INTRODUCTION: Gastrobronchial fistula (GBF) is a rare and potentially life threatening complication following esophagectomy. A high index of suspicion and accurate selection of diagnostic studies is critical to the early diagnosis and treatment of GBF. We describe a case of gastrobronchial fistula following esophagectomy for adenocarcinoma of the esophagus.
CASE PRESENTATION: A 69-year-old man presented with a 2-month history of worsening dyspnea, productive cough of green sputum, and a 100-pound weight loss. He underwent several months of neo-adjuvant chemo-radiation for adenocarcinoma of the esophagus before proceeding to an Ivor Lewis esophagectomy. He was discharged without complication on the tenth post-operative day. He was admitted to an outside hospital for treatment of right lower lobe pneumonia on three occasions. Upon the third admission, he was transferred to our facility for further evaluation of his recurrent pneumonia. On presentation, he had copious sputum production of approximately 2 liters per day. The volume increased following meals but he denied expectoration of food particles. He denied hemoptysis or dysphagia. He did report early satiety. On physical exam, he was cachectic, afebrile, and required 5-liters by nasal canula to correct his hypoxia. His lips were noticeably chapped and swollen. Pulmonary exam demonstrated decreased tactile frematus and egophony in the right base. The remainder of his physical exam was unremarkable. Laboratory studies only revealed anemia, metabolic alkalosis, and hypoalbuminemia. Admission chest radiograph displayed dense consolidation in the right lower lobe. The differential included chronic aspiration from severe reflux following his pull-up procedure versus a fistula communicating between the bronchial tree and gastrointestinal (GI) tract. A barium swallow and upper GI series revealed extraluminal contrast in the right posterolateral mediastinum as well as contrast in both lower lobes. However, no fistulous tract could be identified; and he was noted to aspirate contrast during the study. A CT of the chest demonstrated a contrast enhanced pouch just distal and lateral to the anastomotic site with apparent communication to the right lower lobe. He then underwent esophagogastroduodenoscopy (EGD). A 4 cm defect in the right posterolateral gastric wall just distal to the anastomotic site was identified. Lung parenchyma and several bronchi were visualized through the defect. He proceeded to surgical repair with a prolonged recovery, and was discharged to a rehab facility.
DISCUSSIONS: Gastrobronchial fistula is most commonly associated with prior esophageal or gastric surgery. Pulmonary sepsis resulting from GBF carries a high mortality, and a clinical suspicion for GBF is warranted in post-esophagectomy patients presenting with pneumonia. Patients with GBF present with a history of productive cough and may expectorate food particles. Other findings may include hemoptysis, dyspnea, and malnutrition from recurrent pulmonary infections if the condition goes undiagnosed. Interestingly, our patient presented with severely chapped and swollen lips implying a caustic component of his sputum. This is not described in the literature as a presenting symptom of GBF. Barium swallow with upper GI series is the diagnostic tool of choice, but in our case did not reveal a fistulous tract. Additional diagnostic studies include CT scans with oral contrast, measuring the pH of bronchial secretions, and methylene blue dye test. Bronchoscopy and EGD may be useful depending on the size and location of the fistula, but unlike our case are typically non-diagnostic. Surgical repair is the treatment of choice with close attention to post-op nutritional support.
CONCLUSION: Gastrobronchial fistula is a known but rare complication following esophagectomy for carcinoma of the esophagus. A high clinical suspicion and diagnostic studies to evaluate for GBF are necessary in post-esophagectomy patients presenting with pneumonia in order to expedite definitive treatment.
DISCLOSURE: Heath Latham, None.