CASE 9155 Published on 18.02.2011

Bronchoesophageal fistula

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Dzoic M, Fila J, Vukelic-Markovic M

Patient

74 years, female

Categories
Area of Interest Oesophagus, Thorax ; Imaging Technique Conventional radiography, CT
Clinical History
74-year-old woman presented with sideropenic anaemia and problems with eating crumbling food.
Imaging Findings
A 74-year-old woman without important clinical history presented with sideropenic anaemia and problems with eating crumbling food. Her physician initiated a gastroenterologic evaluation. Oesophagogastroduodenoscopy revealed a narrow extraluminal communication in the distal third of the oesophagus (diverticulum, fistula?) and contrast examination of the oesophagus and CT of thorax was requested.
Contrast medium examination of the oesophagus demonstrated in its distal third at the left dorsal circumference a diverticulum with contrast medium transit into the bronchial system. The broad fistula showed good filling and clearing of contrast medium.
The subsequent CT examination with intravenous contrast administration confirmed the diverticulum with a fistula communicating with a segmental bronchus of left lower lobe. The oesophagus was dilated without signs of an infiltrative process. The affected bronchus was bronchiectatic and had a thickened wall.
Surgery was recommended.
Discussion
Oesophageal diverticula are classified by location into pharyngoesophageal (Zenker diverticulum, 70%), thoracic and mediastinal (10%), and epiphrenic (20%). Almost all oesophageal diverticula are acquired pulsion diverticula [4]. Diverticula of the thoracic oesophagus are uncommon [2]. Perioesophageal inflammation, most commonly secondary to tuberculosis, is a frequent cause of midthoracic diverticula. Today, the majority of these diverticula are the result of oesophageal motility disorders [3]. Although some patients are asymptomatic and diverticula are incidental findings, most patients are symptomatic [1]. The most common symptoms are dysphagia, regurgitation, thoracic pain, and pulmonary manifestations related to aspiration [4]. Contrast medium radiography is the prime diagnostic tool; evaluation of the diverticulum, associated oesophageal abnormalities, and complications are assessed by a barium oesophagogram. Oesophagoscopy adds little to the evaluation of the diverticulum but may be indicated for the assessment of other oesophageal abnormalities. Motility studies, which may be difficult or hazardous to perform, are of little use in the diagnosis and treatment of a Zenker diverticulum. Manometric evaluation of midthoracic or epiphrenic diverticula usually show an associated motility disorder and may influence treatment decisions [1]. Diverticula should not be treated unless they are symptomatic [4]. Fistulisation is a rare and not often described complication of oesophageal diverticula [7]. It is the result of inflammatory necrosis [10]. A fistula with only mild clinical symptoms and persisting over a long time period has been reported, however, owing to the sparse symptoms and absence of pulmonary complications, surgery was not considered. During follow-up the complaints of the patient ceased and endoscopy showed shrinking of the fistula [5]. Patients may also present with a history of chronic recurrent bronchitis and intermittent episodes of paroxysmal attacks of coughing and strangling on the ingestion of fluids (Ono's sign) [6]. The barium oesophagogram remains the study of choice, because it effectively differentiates fistula from aspiration. The lateral projection will generally define tracheoesophageal fistulas best, whereas bronchoesophageal fistulas may require a slightly different obliquity. Aqueous contrast agents should be avoided because of the risk of potentially lethal pulmonary oedema. CT can be a useful adjunct in selected cases for the evaluation of the underlying cause or assessment of tumour burden. In benign fistulas, the goal of treatment is to achieve definitive repair [9]. This requires prompt diagnosis and early surgical management to prevent fatal suppurative pulmonary complication [8].
Differential Diagnosis List
Bronchoesophageal fistula
Diverticulum of esophagus
Carcinoma of esophagus
Final Diagnosis
Bronchoesophageal fistula
Case information
URL: https://www.eurorad.org/case/9155
DOI: 10.1594/EURORAD/CASE.9155
ISSN: 1563-4086