Esophageal diverticulum fistula to the right lung lower lobe presented with massive upper gastrointestinal bleeding: a rare case

Abstract

Background-Esophageal respiratory fistulas are abnormal connections between the esophagus and the respiratory system. Two types of these fistulae may be present as congenital or acquired. Most common sites of acquired esophageal pulmonary fistula are between esophageal tracheal and esophageal bronchial tree and the most common causes are infections or malignant neoplasms. An esophageal pulmonary fistula due to diverticula with presentation of hematemesis is extremely rare. Case presentation: This case concerns a man aged 67years with a lower third of esophageal diverticula and pulmonary fistula presented with abrupt-onset of cough and massive hematemesis. Imaging study findings suggested a fistula between the lower third of the esophagus and the lower lobe of right lung. Fibro-optic-esophagoscopy was performed which showed massive clots in the lumen of esophagus, the diagnosis was an acquired esophageal pulmonary fistula. CT-angiogram of aorta and pulmonary artery revealed pulmonary artery to lower esophagus fistula. The patient underwent right lung lower lobectomy partial esophageal resection. Three days postoperatively an esophagus-pleural fistula developed. After putting a self-expandable metallic stent, leakage was closed. Patient discharged 15 days after operation with good condition. In two months postoperative follow-up, the patient was still in good condition. Conclusions: Esophageal respiratory fistulae with massive hematemesis must be suspected, particularly in a patient with pneumonia in the lower lobs and resistant to antibiotic treatment. Esophageal pulmonary fistulae are diagnoses by means of radiological imaging or esophagoscopy. Esophageal respiratory fistulae can be acute and life-threatening so prompt treatment with endoscopic placement of covered stent or via surgery is needed.