Acquired Broncho-Esophageal Fistula in a Patient with Self-Induced Vomiting

Abstract

Purpose: A broncho-esophageal fistula (BEF) may be congenital or acquired. Esophageal cancer is the most common cause of an acquired BEF. Causes include cuff-related trauma secondary to tracheal intubation, infections and ulcerations from Barrett's esophagus. Patients present with non-specific symptoms of cough, abdominal pain, hemoptysis and recurrent respiratory tract infections. Surgery is usually curative. We present a case of an acquired BEF in a man with a history of self-induced vomiting. A 66-year-old man with alcoholism presented to an outside hospital with dysphasia, odynophagia and recurrent pneumonia (PNA). Medical history was notable for dementia and self-induction of vomiting for multiple years. On admission, an esophagram showed a tight stricture at the gastro-esophageal junction with a contained posterior perforation. CT of the chest revealed perforation of the inferior esophagus with connection to the right lower lobe (RLL) of the lung. The patient was referred to our institution for further care. At our hospital, the patient was hemodynamically stable although mildly tachypneic with a productive cough. On exam, decreased breath sounds over the right lung base were auscultated. Initial blood work was normal. On hospital day two, an esophagogastroduodenoscopy showed a 3 cm wide opening at the distal esophagus exposing multiple bronchi. The fistula was too distal to close with an esophageal stent so closure of the fistula and repair of the esophageal defect was performed by cardiothoracic surgery one week later. Pathology returned negative for any malignant or infectious etiology. Post-surgical esophagram revealed no further evidence of a fistula or active leak. By hospital day 32, the patient began tolerating solids orally and was discharged back to his nursing home soon after. Per nursing home staff, the patient has denies further symptoms nor has been rehospitalized for PNA. He does continue to induce vomiting daily. The etiology of this patient's BEF is unclear, but a few possibilities may be considered. Frequent vomiting over time may have led to a BEF from gastric acid erosion of the esophageal lining with extension into the bronchial tree. Increased intrathoracic pressure with purging may also have lead to a Boerhaave's lesion with formation of a fistula as has been described. Likewise, recurrent PNA may have led to empyema formation with fistulous extension through the esophagus. In this case, all three mechanisms may have played a role. Regardless, early recognition of a patient with a BEF can facilitate diagnosis, corrective treatment and prevention of future morbidity. To our knowledge, this is the first recorded case of BEF in a patient with self-induced vomiting.