Esophageal Bronchopleural Fistula (EBF) Arising From Barrett’s Esophagus Without Dysplasia: A Rare but Life-Threatening Complication

Abstract

Introduction: An EBF is very uncommon and it is formed secondary to instrumentation, malignancy, surgery or post-pneumectomy complication. Barrett’s esophagus refers to the replacement of normal squamous epithelium by columnar epithelia caused by chronic gastric acidic secretions. We report an unusual case of a benign EBF arising from Barrett’s esophagus without dysplasia. A 63-year-old female with PMH of HTN, CKD stage 4, COPD came in with complaints of knee pain, vomiting, fever and chills. During the work-up for septic arthritis, a mild pneumonia was noted and treated as community-acquired pneumonia. After a week of IV antibiotics, the patient continued to have a productive cough with poor oral intake and cachexia. Review of old CT chest scans showed chronic distal esophageal thickening and right lower lobe atelectasis, therefore a chronic aspiration pneumonia was suspected. A repeated CT Chest showed extensive bronchiectatic changes of the lower right lobe and an abnormal distal esophagus concerning for a spontaneous esophageal perforation. Differential diagnosis included iatrogenic perforation, malignancy, and Boerhaave’s Syndrome. Upper gastrointestinal series with gastrografin showed leakage of contrast material from esophagus that accumulated inside the thoracic cavity. The patient was kept strict nothing by mouth and a bronchoscopy was performed to evaluate for possible tracheo-esophageal fistula, but did not show any pathology. Patient continued to have increasing cough and secretions with a high suspicion of a connection between the thoracic cavity and the esophagus. An EGD was performed which showed a large subepithelial mass extending from mid-esophagus to the gastroesophageal junction with superficial ulcerations along with a large fistulous tract opening at the right posterior esophageal wall. Biopsies of the subepithelial mass revealed granulation tissue with extensive intestinal metaplasia consistent with Barrett’s esophagus without dysplasia, same as present with prior EGD. There was evidence of foreign body pigmentation within the Barrett’s esophageal tissue suggestive of pill esophagitis from oral iron. This patient may also have undiagnosed esophageal dysmotility. Patient was a poor surgical candidate and a surgical jejunostomy feeding tube was placed for better nutrition supplementation. Patient underwent an esophageal self-expandable metallic stenting and was managed conservatively. To our knowledge, this is the third reported case of acquired benign EBF associated with Barrett’s esophagus. Albeit this is rare, extensive and friable Barrett’s esophagus in the setting of esophageal dysmotility-induced stasis is a perfect setup for a pill-induced benign EBF.