925: ACUTE RESPIRATORY FAILURE WITH PNEUMOTHORAX DUE TO ESOPHAGOPLEURAL FISTULA AND ESOPHAGEAL CARCINOMA

Abstract

Introduction: Esophagopleural (EPF) is a rare but serious condition that may occur secondary to esophageal instrumentation, malignancy, or as a complication following surgical thoracic procedures. The unfamiliarity of this condition, along with non-specific clinical presentations and elusive imaging makes it a diagnostic challenge. We present an interesting case of EPF causing acute respiratory failure. Description: A 58-year-old female with 40-pack-year smoking history was diagnosed with esophageal carcinoma and presented with dysphagia, shortness of breath, and hematemesis. On arrival, the patient was hypoxic and hypercarbic (PCO2 60mmHg) and in frank respiratory distress requiring intubation and admission to the ICU. Chest x-ray showed a large right pneumothorax and left lung consolidation. A right chest tube was placed, and broad-spectrum antibiotics were started. CT chest with oral contrast revealed contrast extravasation into the bilateral mainstem bronchi, and an esophageal bronchial fistulous communication between the esophageal mass and right pleural space. Esophagogastroduodenoscopy was performed with the placement of an esophageal metallic stent. 2 days later, the patient was extubated to nasal cannula and the chest tube was subsequently removed. Discussion: EPF is an uncommon condition despite the proximity of the trachea and esophagus. Anatomically, the esophagus is in direct contact with the pleura for a considerable distance on the right side, whereas on the left side, the aorta lies in between the esophagus and the pleura, except for a short distance just above the diaphragm. Thus, processes in the esophagus can spread more easily into the right side of the pleura rather than the left as in our patient. In patients with esophageal cancer, the incidence of EPF is 5-15%. Radiological signs of EPF depend upon the site, duration, and severity of perforation; and more importantly, the integrity of the pleura. Esophagographic studies may confirm the presence of EPF, although rarely indicated in the era of CT. Therapeutic strategies for EPF include micro-invasive treatment guided by endoscopy, stent implantation and surgery. Stent placement has a high success rate and is the most used modality given the high morbidity and mortality associated with surgery.