A40-year-old non-smoking woman was referred to the outpatient clinic because of an increasing dry cough and recurrent lower respiratory tract infections over a 10-year period. The patient was diagnosed with Crohn's disease in 1979. The disease was initially confined to the large intestine but despite intensive medical treatment she required a total colectomy with ileostomy formation and, 2 years later, she was treated with a proctectomy. In 1996 she developed a problematic nocturnal cough with associated early morning sputum expectoration and intermittent wheeze, which did not respond to a trial of inhaled bronchodilators. In 1998 she was admitted to hospital with a severe left lower lobe pneumonia, which responded well to oral ampicillin and erythromycin. She subsequently complained of coughing during meals but denied any indigestion or heartburn. There was no background of atopy, or history of asthma or rhinitis. Systemic examination was unremarkable. Review of previous chest radiographs revealed recurrent changes of left lower lobe consolidation (Figure 1). Initial investigations including spirometry, biochemical screen, full blood count, immunoglobulin subclasses, aspergillus precipitins and sputum culture for bacteriology and tuberculosis were normal. An initial diagnosis of minor localized bronchiectasis was made and the patient was referred to the physiotherapy department for postural drainage. Because of the persistent nocturnal cough, gastro-oesophageal reflux with aspiration was considered and a barium swallow arranged. The barium swallow (Figure 2) demonstrated a fistula between the oesophagus and the left lower lobe bronchus arising approximately 10 cm from the gastro-oesophageal junction. Multiple ‘rose-thorn’ ulcers were also seen in the mid- and lower oesophagus. The barium, which passed into the left lower bronchial tree, did not demonstrate bronchiectatic changes (Figure 3). This was confirmed with high resolution computer tomography, which revealed some localized fibrosis in the left lower lobe, but did not show any evidence of bronchiectasis. At endoscopy a 4 mm defect was seen at 32 cm, which was biopsied. The histology showed hyperplastic squamous epithelium with inflammatory changes but no features of malignancy. The patient gained considerable relief of her symptoms from the use of antacid suspensions and propping the head of her bed at night. She discontinued the proton pump inhibitor owing to side effects, but has remained relatively symptom free during the last year. She has consistently refused enteral feeding and surgical intervention despite being aware of the potential risks of complications from the oesophago-bronchial fistula.