Complete history: A 12-year-old, mixed breed male dog presented with a 6-day history of gagging, hematemesis and anorexia. Physical examination upon arrival was unremarkable.

Complete diagnostic investigation and therapy: Blood work revealed leukocytosis without anemia and normal platelet count. Thoracic radiographs demonstrated the presence of an esophageal foreign-body (EFB) with osseous opacity at the level of the heart base. Subsequently esophagoscopy was performed under general anesthesia. A triangular-shaped, osseous EFB was visualized and successfully removed by a grasping forceps and basket. Following its removal, a deep, non-bleeding, presumably non-perforated, esophageal ulcer was noted.

Outcome: While recovering from anesthesia, the dog’s condition acutely deteriorated, becoming laterally recumbent and nonresponsive, tachycardic, with weak femoral pulses, white-pale mucous membranes, hypothermic and without spontaneous respiration. Blood tests revealed severe anemia. A presumptive diagnosis of hypovolemic shock was considered, likely secondary to acute, post-procedural bleeding. The dog was intubated and maintained on mechanical ventilation until return of spontaneous respiration. Medical management included rapid blood transfusion (15 ml/kg, canine pRBC), crystalloid fluid-therapy and tranexamic acid. Esophagoscopy was repeated and corroborated the clinical suspicion of severe esophageal hemorrhage with copious amounts of blood and blood clots in the esophagus and stomach. Despite initial stabilization, several hours post-procedurally, the dog suffered cardiac arrest and CPR was unsuccessful. Post-mortem examination revealed two, bilateral symmetrical, partially perforating ulcers in the esophagus, corresponding to the location of the entrapped EFB. Examination of the thoracic aorta revealed a rough area of endothelial thickening with a central transmural defect directly aligned with the right esophageal ulcer, corresponding with aortic-esophageal fistula (AEF). The stomach, small intestine and colon contained fresh blood and black stool, respectively. There were no hemorrhagic effusions within the abdominal or thoracic cavities.

Discussion: This case report describes a rare, fatal, immediate, post-procedural complication following EFB removal. An AEF should be considered in any patient with severe post-procedural bleeding, since timely surgical intervention is mandatory to prevent fatal exsanguination. Furthermore, a history of sentinel bleeding in a dog with esophageal foreign body, including hematemesis or melena, as described herein, should raise the clinical suspicion of an AEF, and dictate case management accordingly.