Critical Care |

Bubbles in My Brain FREE TO VIEW

Theresa Case, DO; Kevin Smith, MD
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University of Kentucky, Nicholasville, KY

Chest. 2015;148(4_MeetingAbstracts):216A. doi:10.1378/chest.2273235
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SESSION TITLE: Critical Care Cases III

SESSION TYPE: Affiliate Case Report Slide

PRESENTED ON: Wednesday, October 28, 2015 at 11:00 AM - 12:15 PM

INTRODUCTION: Esophageal cancer is among the 10 most frequent cancers in the world and is the seventh leading cause of cancer death. (1) Despite advances in therapy, the overall 5-year survival remains poor at 16.9 %.

CASE PRESENTATION: Mr. R was a 52yo M with a history of esophageal cancer who presented with the sudden onset of new seizures. He was first diagnosed with esophageal cancer in February of 2013. He underwent esophagectomy in 2013 and had received 4 cycles of chemotherapy and radiation. His wife reported that he was in his usual state of health except for reporting a headache for 1 day prior. He was watching TV when he suddenly became acutely unresponsive and was noted to have stiffened arms. He was intubated for airway protection secondary to a GCS of 3. A CT Head was performed which demonstrated extensive air emboli throughout the brain. A CTA chest was performed which was negative for pulmonary embolism but did demonstrate air tracking up the vessels on the right side of the neck. Hyperbaric oxygen therapy was performed and a repeat CT Head showed resolution of the previous air emboli. Later, an MRI of the brain was performed which showed multiple new areas of air emboli. Due to the resolution of the air emboli and then recurrence of air in the brain, it was determined that Mr. R had an esophageal-atrial fistula as a complication of prior esophagectomy. Due to the poor prognosis, the patient was extubated and transitioned to hospice care.

DISCUSSION: The development of a fistulous communication between the upper alimentary tract to the atrium in an adult patient is often iatrogenic. (2) While rare, this can occur as a result of thoracic esophagectomy and proximal gastrectomy which our patient had in 2013. It is unclear if postoperative chemotherapy and radiation increases the risk of fistula. Patients may present with unexplained hematemesis or GI bleeding months to years after esophagectomy.

CONCLUSIONS: In the age of multimodality therapy for esophageal carcinoma, the risk for complications is increasing. Providers and patients should be made aware of the risk for catastrophic events. Attention should be paid to hematemesis and unexplained GI bleeding even years after surgery.

Reference #1: Varghese, Thomas et al. The Society of Thoracic Surgeons Guidelines on the Diagnosis and Staging of Patients with Esophageal Cancer.

Reference #2: Raja, Siva et al. Fatal Cerebral Air Embolus Complicating Multimodality Treatment of Esophageal Cancer. The Annals of Thoracic Surgery. 92:5; 2011; 1901-1903

DISCLOSURE: The following authors have nothing to disclose: Theresa Case, Kevin Smith

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