Page 14 / April 07

---

Discussion - Bronchoesophageal fistula

1. Congenita4l Bronchoesophageal Fistula
Congenital bronchoesophageal fistula is rare. It was first described by Gibson in 1696 and Negusin in 1929. The most recognized classification presented by
Braimbridge and Keith¹ in 1965 divide into 4 types as the followings;

• type I, with esophageal diverticulum
• type II, direct, short tract from the esophagus to the bronchus
• type III, connect to a cyst in the lobe
• type IV, connect to a sequestrated lung

There are less than 120 cases of bronchoesophageal fistulas in the literature ^2-9. Most of the cases with esophageal atresia were diagnosed in infancy due to obvious symptoms of respiratory distress, excessive salivation and pathognomonic radiography. Some cases without esophageal atresia may persist until childhood or adulthood. Possible explanations for the late onset include the presence of a membrane that subsequently ruptures, presence of an esophageal fold that occludes the esophageal opening of fistula subsequently rendering it less mobile, a fistulous tract that may close during swallowing due to spasm of smooth muscle in the fistula wall, an extension of the fistulous tract upwards from esophagus, or adaptation of the patient to minimal symptoms^{2-5, 7}.

Distinguishing congenital from acquired bronchoesophageal fistula is based on the histologic examination. The presence of squamous or columnar epithelium with mucosa and muscularis mucosa suggests a congenital origin; Their absence or presence of inflammatory reaction suggests that fistula was acquired ^2,3,9.

The most common chief complaint are postprandial cough (30%) and hemoptysis (23%)⁵. Esophagography is the most useful diagnostic investigation. Most of cases the fistula was easily visible from esophagoscopy compared to bronchoscopy (11/13 v.s. 4/13)⁵

The largest review of the Communicating Bronchopulmonary Foregut Malformations (CBPFMs) appeared in 1992 and included 57 patients in a 30-year experience(1959 to 1989)¹⁰. Srikanth MS et al proposed the CBPFMs classification be supported by embryogenesis theory.

Group I (16%):	associated with esophageal atresia and tracheoesophageal fistula.
Group II (33%):	one lung originates from the lower esophagus.
Group III (46%):	isolated anatomic lung lobe or segment (extralobar sequestration) communicates with the esophagus or stomach (Figure 13) Figure 13
Group IV (5%):	portion of the normal bronchial system, mostly from right lung, communicates with the lower esophagus, similar to our patient. (Figure 14) Figure 14

2. Acquired Bronchoesophageal fistula
There are approximately 40 cases in literature^11-14. The most common cause is pulmonary tuberculosis, presenting with mediastinal adenopathy. The histology reveals granuloma and positive Acid Fast Bacilli. The treatment of choice is anti-tuberculous drugs and may proceed to surgical resection if failed medical treatment.

There is a case report of tracheobroncheal foreign body that can cause bronchoesophageal fistula¹⁵. However, this is a very rare condition.

---

References & Acknowledgements /