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Barium in the Bronchi

A Tracheoesophageal Fistula

Gnanapandithan, Karthik MD, MS1; Bramley, Kyle MD2; Jamidar, Priya A. MD, FACG, FASGE3

doi: 10.14309/crj.0000000000000189
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1Department of Internal Medicine, Yale University School of Medicine, New Haven, CT

2Division of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, CT

3Division of Digestive Diseases and Advanced Endoscopy, Yale University School of Medicine, New Haven, CT

Correspondence: Karthik Gnanapandithan, MD, MS, Yale University School of Medicine, 20 York St, CB2041, New Haven, CT (karthikpgi@ymail.com).

Received March 08, 2019

Accepted June 26, 2019

Online date: August 21, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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CASE REPORT

A 55-year-old-man with squamous cell carcinoma of the esophagus who was recently on palliative radiation presented with increasing cough productive of copious secretions. He reported feeding himself primarily through a gastrostomy tube and also eating by mouth for pleasure. He reported cough and difficulty in breathing, which was associated with feeding through either route. He was admitted for further evaluation. A chest radiograph was unrevealing. He underwent chest computed tomography with contrast, which showed the esophageal mass with areas of necrosis and a small gas-filled tract extending toward the left mainstem bronchus (Figure 1). There was no definitive evidence of a fistulous tract in the computed tomography. Following that, he was subject to an esophagram with oral barium contrast. There was pooling of barium in the mid-esophagus that was tracking into the bronchial tree at the proximal left main bronchus leading to opacification of the bronchi bilaterally (Figure 2). No reflux of contrast was visualized, and very minimal amount was seen passing into the distal esophagus. This led to the definitive diagnosis of tracheoesophageal fistula (TEF) causing aspiration. He was planned for a joint procedure by the gastroenterology and intervention pulmonology teams to stent the esophagus and left mainstem bronchus. However, during esophagogastroduodenoscopy, the guidewire could not be passed through the completely occluded esophagus and persistently ended up in the left lower lobe of the lung through the fistulous tract. Bronchoscopy revealed a necrotic area in the posterior wall of the left mainstem bronchus with the fistula opening. A covered metal stent was deployed. Later, the gastrostomy tube was replaced with a gastrojejunostomy tube for feeding.

Figure 1

Figure 1

Figure 2

Figure 2

Fifty percent of all TEFs occur in patients with malignancies of the esophagus and lung. Esophageal cancer is the most common cause, especially following radiation or chemotherapy that promotes tumor necrosis.1 In these patients, recurrent aspiration or coughing after feeding should raise the suspicion and prompt workup for a TEF. Esophagram and esophagogastroduodenoscopy are the most useful diagnostic tests. Aspiration prevention measures should be instituted. Malignant TEFs are generally managed with palliative stenting. Those located in the distal esophagus are typically treated with an esophageal stent, whereas those at the mid or proximal esophagus require stenting of both the airway and the esophagus.2 In some patients, esophageal stenting may not be feasible because of complete lumen occlusion. In these cases, it is best to stent the airway, maintain nil per oral status, and resort to alternative means of feeding.

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DISCLOSURES

Author contributions: K. Gnanapandithan wrote the manuscript, reviewed the literature, and is the article guarantor. K. Bramley and PA Jamidar revised the manuscript.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

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REFERENCES

1. Balazs A, Kupcsulik PK, Galambos Z. Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg. 2008;34(5):1103–7.
2. Ramai D, Bivona A, Latson W, et al. Endoscopic management of tracheoesophageal fistulas. Ann Gastroenterol. 2019;32:24–9.
© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.