Bronchoesophageal Fistula in a Female With History of Crohnʼs Disease and Small Cell Lung Cancer

Abstract

Background: Airway-esophageal fistulas are serious complications of lung or esophageal tumors. They arise either as a result of progression of lung or esophageal malignancies or manifest as a complication of chemoradiation therapy. They can also be a rare complication of Crohn's disease of the esophagus. There is limited literature on bronchoesophageal fistulas in lung cancer patients with Crohn's disease. This is a description of a case involving a middle aged female with history of Crohn's disease diagnosed with small cell lung cancer presenting with dysphagia who was found to have a bronchoesophageal fistula. Case Description: This is a 47 year old female who was diagnosed to have stricturing and fistulizing Crohn's disease 15 years ago, treated in the past with mesalamine (Asacol), prednisone, azathioprine, and infliximab on no current maintenance medications for five years who presents to clinic in December 2014 with dysphagia, nausea and vomiting. Imaging revealed a large mass in the left lower lobe abutting the mediastinum and the carina which was confirmed to be small cell lung cancer by bronchoscopy. She completed 4 cycles of cisplatin and etoposide following which she presented to clinic in May 2015 with fever, tachycardia, and hypotension as well as nausea, vomiting, cough and dysphagia. An upper endoscopy was performed revealing a large esophageal ulcer and bronchoesophageal fistula. She subsequently underwent esophageal stenting with a covered esophageal stent and open gastrostomy tube placement. Discussion: We investigate this case of a bronchoesophageal fistula in a patient with prior history of Crohn's disease and small cell lung cancer. Airway-esophageal fistulas are a known complication of tumor growth or recurrence in lung or esophageal tumors. They can also arise secondary to chemotherapy or radiation. Rarer causes include Crohn's disease, laser therapies, biologics like Bevacizumab and pressure necrosis from esophageal stents. Mean survival is 1-6 weeks. Common causes of death are respiratory infections and malnutrition. Esophageal stenting relieved symptoms in 80% of patients, was more effective (p=0.001) and led to better survival (p=0.07) and better quality of life (p=0.01) in multivariate analyses as compared to bypass or resections. Self expanding metallic stents are preferred over silicone or plastic stents.Figure 1Figure 2Figure 3