Abstract Introduction Acquired tracheoesophageal fistula (TEF) in adults is rare and is usually associated with malignancy or prolonged mechanical ventilation. Endoscopic procedures are an exceptionally uncommon cause, particularly when no perforation is initially detected. Here, we present a case of delayed, occult TEF following endoscopy in a patient with severe erosive esophagitis, presenting solely with recurrent right pleural effusion. Case Presentation A 48-year-old woman with alcoholic cirrhosis (Child-Pugh A), moderate persistent asthma, and severe reflux esophagitis presented with progressive right-sided pleuritic chest pain and dyspnea for one month. Two weeks earlier, she underwent EGD for upper GI bleeding, which revealed Los Angeles grade D esophagitis and a 2.2 cm hiatal ulcer without evidence of perforation.On admission, chest X-ray revealed a moderate right pleural effusion. Given her cirrhosis, hepatic hydrothorax was suspected. Therapeutic thoracentesis was reported to have removed approximately 900 mL of yellow fluid; however, the effusion rapidly recurred. Repeat fluid analysis was unexpectedly exudative (protein 3.3 g/dL, LDH 260 U/L), inconsistent with hepatic hydrothorax. She denied odynophagia, dysphagia, or aspiration.Empiric antibiotics were started for presumed parapneumonic effusion, but symptoms persisted. The diagnostic turning point occurred when pleural fluid analysis revealed markedly elevated amylase (1,950 U/L) and the presence of mixed oral anaerobes, raising suspicion of TEF. CT chest with oral contrast showed subtle tracheal contrast tracking. Bronchoscopy confirmed a 6 mm posterior membranous defect, consistent with acquired TEF. It was determined to be a delayed complication from mucosal fragility due to severe esophagitis worsened by a recent endoscopy.She underwent esophageal rest, tracheal stenting, and eventual surgical fistula repair. Her effusion did not recur.DiscussionThis case demonstrates how delayed airway-esophageal injury can occur even after routine EGD, especially in the setting of severe esophagitis. TEF rarely presents with effusion alone, and the absence of dysphagia or aspiration delays suspicion. Elevated pleural amylase and polymicrobial flora were key diagnostic clues. Early recognition is crucial in preventing recurrent aspiration, sepsis, and progressive mediastinal injury. Conclusion Not all recurrent effusions in cirrhotic patients are hepatic hydrothorax. In patients with recent EGD and esophageal disease, TEF must be considered, even in the absence of classic symptoms. Detailed pleural fluid analysis can be lifesaving. This abstract is funded by: None
Fox et al. (Fri,) studied this question.