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Weekly Chest CasesArchive of Old Cases

Case No : 743 Date 2012-01-21

  • Courtesy of Jeong Joo Woo / Eulji University School of Medicine
  • Age/Sex 51 / F
  • Chief ComplaintIntermittent hemoptysis, cough for over 10 years
  • Figure 1
  • Figure 2
  • Figure 3
  • Figure 4
  • Figure 5
  • Figure 6

Figure 1.

Diagnosis With Brief Discussion

Diagnosis
Benign Bronchoesophageal Fistula (associated with chronic pneumonia)
Radiologic Findings
Chest radiograph shows a bulging opacity in the left lower lobe obliterating the descending aortic margin. CT shows a segmental consolidation in the left lower lobe abutting the esophagus and the thoracic aorta. In the area of consolidation, a tubular low density of fluid-filled bronchus looks extending into the esophageal lumen. Below the level of this connection, there is a small radiopaque spot in the consolidation area with marked luminal dilatation of the esophagus. Neither esophageal mass nor other mediastinal disease was defined on the CT images. Following the impression of broncho-esophageal fistula (BEF) on the CT, large BEF tract was noted on the endoscopy (A) and a communication between the lower esophagus and the posterobasal segmental bronchus was demonstrated on the esophagogram (B). Without any evidence of fibrosis, inflammation or lympahdenopathy around the esophagus, a congenital fistula or foreign body erosion could be considered in this case.

A

B

Brief Review
Different from the common events of malignant BEF, benign BEFs are rare and about 120 cases have been reported in the English literature. They can be congenital or acquired. Acquired BEFs were more frequently reported than congenital types and induced by traumatic, inflammatory (tuberculosis, histoplasmosis), or iatrogenic origin (including foreign body).
Compared to tracheo-esophageal fistulas, which has pronounced symptoms, benign BEF presents with rather inconspicuous and insidious symptoms such as chronic cough or asthma not responding to treatment. Those nonspecific symptoms may delay a correct diagnosis (as was the case in our patient).
A wide array of diagnostic tools is applicable in the diagnosis of BEF. Plain radiography and CT scan of chest can give information of the lungs and the mediastinum, but they may not confirm the clinical suspicion. Endoscopic examinations of bronchi and esophagus may fail to identify the anomalous orifice but may reveal inflammatory changes and exclude a malignancy. Esophagography with dilute barium is almost always decisive in the diagnosis of BEF even if sometimes, despite thorough investigation, the diagnosis is made only at surgery. In this case, CT gave a very helpful information, and esophagoscopy and esophagogram confirmed the diagnosis of BEF.
Once diagnosed, benign BEFs require immediate surgical treatment because of the risk of chronic sepsis, wider tissue destruction requiring additional surgery or fatal massive hemoptysis.
References
1. Mangi AA, Gaissert HA, Wright CD, et al. Benign broncho-esophageal fistula in the adult. Ann Thoracic Surg 2002; 73; 911
Keywords
esophagus, infection,

No. of Applicants : 112

▶ Correct Answer : 39/112,  34.8%
  • - Az Osp Santa Maria Terni , Italy angelo carloni
  • - Youngdong Hospital , Korea (South) Sang Min Lee
  • - UWO , Canada S Lee
  • - Toyama University Hospital, Laboratory of Pathology , Japan TOMONORI TANAKA
  • - mums , Iran bita abbasi
  • - Onomichi municipal hospital , Japan Hirofumi Mifune
  • - Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
  • - Sunchun university hospital, Bucheon , Korea (South) So Young Bae
  • - Seoul National University Hospital , Korea (South) YongSub Song
  • - Kohka Public Hospital , Japan Akitoshi Inoue
  • - Dongnam Institute of Radiological and Medical Sciences , Korea (South) Dae-Wook Yeh
  • - , Korea (South) Seung Soo Kim
  • - James Paget Hospital , U.K , United Kingdom nabil mahmood
  • - Song-do Hospital , Korea (South) Ji-young Yun
  • - CHRU lille , France manuel toledano
  • - Chonnam national university hospital , Korea (South) Jang-hyeon Song
  • - Chonnam National University Hospital , Korea (South) Jung hyun Kim
  • - Saga University , Japan Ryoko Egashira
  • - China Medical University ,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - HUEC , Brazil Diogo Pinheiro
  • - Hangang Sacred Heart Hospital , Korea (South) Eil Seong Lee
  • - Asan Medical Center , Korea (South) Sang Min Lee
  • - Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
  • - Asan Medical Center , Korea (South) Hye Jeon Hwang
  • - Bupyong Serim Hospital , Korea (South) Hee Seok Choi
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - Hangang sacred heart hospital , Korea (South) You Mie Han
  • - chp st martin , France Mariotte benoit
  • - CHU de Bordeaux , France Fran�ois Laurent
  • - Hospital M�e de Deus , Brazil Thiago Bento da Silva
  • - KING ABDULAZIZ SPECIALIST HOSPITAL , Saudi Arabia Elbagir Nasser
  • - Cairo University , Egypt Mamdouh Eissa
  • - Korea university , Korea (South) Kun Woo Kang
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - Suncheon Plus Medicine , Korea (South) Park Sang Hyun
  • - All India Institute of medical sciences , India Justin Moses
  • - shengjing hospital china medical university , China yue yong
  • - Ishikawa Matto Central Hospital , Japan Manabu Akimoto
  • - NDMVP Nashik , India Imran Jindani
▶ Correct Answer as Differential Diagnosis : 18/112,  16.1%
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - radiologist, aditya imaging centre , India vivek patel
  • - University of British Columbia , Canada Amr Ajlan
  • - Cardio Center Pontica , Bulgaria VLADISLAV RUSINOV
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
  • - CSSS St Hyacinthe , Canada olivier krief
  • - Vitalife Clinics , Pune , India. , India Rahul Deshmukh
  • - Iwate Medical University , Japan Akio Akahane
  • - Asan medical center , Korea (South) sang young oh
  • - SAISEIKAI KURIHASHI HOSPITAL , Japan YASUO OOKUBO
  • - Kyungpook National University Hospital , Korea (South) Jaekwang Lim
  • - All India Institute of Medical Sciences , India Jitesh Ahuja
  • - Travancore Medical College , India Chary D
  • - Saint Malo , France jean-baptiste Noel
  • - IRSA , France, Metropolitan BIGOT
  • - Asan Medical Center , Korea (South) Eunyoung Kim
  • - Kizawa Memorial Hospital , Japan Yo Kaneko
  • - XiangYa hospital , China Xia Yu
▶ Semi-Correct Answer : 1/112,  0.9%
  • - Korea university , Korea (South) SUMIN HA
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