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 Table of Contents  
CASE REPORT
Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 25-27

Traumatic esophageopleural fistula due to fish bone injury


Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Web Publication12-Dec-2014

Correspondence Address:
Surya Kant
Department of Pulmonary Medicine, King George's Medical University, Lucknow 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-8775.146850

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  Abstract 

Oesophageopleural fistula (EPF) is an abnormal communication in between the oesophagous and pleural space such that the contents of oesophagous are drained into the pleural space surrounding the lungs. We describe a case of a middle-aged female who presented with right sided pyothorax secretions of which consisted of food particles. Chest computed tomography and barium swallow confirmed the diagnosis of oesophageopleural fistula, cause of which was found to be an accidental fish bone injury. Conservative management was done by chest tube drainage along with ryles tube feeding. Patient expired following severe sepsis.

Keywords: Fishbone, fistula, oesophagopleural


How to cite this article:
Verma AK, Prakash V, Joshi A, Kant S, Bhatia A. Traumatic esophageopleural fistula due to fish bone injury . J Assoc Chest Physicians 2015;3:25-7

How to cite this URL:
Verma AK, Prakash V, Joshi A, Kant S, Bhatia A. Traumatic esophageopleural fistula due to fish bone injury . J Assoc Chest Physicians [serial online] 2015 [cited 2020 Apr 3];3:25-7. Available from: http://www.jacpjournal.org/text.asp?2015/3/1/25/146850


  Introduction Top


Esophageopleural fistula (EPF); an uncommon complication arising secondary to esophageal instrumentation, surgery, malignancy, or occasionally after postpneumonectomy. A fistulous track occurring spontaneously between esophagus and pleura is very rare. Contrast-enhanced computed tomography (CECT) is an important imaging modality for EPF.


  Case Report Top


A female immunocompetent 50-years-old with no significant history visited our outpatient department with complaints of fever, right-sided chest pain, breathlessness on exertion, and vomiting since 15 days. Routine blood examination was done suggestive of hemoglobin (Hb) 8.5 g/dl, total leukocyte count (TLC) 19,100 cells/mm 3 with predominant polymorphs, a chest X-ray [Figure 1] was suggestive of a right-sided collection in pleural space, pleural tap of which was suggestive of pyothorax, culture of which revealed Pseudomonas spp. Patient was managed with intercostal chest tube and broad spectrum antibiotics. 1.5 L pus was drained. Blood culture done revealed growth of Pseudomonas spp.
Figure 1: Right-sided collection in pleural space

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Naked eye examination of pus revealed food particles consistent with active tract between the esophagus and pleura. Barium swallow [Figure 2] and [Figure 3] was planned which showed an active communication between the esophagus and pleura in the middle third of esophagus.
Figure 2: CT scan showing leak in the middle third of esophagus

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On repeated and careful interrogation about previous history, patient revealed a history of accidental fishbone ingestion just before the onset of symptoms. A CECT thorax [Figure 4] and abdomen was done which confirmed a track between esophagus and the right pleural cavity.
Figure 3: Barium swallow showing leak in the middle third of esophagus

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Figure 4: Fistulous track between esophagus and pleural space

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Since no other cause for this condition can be proved a diagnosis of traumatic EPF due to fish bone injury was made. Bronchoscopy was planned after management of active sepsis, however, before any intervention could be done patient went into septic shock. Patient was managed with inotropes and supportive management, but patient could not be revived.


  Discussion Top


An esophageal pleural fistula usually arises as a complication of an iatrogenic trauma or postpneumectomy. [1] It presents with vague symptoms such as, chest pain, fever, dyspnea, and autonomic disturbances such as excessive sweating, giddiness, or hypotension. Symptoms that may suggest the diagnosis additionally include foul smelling regurgitation, odynophagia, and dysphagia. [2] The presence of these symptoms postoperatively after an esophageal surgery or instrumentation strongly suggests a diagnosis of EPF. Various imaging modalities play a vital role as the diagnosis is based on clinical suspicion. [1] The esophagus lies in direct proximity with the lung pleura on the right side, but on the left side, the aorta is situated in between the esophagus and pleura, with the exception for a short distance just above the diaphragm. Therefore, processes in the esophagus may spread easily to the right side of pleura than the left. [3],[4] The radiological features are additive towards diagnosis, but can vary according to the site, duration, perforation severity, and pleural integrity. Mediastinitis sets in if the pleura is not breeched followed by subsequent dehiscence of mediastinalpleura, resulting in air entry in pleural space leading to pneumothorax, sometimes a hydrothorax can also occur. If the pleura is already breeched, in that case EPF can occur with resultant unloading of esophageal contents into the pleura sparing the mediastium. The imaging modalities include chest radiograph, ultrasound, barium swallow, contrast-enhanced CT, and MRI.

A CT scan can not only confirms the radiological findings, but also it is helpful during differentiation of pleural from parenchymal disease. [1] A pleural effusion is seen commonly and the presence of a pneumothorax reduces the diagnostic consideration. The presence of orally given contrast media in pleural space is pathognomonic of this uncommon disease. [1],[2] CT can detect even minute amounts of air or fluid and so is highly sensitive, and needs little patient cooperation as compared to esophagography, which is often difficult while performing on seriously-ill patients. [5] Our case is probably the first such reported case in medical literature.

Management of the EPF depends on site, size, duration and severity of perforation, and presence or absence of mediastinitis. Prognosis is poor if the mediastinum is involved. Management of EPF involves medical treatment of the effusion/empyema that results from the fistula as well as correction of the fistula itself. Conservative therapy includes drainage of the empyema. In addition to chest tube drainage and antibiotic treatment, management of empyema may require additional drainage by CT guidance or thoracoscopy and possibly decortication, [6] local irrigation, tube feeding, gastrostomy, or jejunostomy to be started as early as possible followed by definite surgery which includes repair or direct reconstruction of the esophagus. Endoscopic techniques using obliterating agents, such as fibrin glue or cyan acrylic glue, [7],[8] endoscopic clip application, [9] and endoscopic suturing device have been reported. Early diagnosis and management of the EPF is important as it carries poor prognosis.


  Conclusion Top


EPF leads to unloading of swallowed contents resulting in mediastinitis (most commonly), empyema, and aspiration pneumonia. Early diagnostic imaging is of prime importance because of associated morbidity and mortality with this condition. Definitive treatment remains surgical closure or esophageal stunting.

 
  References Top

1.
Vyas S, Prakash M, Kaman L, Bhardwaj N, Khandelwal N. Spontaneous esophageal-pleural fistula. Lung India 2011;28:300-2.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Liu PS, Levine MS, Torigian DA. Esophagopleural fistula secondary to esophageal wall ballooning and thinning after pneumonectomy: Findings of chest CT and esophagography. AJR Am J Roentgenol 2006;186:1627-29.  Back to cited text no. 2
    
3.
Giménez A, Franquet T, Erasmus JJ, Martínez S, Estrada P. Thoracic complications of esophageal disorders. Radiographics 2002;22:S247-58.  Back to cited text no. 3
    
4.
Chuah BY, Khoo KL, Khor CJ. Clinical challenges and images in GI. Esophagopleural fistula. Gastroenterology. 2008;134:919, 1275.  Back to cited text no. 4
    
5.
Heffner JE, Klein JS, Hampson C. Diagnostic utility and clinical application of imaging for pleural space infections. Chest 2010;137:467-79.  Back to cited text no. 5
    
6.
Colice GL, Curtis A, Deslauriers J, Heffner J, Light R, Littenberg B, et al. Medical and surgical treatment of parapneumonic effusions: An evidence-based guideline. Chest 2000;118:1158-71.  Back to cited text no. 6
    
7.
Lopes MF, Pires J, Nogueria Brandão A, Reis A, Morais Leitão L. Endoscopic obliteration of a recurrent tracheoesophageal fistula with enbucrilate and polidocanol in a child. Surg Endosc 2003;17:657.  Back to cited text no. 7
    
8.
Truong S, Böhm G, Klinge U, Stumpf M, Schumpelick V. Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue. Surg Endosc 2004;18:1105-8.  Back to cited text no. 8
    
9.
Raymer GS, Sadana A, Campbell DB, Rowe WA. Endoscopic clip application as an adjunct to closure of mature esophageal perforation with fistulae. Clin Gastroenterol Hepatol 2003;1:44-50.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case Report
Discussion
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