Acquired bronchoesophageal fistula

Unmasking the Invisible: A Case Study of Aspiration Pneumonia Unveiling a Bronchoesophageal Fistula

Bronchoesophageal fistula (BEF) is a rare, yet clinically significant, condition characterized by an abnormal connection between the bronchial tree and the esophagus. We present the case of a 25-year-old female who initially presented with symptoms of aspiration pneumonitis and was subsequently diagnosed with BEF, attributed to poorly differentiated squamous cell carcinoma. Despite initial attempts at palliative intervention through esophageal stent placement, persistent symptoms prompted further investigation, revealing the underlying malignancy. This case underscores the diagnostic challenges associated with BEF, particularly when malignancy is involved, and emphasizes the importance of a multidisciplinary approach in optimizing patient outcomes. Early recognition, thorough evaluation, and comprehensive oncological management are essential in addressing the clinical complexities posed by BEF. Further research is warranted to better understand the pathophysiology and optimal management strategies for this rare but clinically significant condition.

A Successful Treatment of Broncho-Esophageal Fistula with Esophageal Stenting Using Direct Endoscopic Visualization

Broncho-esophageal fistula (BEF) is a severe yet relatively rare connection between the bronchus and esophagus usually caused by esophageal and pulmonary malignancies. We present a case report of a 49-year-old man diagnosed with terminal lung carcinoma who developed a BEF. The thoracic computed tomography scan detected a mass in the left bronchi that partially covers and disrupts the bronchial contour in certain regions and extends to the esophageal wall. After thoroughly evaluating alternative treatment approaches, we opt for the stenting procedure due to the advanced stage of the tumor and the significantly diminished quality of life. The treatment involves the use of a partially covered metal stent that is known to exhibit lower potential to migrate. The treatment is highly successful, resulting in a significant enhancement of the patient's quality of life, a lengthening in his survival, and the ability to pursue additional palliative treatment options. In contrast to the typical prosthesis implantation, our procedure uses a direct endoscopic visualization for the proximal deployment of a partially covered stent, offering a cost-effective and radiation-free alternative that can be particularly beneficial for BEF patients in facilities without radiology services.

Unexpected Presentation of Tracheoesophageal Fistula During Intubation in a Pediatric Patient

Tracheoesophageal fistula (TEF) is an abnormal connection between the trachea and esophagus. This report presents a rare case of a pediatric patient who developed a TEF due to battery ingestion, which was diagnosed during intubation and resulted in cardiac arrest. A 4-year-old child with a two-year history of battery ingestion presented with severe dehydration, weight loss, and recurrent respiratory tract infections. Chest X-ray revealed a radiopaque foreign body in the esophagus. During general anesthesia for central venous line insertion and after endotracheal intubation, some difficulties in ventilation occurred, characterized by the inability to reach tidal volume, absence of capnography, and stomach distention which led to hypoxia and ultimately to cardiac arrest. Prompt resuscitation (CPR) was initiated, and selective right bronchial intubation during CPR improved the patient's condition. Subsequent bronchofibroscopy performed in the ICU confirmed the TEF, which was surgically corrected during the hospital stay. TEF poses challenges in anesthesia and airway management, particularly when positive pressure ventilation is used. In this case, the TEF was diagnosed during intubation, highlighting the critical role of clinical expertise and prompt intervention in managing this unexpected pediatric critical event.

A Rare Case of Conservative Management of Multiple Aerodigestive Fistulas in a Patient

Acquired aerodigestive fistulas include tracheoesophageal fistulas (TEF) and bronchoesophageal fistulas (BEF). Common causes of acquired fistulas are usually malignant in origin. Tubercular tracheoesophageal fistula and bronchoesophageal fistula are rare. The limited availability of literature often presents a challenge in the treatment of tubercular TEF. We present the case of a 47-year-old woman who presented with complaints of progressive dysphagia and epigastric pain. Preliminary investigation showed raised erythrocyte sedimentation rate (ESR) of 65 mm/h and further evaluation by esophagogastroduodenoscopy for dysphagia revealed multiple ulcerated lesions in the esophagus, computed tomography (CT) revealed the presence of tracheoesophageal and bronchoesophageal fistulas with lung consolidation, and histological examination revealed granulomatous inflammation. The symptoms were managed conservatively with anti-tubercular medicine alone and showed good response.

A Case of Esophago-Respiratory Fistula due to Inhalation Smoke Injury Diagnosed by Upper Endoscopy

Esophago-respiratory fistula (ERF) refers to the formation of a pathological connection between the esophagus and respiratory tract. Acquired ERF is a rare but life-threatening diagnosis in adults. We describe a 79-year-old male who was admitted with an inhalation smoke injury. He was diagnosed with ERF by endoscopic visualization and sampling of the hyaline cartilage within the wall of the esophagus. Percutaneous endoscopic gastrostomy placement and conservative measures were effective in the management of ERF.

Cardiac arrest due to massive aspiration from a broncho-esophageal fistula: A case report

BACKGROUND

Tracheo and broncho esophageal fistulas and their potential complications in adults are seldom encountered in clinical practice but carries a significant morbidity and mortality.

CASE SUMMARY

We present a case of a 39-year-old otherwise healthy man who presented to our hospital after ingestion of drain cleaner substance during a suicidal attempt. He unexpectedly suffered from cardiac arrest during his stay in the intensive care unit. The patient had developed extensive segmental trachea-broncho-esophageal fistulous tracks that led to a sudden and significant aspiration event of gastric and duodenal contents with subsequent cardiopulmonary arrest. Endoscopic evaluation of extension of fistulous track proved a slow and delayed progression of disease despite initial management with esophageal stenting for his caustic injury.

CONCLUSION

The aim of this case presentation is to share with the reader the dire natural history of trachea-broncho-esophageal fistulas and its delayed progression. We aim to illustrate pitfalls in the endoscopic examination and provide further awareness on critical care monitoring and management strategies to reduce its morbidity and mortality.

Positron Emission Tomography/Computed Tomography Alert Finding in an Esophageal Cancer Patient

Emergency pathologies often accompany malignancies. We herein report a case of pulmonary abscess in a patient with esophageal cancer which was depicted during the F-18-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) staging study. The patient's history of recent dilatation of the cancer stenosis in adjunct to the previous CT lung imaging, which was normal, made evident the diagnosis of the pulmonary abscess due to the perforation of the esophageal neoplasm. This life-threatening condition was promptly referred and successfully managed.

Giant hiatus hernia presenting as a chronic cough masking a sinister diagnosis

We present a case of an 82-year-old gentleman with an 18-month history of productive cough. Urgent CT scan of the thorax revealed type 1 hiatus hernia (HH). The patient was managed conservatively with lifestyle modifications to help his reflux symptomology. The patient subsequently presented with acute shortness of breath and vomiting. Repeat CT scan reported a giant incarcerated HH (15 cm). Endoscopy revealed an incidental finding of a 3 cm polypoid lesion in the oesophagus at the level of the carina and histology of biopsies reported an invasive adenocarcinoma. During admission, the patient unfortunately had a hospital acquired infection and cardiac complications which prevented surgical intervention. Patients with suspected HH should be investigated thoroughly with imaging studies including chest X-ray, CT or MRI alongside oesophageal manometry and gastroscopy. Endoscopic evaluation is particularly important as these patients are at higher risk of Barrett's oesophagus and invasive malignancy.

Esophageal pulmonary fistula - a rare complication of radiation therapy: a case report

Background

Esophageal respiratory fistulae are abnormal communications between the esophagus and the respiratory system. They are either congenital or acquired. Most acquired esophageal respiratory fistulae are of the esophageal tracheal and esophageal bronchial type and are caused by infections or malignant neoplasms, whereas esophageal pulmonary fistulae are rare.

Case presentation

We report a case of a 72-year-old Caucasian man with squamous cell carcinoma of the lung presenting with abrupt-onset dyspnea during localized mediastinal radiotherapy. His laboratory test results suggested major respiratory infection. A chest x-ray revealed left apical lung radiopacity along with excavated lesions, consistent with secondary tumor infection. No clinical improvement was observed despite antibiotic treatment. A contrast-enhanced computed tomographic scan of the chest confirmed persistent lung infection with unfavorable progression and air in the mediastinum; the latter suggested a fistula from the upper third of the esophagus to the upper left pulmonary lobe. Videofluoroscopy confirmed the diagnosis of an acquired esophageal pulmonary fistula. The patient underwent endoscopy, and an esophageal self-expandable metallic stent was deployed.

Conclusions

Esophageal pulmonary fistulae must be suspected whenever patients undergoing local mediastinal radiotherapy present with acute pulmonary complications, particularly pneumonia resistant to antibiotic treatment. Esophageal pulmonary fistulae are diagnosed by means of radiological imaging. Because esophageal respiratory fistulae are acute life-threatening conditions, prompt treatment with an endoscopically placed covered stent proves vital.

Bronchoesophageal fistula: a rare complication of aortic endograft infection

Endovascular aortic aneurysm repair is an increasingly common approach for aortic aneurysm repair. Infection of the prosthetic is a rare, but devastating complication which may result in the well-known aortoenteric or aortobronchial fistulae. Bronchoesophageal fistula resulting from an infected aortic endograft has not yet been reported in the literature. Early recognition of the symptoms and prompt imaging confirmation are essential for treating an otherwise highly morbid diagnosis.

Tuberculosis presenting as broncho-oesophageal fistula in a young healthy man

A 21-year-old Saudi man presented with a history of dysphagia and choking. CT scan of the chest showed clear evidence of chronic recurrent aspiration pneumonia in the left lung. It also showed a fistula connecting the left main bronchus to the oesophagus. Endoscopy showed clear opening on the oesophageal side. Bronchoscopy also confirmed the presence of a broncho-oesophageal fistula on the left bronchial side with the presence of secretions on swallowing. Bronchoalveolar lavage (BAL) was done and sent for mycobacterial tuberculosis culture. The fistula was closed with clips under endoscopic guidance, which alleviated his symptoms of dysphagia and choking. The BAL culture grew mycobacterial tubercle bacilli. The patient showed marked improvement after starting antitubercular therapy and was discharged to be followed up in the clinic.

Multislice computed tomography and virtual bronchoscopy diagnosis of interbronchial fistula

Although tuberculosis is a rather common disease in the Indian subcontinent, tracheobronchial involvement in tuberculosis is still rare. Fistula formation between bronchi is very rare considering that only four cases have been published in the English literature. We present a case of multislice computed tomography (CT) and virtual bronchoscopy diagnosis of interbronchial fistula in a patient with tuberculosis along with a review of literature of the same. This happens to be the smallest of the interbronchial fistula identified on imaging so far and the first case from the Indian subcontinent. This is also the first instance where the diagnosis appears to have been made using only multislice CT generated virtual bronchoscopy without the aid of fiber optic bronchoscopy.

Esophageal Microperforation due to Calcified Mediastinal Lymph Node Leading to Tracheoesophageal Fistula

A 42-year-old male presented with worsening gastroesophageal reflux disease symptoms and cough. The clinical symptoms during the early course of illness were striking for aspiration pneumonia. He was given a prescription of proton pump inhibitors and antibiotics. Rapid decline in the clinical condition with worsening respiratory status was noted. Worsening symptoms of fever, cough, and chest pain prompted further diagnostic work-up suggesting esophageal microperforation. Esophagogram was found to be suggestive of tracheoesophageal fistula. The tracheoesophageal fistula was due to subcarinal lymph node of nontuberculous origin.

Bronchial-oesophageal fistula: a rare initial presentation of squamous cell carcinoma of the lung

A 61-year-old Caucasian man with hypertension and hepatitis C presented to the emergency department with 7 days of productive cough and low-grade fevers despite outpatient therapy with oral azithromycin. On initial evaluation, he was lethargic with peripheral cyanosis and oxygen saturation in the low 70 s on room air, necessitating endotracheal intubation. Chest imaging revealed diffuse bilateral infiltrates compatible with the diagnosis of acute respiratory distress syndrome. Patient subsequently developed profound hypoxaemia and on day 2 of admission, veno-veno extracorporeal membrane oxygenation (ECMO) was initiated. Bronchoscopy revealed a necrotic ulcer on the posterior wall of the left mainstem bronchus, compatible with a bronchial-oesophageal fistula, which was later confirmed by endoscopy, and stented. Histology revealed poorly differentiated squamous cell carcinoma of the lung. Despite stenting of the fistula and ECMO support, the patient expired 5 days after admission.

Successful medical management of tuberculous broncho-oesophageal fistula

Broncho-oesophageal fistula (BEF) of benign aetiology is rare. BEF is a rare complication of intrathoracic involvement with tuberculosis. A high index of suspicion and appropriate investigations can lead to achieving an early diagnosis following which appropriate management can be timely instituted. Surgery can be avoided if the condition is recognised in early stages. We present a case of a young female patient with tubercular mediastinal lymphadenopathy complicated by left broncho-oesophageal fistulisation. Timely initiation of conservative medical management was followed by an uneventful recovery.

Broncho-esophageal fistula leading to lung abscess: A life-threatening emergency detected on FDG PET/CT in a case of carcinoma of middle third esophagus

Sinister undesirable pathologies often accompany malignancies. Though the entire emphasis is on cancer management, these benign conditions are more life-threatening than the primary malignancy itself. We report an interesting imaging finding of broncho-esophageal fistula leading to lung abscess on ¹⁸F– fluoro-deoxy-glucose positron emission tomography/computed tomography (FDG PET/CT) in large middle esophageal cancer, which due to early detection, was promptly managed.

Esophagobronchial fistulae: Diagnosis by MDCT with oral contrast swallow examination of a benign and a malignant cause

We report two cases of esophagobronchial fistulae diagnosed by Multi-detector computed tomography (MDCT) oral contrast swallow examination. It is helpful to supplement the CT study with an oral contrast swallow as it aids in confirmation of a suspected fistula and also demonstrates the fistula tract better. We present the clinical details and the imaging findings on MDCT of two cases of esophagobronchial fistulae – one secondary to chronic chest tuberculosis and the other secondary to a squamous cell carcinoma of the upper esophagus – followed by discussion of the etiology, pathogenesis, and imaging of these fistulae.

Broncho-Oesophageal Fistula (BOF) Secondary to Missing Partial Denture in an Alcoholic in a Low Resource Country

The clinical course of a missing partial denture with secondary BOF in an alcoholic is presented. In the index case we report an exceptional clinical course of a patient who did not ascribe his symptoms to his ''missing'' dentures for several years, the odontologist who replaced an unrecovered denture, and the generalist who administered the barium swallow in an unsuspected BOF. Preoperative optimization of the patient was by blenderized local feeds through a feeding tube gastrostomy and by chest physiotherapy. Extraction of the denture and closure of fistula were done through a right thoracotomy. The importance of a high index of clinical suspicion of BOF in a low resource setting to avoid the morbidity and mortality associated with missing dentures is discussed. Odontologists, caregivers and clinicians must educate patients on the hazards of missing dentures and cases of missing / lost dentures should be adequately investigated / explored in the patient's history and clinical assessment before they are replaced.