Massive Upper Gastrointestinal Bleeding From a Mediastinal Tuberculous Esophageal Fistula

Upper gastrointestinal bleeding (UGIB) is a common medical emergency, most often caused by peptic ulcer disease, variceal rupture, or severe erosive mucosal injury. However, rare etiologies like vascular malformations or infectious processes, including tuberculosis, may also result in severe and life-threatening hemorrhage. Mediastinal tuberculosis with esophageal involvement is an exceptionally rare cause of UGIB. We report a case of a 43-year-old man admitted for massive hematemesis and hemodynamic instability. Endoscopy revealed a large ulcer in the mid-esophagus with active bleeding. Endoscopic ultrasound and contrast-enhanced CT demonstrated a complex esophago-mediastinal lesion with fistulous communication and a pseudoaneurysm of the right bronchial artery. Despite multiple non-diagnostic endoscopic and surgical biopsies, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) identified necrotizing granulomatous inflammation consistent with tuberculosis. Transarterial embolization was performed successfully to control bleeding, followed by initiation of standard anti-tuberculosis therapy. The patient's clinical and radiological outcomes were favorable over follow-up. Mediastinal tuberculosis with esophageal extension is a rare but important differential diagnosis in patients presenting with unexplained UGIB. This case highlights the diagnostic value of EBUS-TBNA in identifying deep mediastinal tuberculosis when conventional biopsies are inconclusive and the role of transarterial embolization as an effective hemostatic intervention. Early multidisciplinary management is essential to ensure both etiologic treatment and prevention of recurrence.