A case of traumatic oesophageal pleural fistula

A 27-year-old male presented to emergency department with history of stab injury to left side of chest. At the time of presentation, the patient was breathless and complained of pain in left side of chest. His vitals were stable.

An initial evaluation with supine chest radiograph (CXR) showed homogenous diffuse opacity in left hemithorax. Ultrasound evaluation confirmed presence of fluid within the left pleural cavity and subsequently intercostal drainage tube was inserted. He was further evaluated with plain Computed tomography (CT) of thorax which revealed left-sided hydropneumothorax with multiple high-density contents within the left pleural cavity and air space opacities in left basal segments, suggesting underlying lung contusion. A suspicious abnormal communication between left lateral wall of upper thoracic oesophagus and the left pleural cavity prompted the radiologist to perform. Dynamic and static fluoroscopic imaging, which confirmed oesophageal fistula communicating with left pleural cavity. The findings were confirmed by oesophageal endoscopy, and oesophageal stent was deployed.

The patient was further taken up for CT thorax with positive orally administered contrast to delineate the fistula prior to definitive surgical management, which revealed accumulation of orally administered contrast into the left pleural cavity via a fistulous communication between oesophagus and pleura.

Background

An abnormal communication between oesophagus and the pleural cavity called as esophago-pleural fistula (EPF) is a rare entity[1]. The common predisposing factors leading to this condition are iatrogenic injury due to oesophageal instrumentation, malignancy of oesophagus, irradiation or rarely as a complication of pneumonectomy[2].

Clinical Perspective

The signs and symptoms are non-specific, hence clinical diagnosis of esophagopleural fistula(EPF) becomes difficult. The diagnosis of EPF can be suspected clinically when a patient presents with retrosternal chest pain, fever, dysphagia, and dyspnea in the background of antecedent history of instrumentation or surgery.; however, for confirmation, imaging is required [3].

Imaging Perspective

The imaging modalities include chest radiograph, ultrasound, barium swallow, contrast-enhanced computed tomography (CT), and magnetic resonance imaging (MRI) with each modality having its advantages, and chest CT is a very useful modality.

Radiographic findings in EPF include pneumothorax, hydropneumothorax and localized pneumonitis[4]. Ultrasound is helpful in detecting the hydro- or hydropneumothorax.

A thoracic CT with oesophageal contrast will demonstrate oesophageal pleural fistulas [5]. CT also plays a role in the management of the EPF as its prognosis depends upon the extent of the mediastinal involvement. EPF without mediastinal involvement usually carries good prognosis and may respond to percutaneous pleural drainage[1].

Single contrast esophagogram with barium or water-soluble contrast media can show leakage of contrast from the oesophagus into pleural cavity, although rarely indicated in this era of CT.[6].

Outcome

Management of the EPF depends on site, size, duration, and severity of perforation. Another important prognostic factor is extent of mediastinal involvement, which is better evaluated by chest CT. Conservative therapy includes drainage of the empyema, local irrigation, tube feeding, surgery which includes repair or direct reconstruction of the esophagus. Early diagnosis and management of the EPF are important as it carries poor prognosis.

Treatment of EPF depends on the site and size of defect in the oesophagus. Conservative management includes drainage of pleural cavity, with local irrigation and feeding by means of gastrostomy, or jejunostomy[1]. Systemic antibiotics should be administered for at least 4-6 weeks for sterilization of the empyema cavity. Definitive management is by closing with self-expanding metal stents or by surgical exploration with a muscle flap[7].

Take-Home Message/Teaching Points

Esophageal-pleural fistula (EPF) is a rare clinical entity with a high degree of morbidity and mortality. The lack of familiarity, along with non-specific clinical manifestation and subtle findings in routine imaging modality, warrants specific imaging protocols, making it a diagnostic challenge. High index of suspicion is needed to detect this potentially fatal entity.