Malignancy of the Esophagus, with Bronchial Fistula

Abstract

Erosion of the trachea or a bronchus, with the formation of a fistulous tract, is not common; however, it occurred in the two cases herein reported. The picture is characteristic and, once seen, can hardly be misinterpreted. The ingested barium mixture (barium mixture is spoken of because these fistulæ were discovered during the course of a routine gastro-intestinal examination) is seen to leave the esophagus at the point of communication and to enter the trachea or a bronchus. A severe dyspneic and coughing attack follows immediately. The barium is seen in the bronchi both fluoroscopically and on the plates. Of course, in the presence of a known esophagobronchial fistula, the condition is best studied by means of iodized oil. Case 1. Colored male, aged 49, was admitted on Sept. 25, 1931, complaining of inability to swallow without vomiting. The family history was negative. He admitted pleurisy, syphilis, and several attacks of neisserian infection, having received intensive treatment for the latter two conditions. Although the patient attributed his present illness to his having swallowed a fish bone four weeks prior to his admission, he admitted having been treated at another hospital for six months in 1929 and again for several weeks during 1931 for pains in the epigastrium which migrated to the right hypochondrium. For the past few months he had gradually lost weight and had suffered with anorexia and gastric upsets. Violent attacks of emesis accompanied by expectoration of blood, pus, and mucus had followed every attempt to swallow, even water, for six days before he sought hospitalization. Physical examination revealed a markedly emaciated adult male lying uncomfortably in left lateral decubitus. There was slight anemia of the mucous membrane. Vocal fremitus was increased over the lower chest. The breath sounds were harshly bronchial in character and whispering pectoriloquy was heard over the left lower lobe. There were no tender areas or palpable masses in the abdomen, but there was an exquisitely tender spot in the back, at the level of the twelfth thoracic vertebra. The cervical, axillary, inguinal, and epitrochlear lymph nodes were enlarged. There was extreme clubbing of all fingers. The Wassermann reaction was 2+; blood pressure 128∕92; red blood count, 3,200,000; white blood count, 6,100; coagulation time, 4.5 minutes; hemoglobin, 60 per cent; urinalysis disclosed nothing of significance. A roentgenogram of the chest revealed a marked increase in the peribronchial markings of both lungs, extending well into the periphery and assuming somewhat of a honeycomb formation, a condition which appeared highly suggestive of bronchiectasis. A barium meal was administered and the patient examined under the fluoroscope.