RARE GASTROBRONCHIAL FISTULA MISTAKEN FOR ASPIRATION PNEUMONIA IN A PATIENT WITH ESOPHAGEAL CANCER: A CASE REPORT

Abstract

SESSION TITLE: Medical Student/Resident Disorders of the Mediastinum Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Aspiration pneumonia in the setting of known esophageal cancer typically raises suspicion for dysphagia as the primary cause. Here, however, we present a rare case caused by a gastrobronchial fistula (GBF). This study was written according to the CARE case report guidelines [1]. CASE PRESENTATION: A 64 year old Caucasian female with stage IV esophageal cancer presented with acute nausea, vomiting and dyspnea. She had completed radiation and chemotherapy and underwent esophagogastrectomy with gastric pull through eight months prior. She presented with pulmonary sepsis and was treated with antibiotics. She then became acutely hypoxic and hypercapnic and required emergent intubation. An ETT cuff leak persisted despite radiographic confirmation of placement and appropriate cuff inflation. An urgent bronchoscopy showed bilious, projectile material in the RLL. An upper GI series – challenging given the high volume of gastric reflux – opacified the right mainstem bronchus below the carina. Concurrent bronchoscopy/endoscopy visualized a 1 cm gastric fistula at the surgical anastomosis without evidence of ulceration, infection or recurrent neoplasm, communicating with the posterior bronchus intermedius. Successful fistula closure was achieved with endoscopic OverStitch (TM). DISCUSSION: GBFs are rare, and can occur in the setting of infection, neoplasm, trauma or ulcers [2]. One clue is a persistent ETT cuff leak and a high volume of gastric contents refluxing into the ventilatory circuit. The persistence of hypercapnia despite high minute ventilation (presumably from increased physiologic dead space) should also raise suspicion for GBF [2]. GBFs are rarer than esophagobronchial fistulas. In this case, the proximity of the bronchial tree to the thoracic gastric pull through likely contributed to the GBF. A novel feature of this case was the treatment, achieved via an endoscopic OverStitch. Whereas typical treatment might involve the placement of stents on both sides of an enteropulmonic fistula, the OverStitch technique is able to create a tighter, full thickness closure without the complications of in-dwelling stents [3]. CONCLUSIONS: In patients with refractory aspiration pneumonia and an esophagogastric surgical history, consider GBF as a possible cause. Initial testing is an upper GI series followed by dual bronchoscopy and endoscopy for diagnosis and fistulotomy. Reference #1: Riley DS, Barber MS, Kienle GS, AronsonJK, et al. CARE guidelines for case reports: explanation and elaboration document. JClinEpi 2017 Sep;89:218-235. doi: 10.1016/jclinepi.2017.04.026 Reference #2: Greenberg S, Kanth N, Kanth A. A woman with cough: gastrobronchial fistula as a delayed complication of bariatric surgery. Case report and literature review. Am J Emerg Med. 2015;33(4):597.e1-597.e5972. doi:10.1016/j.ajem.2013.11.022 Reference #3: Chon SH, Toex U, Plum PS, et al. Efficacy and feasibility of OverStitch suturing of leaks in the upper gastrointestinal tract [published online ahead of print, 2019 Oct 7]. Surg Endosc. 2019;10.1007/s00464-019-07152-8. doi:10.1007/s00464-019-07152-8 DISCLOSURES: No relevant relationships by Alan Gandler, source=Web Response No relevant relationships by Eric Gold, source=Web Response No relevant relationships by Prarthna Kulandaisamy, source=Web Response