of an aberrant right subclavian artery aneurysm: a rare differential diagnosis in upper gastrointestinal bleeding.

A 78-year-old man was admitted to hospital due to massive, bright red hematemesis. As he was hemodynamically unstable, vigorous resuscitation procedures were initiated. Esophagogastroduodenoscopy (EGD) showed a large Mallory– Weiss lesion and a necrotic polypoid lesion about 4 cm below the upper esophageal sphincter (Figure 1). No active bleeding was visible. Six hours later, there was again an abrupt onset of torrential, bright red hematemesis. The bleeding did not stop before the insertion of a Sengstaken–Blakemore tube into the upper esophagus. Angiography of the thoracic aorta revealed a ruptured aneurysm in an aberrant right subclavian artery (ARSA). Because of the expected high mortality of a surgical intervention in this situation, all treatment efforts were withdrawn, and the patient died 14 h after admission. The autopsy showed a ruptured aneurysm of an ARSA with an arterioesophageal fistula (Figure 2).