LETTERS TO THE EDITOR

Esophago-pleural fistula in Barrett's esophagus

Fístula esófago pleural en esófago de Barrett

Key words: Barrett's esophagus. Esophagopleural fistula. Esophageal perforation.

Palabras clave: Esófago de Barrett. Fístula esófago-pleural. Perforación esofágica.

Dear Editor,

Perforation of the esophagus due to Barrett's esophagus resulting in the formation of a fistula to the pleural cavity is an extremely rare cause of esophageal perforation.

Case report

We report the case of an 80-year-old man who developed esophago-pleural fistula, empyema, respiratory failure and sepsis. He was diagnosed of right lower lobe pneumonia and right pleural effusion, so a chest drain was placed. On the 8th day after admission, the patient resumed oral intake. Forty-eight hours later, a material similar to the diet drained from the chest drain. Since an oesophagopleural fistula was suspected, methylene blue was given and immediately drained from the chest drain.

Emergency endoscopy showed a fibrin-covered ulcer 3 cm in diameter on the right side of distal esophagus, with a fistulous orifice greater than 8 mm at its lower part, over a 3-cm hiatal hernia. The biopsies taken from the ulcerated area and around the fistula showed superficial gastric mucosa with inflammatory cells and intestinal metaplasia, without histological signs of malignancy. The diagnosis of benign esophago-pleural fistula secondary to Barrett's esophagus was confirmed and a "Hanoster" stent was placed as a rescue treatment (Fig. 1).

Seven cases of perforation and fistulisation of benign ulcers in Barrett's esophagus have been reported so far: five cases of esophago-pleural fistulas (1-4), and two cases of esophagobronchial fistulas (5,6).

Discussion

There is not much consensus regarding treatment. The use of stents has been reported in patients with delayed diagnosis of the perforation who are not surgical candidates. At present, removable covered metallic stents and silicone-covered polyester stents (Polyflex) allow certain benign conditions to be amenable to this rescue treatment.

M. Morán Ortiz de Solórzano, M. E. Quintanilla Lázaro, I. Guerra Marina, D. Collado Pacheco, J. L. Castro Urda, L. R. Rábago Torre and F. Gea Rodríguez

Department of Gastroenterology. Hospital Severo Ochoa. Leganés, Madrid. Spain

References

1. Andersson R, Nilsson S. Perforated Barrett's ulcer with esophago-pleural fistula. A case report. Acta Chir Scan 1985; 151(5): 495-6.        [ Links ]

2. Byard RW. Barrett esophagus and unexpected death. Am J Forensic Med Pathol 2007; 28(2): 147-9.        [ Links ]

3. Matsumoto MA, Rockoff SD, Aaron BL. Tension pyoneumothorax. Rare presentation of Barrett's esophagus. Chest 1993; 103(5): 1604-6.        [ Links ]

4. Limburg AJ, Hesselink EJ, Kleibeuker JH. Barrett ulcer: cause of spontaneous esophageal perforation. Gut 1989; 30(3): 404-5.        [ Links ]

5. Gerstenberger PD, Pellegrini CA, Tierney LM. Barrett's ulcer of the esophagus. Previous unrecognized cause of adquired esophagorespiratory fistula. Am J Med 1986; 81(4): 713-7.        [ Links ]

6. Nigro JJ, Bremmer RM, Fuller CB, Theisen J, Ma Y, Starnes VA. Perforating Barrett's ulcer resulting in a life threatening esophagobronquial fistula. Ann Thorac Surg 2002; 73(1): 302-4.        [ Links ]