Online Images in the Medical Sciences| Volume 364, ISSUE 3, e35-e36, September 2022

Esophago-pleural fistula

      A 58 year-old male with end-stage COPD presented for bilateral sequential cadaveric lung transplant. Two weeks post-transplant, he became febrile to 101°F, tachycardiac, and tachypneic. Laboratory studies showed leukocytosis with white blood cell 21.5 (normal range, 4.0 - 10.0 1000/mm3). Imaging studies revealed bilateral hydropneumothoraces with associated consolidation. Bilateral chest tubes were placed. Pleural studies showed pH 6.00, total protein 1.4 g/dL, LDH 2184 IU/L, glucose 173 mg/dL, and Actinomyces odontolyticus on culture—consistent an empyema. Ampicillin/Sulbactam was initiated. Despite a negative amylase <3 U/L, there was concern for an esophageal rupture due to significant chest tube output correlating with his oral intake. Computed tomography (CT) of the chest with oral iodinated media contrast demonstrated communication between the esophagus and pleura at the T9 level (Figure 1) and oral contrast leakage into the right pleural space (Figure 2). An endoscopic closure was performed with Ovesco clip, and a covered esophagus stent was placed to ensure complete occlusion. A barium esophagram confirmed closure without additional extravasation into the pleural space. During his hospitalization, nutrition was administered via endoscopically-placed nasojejunal feeding tube and eventually percutaneous endoscopic gastrostomy (PEG), rather than orally. After his hospitalization, serial evaluations were performed to assess the healing of his esophageal mucosa. Due to a small persistent leak, the esophageal stent remained in place for four months. It was ultimately removed after complete resolution of this defect.
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