The patient is a 44 year old white female with a history of mental impairment who presented with shortness of breath and associated right lower lobe pneumonia noted on the chest roentogram. Parenteral antibiotics were instituted. The patient became septic with significant respiratory insufficiency. She was therefore placed on mechanical ventilation through an oral endotracheal tube.During ventilation there was a constant leak of 150 cc of the tidal volume with each breath. The endotracheal tube was replaced without improvement in the consistent loss of the tidal volume. For this reason, emergency bronchoscopy was performed and identified a 1 cm left sided bronchoesophageal fistula close to the carina.Esaphagogastroduodenoscopy confirmed this finding at 30 cm from the incisor teeth. Biopsies from the esophageal and bronchial sides of the fistula showed Barrett’s mucosa. No neoplasia was present. Computed tomography of the chest did not show any other mediastinal abnormalities.Primary surgical repair was undertaken with longitudinal suturing of the individual bronchial and esophageal components of the fistula. A small post-operative leak was identified on the barium esophagogram that was successfully treated with conservative management consisting of jejunal feeding tube and proton pump inhibitor.Barrett’s esophagus is an intestinal metaplastic response of the esophageal squamous mucosa to chronic gastroesophageal reflux. It can present initially as tongue-like extensions or scattered islands of columnar epithelium, circumferential involvement of the distal esophagus is seen in advanced cases. Ulceration is noted in 10% of cases with Barrett’s esophagitis, and deep wide-mouthed ulcer can penetrate or perforate to adjacent mediastinal structures. The majority of patients with bronchoesopahgeal fistula present with dysphagia, cough and choking on swallowing, and less commonly wheezing, dyspnea, weight loss, hemoptysis and epigastric or chest pain. Surgical therapy of benign fistula offers an excellent chance of cure.Further, the present report underscores the diagnostic importance of pursuing associated clinical findings including unexplained loss of tidal volume in the intubated patient.
B. Pichurko, None.