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Special Feature
June 2012

Image of the Month—Diagnosis

Author Affiliations


Arch Surg. 2012;147(6):574. doi:10.1001/archsurg.147.6.574
Answer: Colobronchial Fistula

Fistulous tracts between the gastrointestinal tract and respiratory tract lead to chronic respiratory infections and foul-smelling sputum. Case reports of colobronchial fistula are scarce. Colobronchial fistulas are most frequently associated with Crohn disease but have also been linked to infection, trauma, peptic ulcer disease, abscess formation, malignant neoplasm, and surgical injury.15 Because colobronchial fistulas mimic more frequently encountered pulmonary disease, they may be extremely difficult to diagnose. Clinical presentation most commonly includes production of thick, foul-smelling sputum and left-sided recurrent pneumonia caused by enteric flora. A high index of suspicion is required for diagnosis, and the most reliable examination is a barium enema.2,3 Abdominal computed tomography may be useful if enteric contrast material is administered.2,4

Management requires surgical resection of the fistula and control of the inciting inflammatory process. Thoracic drainage and pulmonary resection are rarely required.5 Diversion of the fecal tract may also be necessary depending on the cause of the fistula.1 When the fistula is recognized and treated early, significant and irreversible lung injury is uncommon.

Our patient developed a colobronchial and cologastric fistula following splenectomy, most likely due to an injury to the tail of the pancreas. Activated pancreatic enzymes induced an inflammatory response that extended to the left lower lobe of the lung through the rent in the diaphragm. His relative immunocompromised state due to lymphoma may have contributed. Surgical resection of the colon, stomach, and distal pancreas with primary closure of the bronchial fistula was curative. To avoid ongoing contamination in the left upper quadrant, a transverse colostomy was created. The patient had an uneventful postoperative course and was discharged home 8 days after surgery. Final pathological analysis results were negative for lymphoma. His colostomy was reversed 4 months postoperatively, and he continues to do well.

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Article Information

Correspondence: Cheryl K. Six, DO, Department of Surgery, UPMC Mercy Hospital, 1400 Locust St, Pittsburgh, PA 15219 (sixc@upmc.edu).

Accepted for Publication: July 18, 2011.

Author Contributions:Study concept and design: Six, Young, and Sell. Acquisition of data: Six, Young, and Sell. Analysis and interpretation of data: Six and Sell. Drafting of the manuscript: Six and Young. Critical revision of the manuscript for important intellectual content: Six and Sell. Administrative, technical, and material support: Young. Study supervision: Sell.

Financial Disclosure: None reported.

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