Triple Lumen Esophagus

Abstract

A 55 year-old-lady with history of HIV (CD 4+ count 268/ μL) was evaluated for a one day history of hematemesis. She had long-standing history of dysphagia and had history of G tube placement as a child. EGD on admission revealed ulcerated and friable distal esophageal mucosa. Blood was seen in the stomach and the area could not be examined well due to blood clots. Biopsy specimens from esophagus showed acute and chronic inflammation. Candida was seen however the stains for CMV, HSV I and II were negative. AFP smear and cultures were negative. An Esophagram was performed which showed collection of contrast material at aortic arch, likely secondary to contrast within a fistulous connection. There were also a few linear collections of contrast in the expected location of the gastroesophageal junction, also likely within tiny fistulous tracts. [Figure 1A].Figure 1Follow up EGD at 10 weeks showed a long mucosal bridge in the mid esophagus, giving esophagus a shape of double lumen [Figure 1B]. The distal esophagus near the GE junction separated into three lumens. [Figure 1C] One was true GE junction and other two were fistulous tracts. The gastroscope itself could not be traversed through the fistulous tracts. Retroflexion showed openings of both fistulous tracts into stomach evident from secretions coming out of fistulous tracts. [Figure 1D]. Biospy specimens from the mucosal bridge in mid esophagus showed squamous mucosa with atypia and parakeratosis. Esophagogastric fistula is a rare condition. Term double lumen esophagus has been used for esophagogastric fistulas in literature when a neo-lumen is formed in the esophagus due to fistula. Only a few cases have been reported in literature. Our patient has two esophagogastric fistulas giving rise to a triple lumen esophagus. Typically patients with EG fistulas present with symptoms of dysphagia and have history of GERD, esophageal ulcers, strictures and dilations. Esophageal Crohn's disease, carcinoma, fungal and viral infections needs to be ruled out in these patients with biopsy specimens and special staining. Treatment options include aggressive control of reflux disease and treatment of specific etiologies, which may be responsible for fistulas. Surgery remains the last option since these patients are generally poor surgical candidates due to repeated interventions and presence of inflammation. Our patient was treated with PPI BID. She has improved symptoms of dysphagia. She is scheduled for a CT scan of chest and abdomen and a repeat EGD to access for healing and repeat biopsies.