S3551 Unique Communication: A Case Report of Acquired Esophageal Pulmonary Fistula

Abstract

Introduction: Esophageal respiratory fistula is an abnormal communication between the esophagus and the respiratory system. We present a case of esophageal pulmonary fistula in a patient with a history of broncho-esophageal fistula treated with esophageal stent placement. Case Description/Methods: A 53-year-old homeless male with a history of alcoholism, perforated peptic ulcer status post antrectomy with type II billroth reconstruction, pseudodiverticulum of the distal third of esophagus, broncho-esophageal fistula and HIV presented with dyspnea and productive cough for 2 weeks. He reported dysphagia to liquids and unintentional weight loss. Review of medical records revealed admission for pneumonia 3 years ago with workup suggestive of broncho-esophageal fistula followed by endoscopic fully covered self-expandable metallic stent placement with removal after 2 months to reassess fistula. Repeat Computed tomography (CT) chest showed resolution of fistula. However, he lost the follow up afterwards. On this admission, the patient appeared disheveled with crackles on the right side. CT chest without contrast showed debris filling the middle and lower esophagus, right pleural effusion with multiple areas of gas. CT chest with contrast showed irregular and debris distended esophagus with locules of air extending from the region of the esophagus into the mediastinum and right lower lung parenchyma. Fluoroscopy esophagram documented contrast extravasation from the right side of the distal esophagus into the right lower lobe parenchyma compatible with esophageal pulmonary fistula. An esophageal stent placement was planned but was declined by the patient. Discussion: Non-malignant etiologies of acquired esophageal respiratory fistula include post-operative, intubation associated, history of tracheal and esophageal stents, blunt trauma and pseudodiverticulum of the esophagus. In our case, etiologies of broncho-esophageal fistula and then esophageal-pulmonary fistula were multifactorial which include esophagitis due to history of chronic gastroesophageal reflux disease (GERD), history of antral gastrectomy, history of stent placement for a broncho esophageal fistula and pseudodiverticulum of distal third of the esophagus. Given the significant morbidity and mortality associated with a missed diagnosis of esophageal pulmonary fistula, early diagnosis with prompt treatment with an endoscopically placed covered stent and close follow up is crucial.Figure 1.: The distal one third of esophagus is markedly dilated and irregular in contour. Contrast is seen extravasating from the right side of the esophagus into the right lower lobe parenchyma consistent with esophageal pulmonary fistula.