Acquired non-malignant tracheoesophageal fistula secondary to esophagogastroduodenoscopy in a patient on mechanical ventilation

Abstract

A 73-year-old woman presented to the hospital with a non-ST segment elevation myocardial infarction and cardiomyopathy. She was intubated for mechanical ventilation, underwent a left heart catheterization, and had a stent placed in her LAD. Because of her cardiomyopathy, she did poorly during weaning trials. After discussions with the patient and family, she underwent an open tracheostomy and then a percutaneous gastrostomy (PEG) tube placement on consecutive days. The patient was disoriented the following day, had an elevated WBC, and started on broad spectrum antibiotics. She did not have any difficulty with mechanical ventilation at this time. There was no air leak or changes in peak airway pressures. There was no difficulty in passing the suction catheter through the tracheostomy tube. Clinical examination did not reveal any subcutaneous emphysema. A chest x-ray did not show any obvious pathology. She was tolerating her enteral feeding well. An abdominal ultrasound did not reveal any abnormality. She had a bronchoscopy through the tracheostomy which showed minimal secretions, a normal carina, and normal left and right bronchial trees (Figure1). The bronchoscope was then introduced through the mouth to evaluate the hypopharynx and cricopharynx. She had acquired a tracheoesophageal fistula (TEF) with an inflated tracheostomy cuff visible in the esophagus (Figure 2). Methylene blue was injected to the stomach through the PEG tube; this procedure was negative for a gastropulmonary fistula.