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TopCase Report
A 60-year-old male with a diagnosis of right hydropneumothorax was referred to our hospital with complaint of dislodgement of intercostal tube drainage inserted in their hospital and discharge of pus containing ingested food particles through intercostal tube drainage wound. He presented with cough and expectoration, severe retrosternal chest pain, shortness of breath and copious vomiting for three days. The pain was non-colicky, radiating to back, and there were no aggravating or relieving factors. There was no previous history of the upper gastrointestinal endoscopy or esophageal instrumentation. On coming to our hospital, there was discharge mixed with ingested food particles from the wound site. On respiratory examination, air entry and vocal resonance were decreased on right side basal areas. Patient did not bring chest x-rays taken at first hospital. Chest radiograph (Figure 1), taken at our hospital showed right loculated hydropneumothorax. On drinking a glass of milk, there was oozing of same through the wound which increased after a bout of cough. In order to confirm the esophageo-pleural communication, Computed Tomography of Chest with non-ionic oral contrast (Figure 2) which showed esophageo-pleural fistula in interbronchial and proximal retro cardiac oesophageal segment and circumferential pleural thickening in right pleural cavity. Large pocket of air located in right pleural cavity laterally with fluid and debris with air-fluid level. Contrast was outlining the pleural cavity, accumulating in the paraspinal component of pleura and subsequently tracking into pleural cavity posteriorly with an irregular track, communicating between pleura & esophagus. Right lung showed mild degree of positive compression. There was no evidence of mediastinitis, or hilar or mediastinal lymhadenopathy. There was no evidence of contrast extravasation into mediastinum. Liver, spleen, pancreas appeared normal. Upper Gastrointestinal endoscopy was done to rule out any associated esophageal malignancy or inflammation which showed fistula opening at 32 centimeters of esophagus. The fistulous opening was one centimeter in size with healthy surrounding mucosa. Biopsy from the fistulous opening showed no evidence of necrosis or granulomas or malignancy. Hence, we diagnosed it as a case of spontaneous esophageal-pleural fistula. He was managed conservatively with tube thoracostomy, antibiotics, nasogastric tube feeding and intravenous fluids. Patient was discharged at request after one week. Patient need immediate surgical repair for complete healing up. Later on patient did not turn up. Surgical repair of fistula could not be performed as the patient lost to follow-up even after four months.
Figure 2. Computed tomography of chest with non-ionic oral contrast
TopDiscussion
Esophageal injury may be iatrogenic, example secondary to esophageal instrumentation or can be due to external trauma or can be due to diseases of esophagus such as esophageal ulcer or neoplasm or corrosive esophagitis. Rarely, it can be spontaneous (Wechsler, 1986; Al-Shawwa, D'Andrea, & Quintero, 2008; Pache, Thuerl, Bley, Kotter, & Ghanem, 2005). Spontaneous rupture of esophagus also called as Boerhaave's syndrome is usually associated with forceful vomiting or retching (Al-Shawwa et al., 2008) It occurs from sudden rise of intraesophageal pressure (due to spasm of cricopharyngeus muscle and closing of pyloric sphincter). Forceful or long-term vomiting, retching, or coughing can cause mucosal tears called as Mallory-Weiss tears presenting with gastrointestinal bleeding and these tears usually heal spontaneously. Sammer Vyas et al, [7] reported a case of spontaneous esophageal-pleural fistula in a 40-year-old female.