Gastrointestinal: Tuberculous bronchoesophageal fistula

Abstract

What abnormalities are shown on the barium swallow radiograph shown in Figure 1? One obvious abnormality is the presence of barium in the trachea and right main bronchus. In addition, there is a fistula between the lower lobe bronchus and the midportion of the esophagus (arrow). There are no obvious radiological features of cancer of the esophagus or lung. At esophagoscopy, the esophagus was deformed in the region of the fistula and biopsies from the mucosa around the esophageal orifice revealed chronic inflammation with granulomas and Langerhan’s giant cells (H&E ×10; Fig. 2). The diagnosis was that of a bronchoesophageal fistula caused by tuberculosis. The patient was a 20-year-old woman who was investigated because of a non-productive cough and low-grade fever for 2 months, with the subsequent development of paroxysms of coughing after drinking fluids. She was treated with nasogastric feeding and antituberculous drugs, and the fistula closed after 6 weeks. A communication between the esophagus and the tracheobronchial system is an unusual clinical disorder that can be either congenital or acquired. Congenital fistulas are usually diagnosed in the neonatal period because of respiratory distress and cyanosis during feeding. However, rare examples of congenital fistulas have been described in adults who are investigated because of recurrent pneumonia or bronchiectasis. The most common cause of acquired fistulas is an advanced cancer that arises from the esophagus or lung. Most of these fistulas involve a communication between the upper esophagus and the trachea. Non-malignant causes of fistulas are rare but include infections such as tuberculosis and syphilis, mediastinal abscesses, chest trauma and complications of prolonged intubation. Possible mechanisms for the development of tuberculous fistulas include rupture of caseonecrotic subcarinal lymph nodes into the esophagus and respiratory tract, erosion of primary tracheal ulcers into the esophagus or the development of traction diverticula between the respiratory tree and the esophagus. In contrast to malignant disease, tuberculous fistulas usually involve the right or left main bronchus rather than the trachea. Closure of tuberculous fistulas can usually be achieved with conservative measures as described above. However, surgical repair may be required for large fistulas complicated by recurrent pneumonia.