Tracheoesophageal fistula associated with Barrett's ulcer: the importance of reflux control

Natural history of Barrett's esophagus

The natural history of Barrett’s esophagus (BE) is difficult to quantify because, by definition, it should describe the course of the condition if left untreated. Pragmatically, we assume that patients with BE will receive symptomatic treatment with acid suppression, usually a proton pump inhibitor, to treat their heartburn. This paper describes the development of complications of stricture, ulcer, dysplasia and adenocarcinoma from this standpoint. Controversies over the definition of BE and its implications in clinical practice are presented. The presence of intestinal metaplasia and its relevance to cancer risk is discussed, and the need to measure the extent of the Barrett’s epithelium (long and short segments) using the Prague guidelines is emphasized. Guidelines and international consensus over the diagnosis and management of BE are being regularly updated. The need for expert consensus is important due to the lack of randomized trials in this area. After searching the literature, we have tried to collate the important studies regarding progression of Barrett’s to dysplasia and adenocarcinoma. No therapeutic studies yet reported show a clear reduction in the development of cancer in BE. The effect of pharmacological and surgical intervention on the natural history of Barrett’s is a subject of ongoing research, including the Barrett’s Oesophagus Surveillance Study and the aspirin and esomeprazole cancer chemoprevention trial with interesting results. The geographical variation and the wide range of outcomes highlight the difficulty of providing an individualized risk profile to patients with BE. Future studies on the interaction of genome wide abnormalities in Barrett’s and their interaction with environmental factors may allow individualization of the risk of cancer developing in BE.

Clinical Manifestations and Esophageal Complications of GERD

This report focuses on the manifestations of gastroesophageal reflux disease (GERD) that are caused directly by contact between refluxed gastric juice and the esophageal mucosa. These manifestations include heartburn, peptic esophageal erosion and ulceration, peptic esophageal stricture, and Barrett esophagus. Peptic esophageal erosions and ulcerations are excavated defects in the esophageal mucosa that result when epithelial cells succumb to the caustic effects of refluxed acid and pepsin. Uncommonly, esophageal ulcers are complicated by hemorrhage, perforation, and penetration into the airway. Esophageal ulcers can stimulate fibrous tissue production and collagen deposition that result in stricture formation, and the ulcers can heal through a metaplastic process in which an intestinal-type epithelium replaces the damaged squamous cells (Barrett esophagus). The management of these conditions is discussed below.

Esophageal complications of gastroesophageal reflux disease: Presentation, diagnosis, management, and outcomes

The esophageal complications of gastroesophageal reflux disease include peptic esophageal erosion and ulceration, peptic esophageal strictures, and Barrett's esophagus. Endoscopy is the diagnostic procedure of choice for the initial evaluation of lesions. For most patients, symptoms can be controlled with proton pump inhibitor (PPI) therapy. PPIs are also highly effective for healing esophageal erosions and ulcerations and for preventing recurrence of peptic esophageal strictures. Because Barrett's esophagus predisposes individuals to esophageal adenocarcinoma, these patients are advised to have regular endoscopic surveillance to detect early, curable neoplasms.

Perforating Barrett's ulcer resulting in a life-threatening esophagobronchial fistula

Perforating benign ulcer is a very rare complication of Barrett's esophagus. This report presents the management of a patient with a Barrett's ulcer that penetrated into the left mainstem bronchus resulting in a life-threatening bronchial esophageal fistula. This rare complication was successfully managed by using a staged surgical approach, which combined the principles used for treating benign esophagorespiratory fistulas and perforating Barrett's ulcers.

Perforation of Barrett's ulcer: a challenge in esophageal surgery

BACKGROUND

Barrett's ulcer, which develops within Barrett's esophagus, is frequently responsible for bleeding. Perforation is a rare complication constituting a great challenge for diagnosis and management.

METHODS

Three personal cases and 31 published reports of perforated Barrett's ulcer were reviewed retrospectively. The site of perforation, clinical presentation, management, and outcome were assessed.

RESULTS

The clinical presentation proved to be heterogeneous and was determined by the site of perforation: this was the pleural cavity (20% of cases), mediastinum (20%), left atrium (16.6%), tracheobronchial tract (13.3%), aorta (13.3%), pericardium (10%), or pulmonary vein (6.6%). Early esophagectomy and esophageal diversion-exclusion were the most frequent procedures, and overall mortality was 45%.

CONCLUSIONS

The poor prognosis of perforated Barrett's ulcer should be improved by earlier diagnosis and adequate emergent operation. Although early esophagectomy constitutes the recommended procedure, esophageal diversion-exclusion, which allows control of both sepsis and bleeding, is also of interest.

Tension pyopneumothorax. Rare presentation of ruptured Barrett's esophagus

Tension pneumothorax following esophageal rupture is very rare. We report a case in which a perforated Barrett's esophagus rapidly developed a spontaneous tension pyopneumothorax. The mechanism for the tension remains obscure. Knowing that a tension pneumothorax can occur with esophageal rupture can help prevent misdiagnosis.

Barrett's esophagus. A continuing conundrum

Barrett's esophagus, a condition in which the distal esophagus is lined by columnar epithelium, is almost always caused by gastroesophageal reflux and often occurs in conjunction with a sliding hiatal hernia. Patients are typically white men in their 50s who smoke and drink, and they present with complaints of regurgitation, heartburn, and/or dysphagia. Endoscopic biopsies are required to confirm the diagnosis. Complications, such as stricture, ulcer, dysplasia, and malignant degeneration, occur in many cases. Adenocarcinoma is the most serious complication. Medical treatment, including life-style changes as well as pharmacologic therapy, usually relieves symptoms and heals esophagitis, but when it fails, antireflux surgery is indicated. Patients without evidence of dysplasia should undergo endoscopy yearly; those with mild dysplasia require more frequent surveillance. If biopsies disclose severe dysplasia, esophagogastrectomy should be performed.

Acquired tracheoesophageal fistula in infancy and childhood

Acquired tracheoesophageal fistula (TEF) is a rare entity in the pediatric age group. We report two pediatric patients with acquired TEF caused by shells of pistachio nuts. In both patients the primary operation did not resolve the problem and a second intervention for recurrent fistula was needed. The special nature of acquired TEF, particularly the one described herein, requires delayed surgical intervention and meticulous separation of the respiratory and alimentary tracts by an intercostal muscle flap.