We report a case of a 14-year-old male patient referred to us as a case of right-sided lung abscess. The patient was treated for the entericperforation elsewhere, following which he developed productive cough, which progressively worsened. The preoperative diagnosis ofentero-pleural fistula was made with the help of thoraco abdominal computed tomography scan after 4 months of antitubercular andantibiotic treatment. Enteric perforation leading to entero-pleural fistula is very rare. The patient did well after laparotomy and completeexcision of the fistula

Agarwal, Prakash

James, Saji

Rakesh, P

Subramanian, Balagopal

Vinoth, P N

English

Atharva Scientific Publications (E-Jounals)

Vol 2 | Issue 1 | Jan - Mar 2015 Indian J Child Health 18
James et al. Enteropleural fistula: A rare case report
Case Report
A rare case of pediatric enteroplueural fistula, which presented as lung abscess
Saji James1, Prakash Agarwal2, P N Vinoth1, Balagopal Subramanian2, P Rakesh1
From 1Department of Pediatric Medicine, Sri Ramachandra Medical College & Research Institute, Chennai, Tamil Nadu, India, 
2Department of Pediatric Surgery, Sri Ramachandra Medical College & Research Institute, Chennai, Tamil Nadu, India
Correspondence to: Dr. Prakash Agarwal, F-31, H Block, Jains Avantika Apartments, Manapakkam, Chennai - 600 125, Tamil Nadu, 
India. Phone: +91-9840114749, E-mail: agarwal_prakash@hotmail.com
Received – 01 January 2015 Initial Review – 19 January 2015 Published Online – 27 February 2015
Abstract
We report a case of a 14-year-old male patient referred to us as a case of right-sided lung abscess. The patient was treated for the enteric 
perforation elsewhere, following which he developed productive cough, which progressively worsened. The preoperative diagnosis of 
entero-pleural fistula was made with the help of thoraco abdominal computed tomography scan after 4 months of antitubercular and 
antibiotic treatment. Enteric perforation leading to entero-pleural fistula is very rare. The patient did well after laparotomy and complete 
excision of the fistula.
Key words: Entero-pleural fistula, Lung abscess, Ileal perforation
Entero-pleural fistula is a rare entity in which there is a communication between the intestinal tract and pleural cavity. Entero-pleural fistula following the enteric 
perforation may be caused by communication between the 
small bowel loops and the abscess cavity, eroding through 
the diaphragm into the pleural space [1,2]. There are very 
few case reports in English literature about this, based on 
PubMed citations. We present a case of entero-pleural fistula 
in a 14-year-old child, which presented as a case of lung 
abscess after he underwent a surgery for ileal perforation as a 
complication of enteric fever.
CASE REPORT
A 14-year-old, developmentally normal boy, who was born 
of a non-consanguinous marriage, presented with complaints 
of cough and difficulty in breathing for 3 months. The patient 
had no complaints of fever, loss of weight, or appetite. There 
was no history of contact with tuberculosis. The patient had 
a history of enteric fever 4 months back, followed by ileal 
perforation and was operated for the same elsewhere. Patient 
was asymptomatic for 1 month, after which he developed 
cough, which progressively worsened. The cough was 
aggravated on lying down (expectorating copious amounts of 
sputum) but was relieved in the sitting position. The patient 
was unable to sleep for days together in the supine position, 
and he used to sleep in an upright position. The patient was 
taken to a nearby hospital, where he was started on antibiotics 
and, later on the antitubercular medication as there was no 
significant improvement. After taking antitubercular drugs 
for a period of 1 month, the patient showed no clinical 
improvement. Hence, the patient was referred to us for further 
management.
On admission, the patient’s anthropometric measurements 
were: weight of 32 kg (<5th centile on the centers for disease 
control [CDC] growth chart), height of 153 cm (10th centile 
on CDC growth chart), and body mass index of 13.7. On 
examination, the patient was grossly emaciated with pallor, 
showed significant cervical and axillary lymphadenopathy with 
minimal dilated veins on the abdomen and a large incisional 
hernia of about 10 cm × 8 cm. Systemic examination showed 
bilateral coarse crepitations with decreased air entry on the 
right infra scapular region.
Blood investigations showed hemoglobin of 7 g/dl, 
peripheral smear showed hypochromic microcytic anemia, 
erythrocyte sedimentation rate was mildly elevated, and work 
up for tuberculosis was negative. Chest X-ray showed features 
suggestive of lung abscess (Fig.1). Intercoastal drainage was 
done, and about 800-900 ml of pus was drained. The patient 
was empirically started on intravenous antibiotics. On further 
probing, a history of food particles in the sputum was revealed. 
A computed tomography (CT) scan (Fig. 2) of the chest and 
abdomen were performed to rule out any abnormal connection 
between the pleural cavity and the intestine. The scan confirmed 
the entero-pleural fistula.
The patient was taken up for surgery with preoperative 
blood transfusion to build up the patient for surgery. Explorative 
laparotomy was done, and fistula of approximately 2 cm was 
identified between the distal small intestine and diaphragmatic 
Vol 2 | Issue 1 | Jan - Mar 2015 Indian J Child Health 19
James et al. Enteropleural fistula: A rare case report
area on the right side. It was suture ligated and closed. The 
thorax was not opened as it was deemed unnecessary due to 
fragile patient condition. The option to do a thoracotomy in 
case he did not improve was kept in mind. The incisional hernia 
was also repaired in the same sitting. An intercostal drain was 
kept in the right thorax. Patient was kept in intensive care unit 
for continuous monitoring. Patient improved significantly after 
2 weeks with no new symptoms.
DISCUSSION
Fistula is an abnormal passage or connection usually between 
two internal organs, or leading from an organ to the surface 
of the body. External fistulae connect any portion of the 
gastrointestinal tract with the skin. Internal fistulae connect the 
gastrointestinal tract with another internal organ, peritoneal 
space, retroperitoneal areas, or the thorax (pleural cavity or 
mediastinum) [1]. Gastrointestinal fistulae occur mostly 
following surgery (80%) but they occur spontaneously as 
well. They are associated with substantial morbidity and 
mortality [2]. Pleural space may communicate pathologically 
in the form of gastrointestinal fistula, gastropleural fistula, 
esophagopleural fistula, colopleural fistula and small bowel 
fistula.
The diaphragm is a strong barrier that separates the pleural 
and abdominal cavities. In certain situations formation of a 
fistulous tract might occur, for example, in cases of trauma, 
malignancy, sub diaphragmatic infection, post radiation and 
viscous perforation [3,4]. In such cases thorough history, 
physical examination, nature of pleural fluid drainage, pus 
culture and radiological examination is essential to diagnose 
the underlying pathology.
In 1987, Ronald L. Richterman reported a case of 
jejunopleurobronchial fistula and he mentioned that he found 
a similar case by reviewing the literature [5]. In 2012, Jamal, 
Alaydi reported a case of entero-pleural fistula in a 65-year-old 
man following an emergency left hemicolectomy for colonic 
gastrointestinal stromal tumor [6].
In the present case, an improperly treated enteric 
perforation led to secondary infection and accumulation 
of pus, which eroded the liver parenchyma and entered the 
base of the diaphragm. This led to continuous friction on the 
diaphragm which resulted in the formation of a blind tract that 
is fistulous connection between the small intestine and pleural 
space. Second, the pus culture, which was taken from the site 
grew non-specific organism Escherichia coli which again 
indicates that the infectious agent is from the small intestine. 
Radiologically, X-ray will not properly confirm the diagnosis; 
hence the best modality will be either CT or magnetic 
resonance imaging [3]. Fluctuation of pleural catheter output in 
relation to oral intake was indicative of the fistula. In summary, 
gastrointestinal pleural fistula must be considered as a possible 
cause of refractory empyema.
CONCLUSION
Improperly operated ileal perforation may lead to the collection 
and secondary infection which later causes fistulous tract that 
leads to morbidity to the patient. Gastrointestinal pleural 
fistula must be considered as a possible cause of refractory 
empyema.
REFERENCES
1. Falconi M, Pederzoli P. The relevance of gastrointestinal fistulae 
in clinical practice: A review. Gut. 2001;49 Suppl 4:iv2-10.
2. Rejchert S, Karpocheva M, Brunes J. Current approach 
to gastrointestinal fistula. Folia Gastroenterol Hepatol. 
2007;5(1):18-32.
3. Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal 
fistulas: Classification, etiologies, and imaging evaluation. 
Radiology. 2002;224(1):9-23.
4. Nwose PE, Nwofor AM, Ogbuokiri UC. Duodeno-pleural fistula: 
Figure 1: Chest X-ray shows air fluid level suggestive of 
lung abscess
Figure 2: Computed tomography scan of chest and abdomen 
suggestive of abnormal communication between the chest 
and abdomen
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James et al. Enteropleural fistula: A rare case report
A rare complication of peptic ulcer perforation. Niger J Clin 
Pract. 2006;9(1):84-6.
5. Richterman RL, Caroline DF, Friedman AC, Rubin RN, Boyd R, 
Radecki PD, et al. Enterobronchial fistula. Gastrointest Radiol. 
1987;12(3):194-6.
6. Jamal A. An entero-pleural fistula referred as a case of right sided 
lung abscess. Rawal Med J. 2012;37(2):217-9.
Funding: None; Conflict of Interest: None Stated
How to cite this article: James S, Agarwal P, Vinoth PN, 
Balagopal, Rakesh P. A rare case of pediatric enteroplueural 
fistula which presented as lung abscess. Indian J Child Health. 
2015;2(1):18-20.


A rare case of pediatric enteroplueural fistula, which presented as lung abscess

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A rare case of pediatric enteroplueural fistula, which presented as lung abscess

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