|Year : 2015 | Volume
| Issue : 1 | Page : 23-24
Esophageo pleural fistula due to esophageal cancer
Ruchi Sachdeva1, Sandeep Sachdeva2
1 Department of Tuberculosis and Respiratory Medicine, Pandit Bhagwat Dayal Sharma, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
2 Department of Community Medicine, Pandit Bhagwat Dayal Sharma, Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
|Date of Web Publication||12-Dec-2014|
Department of Tuberculosis and Respiratory Medicine, Pandit Bhagwat Dayal Sharma, Post Graduate Institute of Medical Sciences, Rohtak 124 001, Haryana
Source of Support: None, Conflict of Interest: None
A 61-year-old male admitted in chest clinic with complaints of left-sided chest pain, sudden onset breathlessness, and cough since last 15 days. Patient was anex-smoker with no past history of tuberculosis. He was diagnosed with esophageal cancer and received radiotherapy 1 year back. On chest X-ray, left-sided hydropneumothorax was found and intercostal drainage insertion was done. A week later patient complained of extrusion of food particles into intercostal drainage bag. On evaluation, esophageopleural (EP) fistula was confirmed.
Keywords: Fistula, malignancy, radiotherapy, respiratory distress, smoker
|How to cite this article:|
Sachdeva R, Sachdeva S. Esophageo pleural fistula due to esophageal cancer. J Assoc Chest Physicians 2015;3:23-4
| Case Report|| |
A 61-year-old male admitted with complaints of left-sided chest pain, sudden onset breathlessness, and cough since last 15 days. He was a smoker since 40 years, but left since 1 year. He was diagnosed withesophageal (poorly differentiated squamous cell) carcinoma and received radiotherapy 1 year back. There was no past history oftuberculosis. On physical examination, he was febrile, in respiratory distress and was found using accessory muscles; pulse rate-130/min, blood pressure (BP) -90/70 mmHg, and respiratory rate (RR) -38/m. ChestX-rayshowed left-sided hydropneumothorax. ECG and cardiac evaluation was within normal limits. Intercostal drainage insertion was done on left side in fifthintercostal space in mid-axillary line in order to relieve dyspnea followed by antibiotics, bronchodilators, and oxygen therapy. Oneweek later, patient complained that food particles were coming intointercostal drainage bag. Then contrast-enhanced computed tomography (CECT), upper gastrointestinal (GI) endoscopy, and barium swallow were planned. CECT thorax revealed left-sided hydropneumothorax with left side EP fistula [Figure 1]; upper GI endoscopy-stricture noted at terminal 5cm of esophagus near gastroesophageal (GE) junction, scope passed with difficulty. Bariumswallow confirmed EP fistula [Figure 2]. Surgical referral was sent for EP repair; however, patient succumbed to his illness.
|Figure 1: CECT thorax revealed left sided hydropneumothorax with left side EP fistula. CECT = Contrast-enhanced computed tomography, EP = esophageopleural|
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| Discussion|| |
EP fistula is a rare condition, but represents one of the more common complications of esophageal perforation. Anatomically, the esophagus is in direct contact with the lung pleura for a considerable distance on the right side, whereas on the left side, the aorta lies in between the esophagus and the pleura, except for a short distance just above the diaphragm. Therefore, processes in the esophagus can spread more easily into the right side of pleura rather than the left. , In our case, perforation occurred on left side which is a very rare presentation.
Esophageal fistula is usually an acquired lesion in adults and can occur as a complication of intrathoracic malignancies due to direct extension, but can also manifest as a complication of esophageal tuberculosis, surgical procedures, andtherapeutic interventions such as biopsy, dilatation, hemostasis, stent placement, foreign body removal, cancer palliation, and endoscopic ablation techniques can also dramatically increase the risk of perforation. In patients with esophageal cancer, incidence of EP fistula is 5-15%. ,
Fistulaefurther lead to development of complication in the mediastinum, trachea-bronchial tree, pleura, and lung which includes mediastinitis, empyema, and aspiration pneumonia.  Because of the potentially high morbidity and mortality associated with these complications, early diagnosis with imaging is important. Untreated fistulae results in continued respiratory contamination, sepsis, and death. EP fistulas have a propensity to develop in extremely later stages of esophageal cancer, when remedial surgery is no longer considered.
Systemic antibiotics should be administered for at least 4-6 weeks for sterilization of the empyema cavity. Definitive management involves complete drainage of empyema and obliteration of empyema cavity by lung expansion that can be addressed following closure of EP fistula. Fistula can be closed with self-expanding metal stents or by surgical explorationwith a muscle flap. , However, even with appropriate procedural intervention, prognosis is poor if the mediastinum is involved.
| Acknowledgement|| |
Department of Gastroenterology and Radio-diagnosis, Pt. B. D. Sharma, PGIMS, Rohtak-124001, India.
| References|| |
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[Figure 1], [Figure 2]
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