The "herald bleed
" is a common presentation of AEF that needs to be recognized early in order to prevent a later catastrophic hemorrhage.
The literature describes a wide range of complications, including aortooesophageal fistula, [9,10] which commonly presents as a herald bleed
followed by a fatal upper gastrointestinal bleed, bilateral vocal cord paralysis,  tracheo-oesophageal fistula,  commonly presenting as aspiration pneumonia, oesophageal necrosis and oesophageal stenosis.
The majority of these patients presented with a herald bleed
Aortoesophageal fistula presents with a Chiari's triad of chest pain, a symptom-free interval, and a transient, self-limiting "herald bleed
." (4) When untreated, this series of symptoms precedes a fatal hemorrhage.
Use of plastic tracheostomy tubes, low pressure-high volume cuffs, tube placement at second or third tracheal rings and flexed positioning of neck may prevent formation of TIF.4 A 'sentinel' or 'herald bleed
' is an early warning sign which is reported in more than 50% of patients who developed subsequent massive delayed haemorrhage.5 A sentinel bleed renders the need of close monitoring and immediate medical attention.
The first bleedings are known as "herald bleeds
" and they are usually mild and self-limited.