A Rare Cause of Chronic Post-prandial and Recumbent Cough: Gastro-pulmonary Fistula Post Oesophagectomy

Abstract

We present a case of 75 years old male who underwent oesophagectomy for T3N2 adenocarcinoma. He developed post-op anastomotic leak requiring further surgery and subsequent covered oesophageal stent insertion, which was removed 4 months later. He required multiple OGDs and balloon dilatation for anastomotic stricture. 8 months post-op, an OGD showed non-malignant peptic ulceration of upper stomach. This healed subsequently. He then developed recumbent cough and was treated with multiple courses of antibiotics for x-ray proven right basal pneumonia. He improved clinically, however he continued to have cough which particularly comes when he lies down or after his meals. Repeat OGD showed a rare appearance of a gastro-pulmonary fistula as a cause for his symptoms. This was confirmed on CT. The biopsies were negative for malignancy. He was discussed in MDT and was seen by upper GI surgeons who are managing him conservatively due to his comorbidities. Our patient presented with 2 month history of cough after meals and on lying flat. He denied any significant reflux symptoms. He was given repeated courses of antibiotics by GP for chest infection which temporarily improved his symptoms. Past medical history includes myocardial infarction, protein C deficiency, recurrent DVTs and pulmonary emboli, IVC filter in situ. He was a non-smoker and drank alcohol only on occasions. His investigation consisted of, Blood tests showed mild leucocytosis, normocytic anaemia, raised CRP. CXR showed right basal consolidation. OGD showed fistulous connection between proximal stomach and lungs, the gastropulmonary fistula (Figure 1). A CT scan showed fistulous connection of stomach with right lung, right basal consolidation and effusion (Figure 2 & 3).Figure 1