Ann Thorac Surg 2004;77:324-326
© 2004 The Society of Thoracic Surgeons
Case report
Empyema resulting from a true colopleural fistula complicating a perforated sigmoid diverticulum
Kostas Papagiannopoulos, MMEDa*,
Dimitrios Gialvalis, MDa,
Ibrahim Dodo, MRCSa,
Mike J. Darby, MDb
a Cardiothoracic Surgery, Leeds General Infirmary, Leeds, United Kingdom
b Radiology, Leeds General Infirmary, Leeds, United Kingdom
Accepted for publication April 29, 2003.
* Address reprint requests to Dr Shiraishi, Division of Pediatrics, Children's Research Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan 602-8566.
e-mail: isao{at}koto.kpu-m.ac.jp
 |
Abstract
|
|---|
Empyemas developing after traumatic rupture of intraabdominal organs have been previously reported. We report a case of a true nontraumatic colopleural fistula following surgery for spontaneous rupture of a sigmoid diverticulum. The diagnosis was suspected by the presence of an air-containing tract seen in a computerized tomogram of chest and abdomen and was established with a contrast study. The empyema cavity was initially drained, followed by a laparotomy and fistulectomy with primary large bowel anastomosis and loop ileostomy. Although rare, colopleural fistulas present a diagnostic challenge and delayed management can lead to increased morbidity.
|
Introduction
|
|---|
Empyemas following inflammatory bowel diseases or intestinal trauma could indicate a fistulous connection of bowel with the pleural cavity. Careful evaluation of the pleural fluid, computerized tomograms of chest and abdomen, and contrast studies could provide early, prompt diagnosis leading to appropriate management.
A 46-year-old male smoker, with no significant past medical history, presented in the Accident and Emergency Department with an acute abdomen. An emergency laparotomy and Hartmann's procedure was undertaken for a perforated sigmoid diverticulum, complicated with abscess formation and fecal peritonitis. His postoperative recovery was slow but uneventful. Two months later he was readmitted with fever, left sided upper abdominal and thoracic pain, and significant weight loss. On examination he looked pale and malnourished. The chest film revealed left sided pleural effusion, which was initially drained with insertion of an intercostal drain. Computerized tomography (CT) of the chest and abdomen showed a basal empyema pocket with a trapped left lower lobe and no intraabdominal collection. He was transferred across to our department. Due to his general condition, a rib resection was performed with evacuation of the empyema, curettage of the cavity, and placement of a thick bore drain. His condition improved dramatically and he was discharged 48 hours later. He was readmitted though with left upper abdominal pain and fever. The chest drain fluid had now become severely malodorous and turbid. Cultures revealed coliforms and streptococcus group D growth. An urgent CT of chest and abdomen showed a small residual effusion and a suspicious looking air-containing tract which could be followed in the peritoneal cavity close to the colostomy area (Fig 1).
A colostomy enema was performed with 400 mL of Niapam 300 contrast. The sinogram revealed a network of true colopleural fistulas, the longest extending from the colostomy site to the pleural space, and a communicating channel with the distal large bowel stamp (Fig 2).
The patient received an urgent laparotomy with adhesiolysis, further en bloc resection of the fistula and colon, with primary large bowel anastomosis and loop ileostomy. He was finally discharged 10 days later in very good clinical condition. Two months later his empyema cavity had resolved with full reexpansion of the left lung. No further surgical management was necessary.
View larger version (113K):
[in this window]
[in a new window]
|
Fig 1. Suspicious (circle) air-containing tract, showing in computed tomography of the chest and abdomen.
|
|
View larger version (124K):
[in this window]
[in a new window]
|
Fig 2. Contrast study through colostomy (1) revealing a long fistulous connection (2) with the left pleural space.
|
|
|
Comment
|
|---|
In our case, the empyema was the result of a colopleural fistula. Although visceropleural fistulas are rare entities, their presentation can be dramatic upon failure of early diagnosis.
Our literature review revealed four similar cases. Olesen and associates reported a nontraumatic colopleural fistula causing empyema with no definitive etiology [1]. Radin and associates, as well as Sinha and associates [2, 3], have reported cases of colopleural fistulas, after undiagnosed diaphragmatic ruptures or congenital diaphragmatic hernias, leading to colon herniation and necrosis with rupture and empyema. Roberts and associates [4] reported a similar case of empyema due to gastric wall erosion and rupture into the pleural cavity with associated gastro colonic fistula. Our case presented as a true colopleural fistula with tract formation and no direct continuity of the colonic lumen with the diaphragm.
How can anyone suspect such a rare pathology? There is no specific protocol other than high suspicion in cases of combined upper abdominal and chest pain with associated unexplained pleural effusion. The microbiology and biochemical analysis of the pleural effusion might give further information combined with previous medical history, detailed clinical examination, and CT of the chest and abdomen. We found, nevertheless, that the contrast study of the gastrointestinal tract not only demonstrates effectively the pathology, but provides useful information for further treatment planning.
There is no universally accepted management for colopleural fistulas. Conservative treatment with total parenteral nutrition can be considered in selected uncomplicated cases, or where surgery is contraindicated with associated comorbidity [1, 5]. Successful conservative management might be compromised, due to the pressure gradient between the abdominal and pleural end of such fistulas, since the intrapleural pressure is negative or when the fistulous tract is covered with mucosa.
Surgical management is essential when there is associated complex pleural pathology, with or without colonic pathology such as distal obstruction, ischemic bowel necrosis, malignancy, or a complex network of established true fistulas.
In conclusion, colopleural fistulas are rare and present, almost always, a diagnostic challenge. They could be classified as traumatic or nontraumatic and false or true when an established sinus is present. Diagnosis should be suspected by the presence of colonic flora in the pleural cavity following colonic injuries or benign and malignant abdominal pathology, or ongoing unexplained pleural effusion with abdominal pain. Delayed recognition might lead to complications requiring complex management with escalation of hospitalization cost and increased morbidity.
|
References
|
|---|
- Olesen L.L., Pedersen J.T. Colo-pleural fistula. Eur Respir J 1989;2(8):792-793.[Abstract]
- Radin D.R., Ray M.J., Halls J.M. Strangulated diaphragmatic hernia with pneumothorax due to colopleural fistula. AJR 1986;146:321-322.[Free Full Text]
- Sinha M., Gibbons P., Kennedy S.C., Matthews H.R. Colopleural fistula due to strangulated Bochdalek hernia in an adult. Thorax 1989;44:762-763.[Abstract/Free Full Text]
- Roberts C.M., Gelder C.M., Goldstraw P., Spiro S.G. Tension pneumothorax and empyema as a consequence of gastro–pleural fistulae. Resp Med 1990;84(3):253-254.[Medline]
- Graham J.A. Conservative treatment of gastrointestinal fistulas. Surg Gynaecol Obstet 1977;144:512-514.
This article has been cited by other articles:
|
|
|
|
 
B. O. Olubaniyi, E. J. Fontaine, and R. D. Page
Colo-pleural fistula following pneumonectomy
Eur. J. Cardiothorac. Surg.,
December 1, 2006;
30(6):
950 - 951.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
T. S. Vasu, J. Saluja, D. Landsberg, and R. Lenox
An elderly man with sudden-onset shortness of breath and hydropneumothorax
Can. Med. Assoc. J.,
January 31, 2006;
174(3):
311 - 312.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
