Ruptured Thoracic Aneurysm Causing Hematemesis

We present a 72-year-old man who was admitted to the gastroenterology ward after a frank hematemesis. He had been seen 5 days prior in clinic with dysphagia, anorexia, weight loss, and pain in the epigastrium and thoracic spine. At admission he was stable with normotensive blood pressure, not tachycardic, and had hemoglobin 12.5 g/dL. On examination there was epigastric tenderness, but the abdomen was soft with normal bowel sounds and there were no significant findings on rectal examination. After intravenous fluid resuscitation, his hemoglobin was 9.1 g/dL. The Blatchford and pre-endoscopy Rockall scores were calculated as 6 and 4, respectively. Esophagogastroduodenoscopy (EGD) revealed a bulging of the posterior wall in the mid-esophagus, with a small tear that was thought to be a Mallory-Weiss tear with underlying intramural hematoma (Figure 1). Computed tomography (CT) scan of the thorax showed the presence of a mid descending thoracic aneurysm (7.2 x 5.2 x 5.7 cm) that was ruptured, inflamed, and compressing the esophagus (Figure 2). Shortly after the CT scan, the patient deteriorated with worsening hypotension, tachycardia, and back pain. After urgent cardiothoracic and vascular surgery consult, the patient was transferred to a specialist center for a thoracic endovascular aortic repair.