Gastro-bronchial fistula.

OF the various gastric fistulae described in the literature those communicating with the bronchi appear to be among the rarest. Aird (1957) devotes only four lines to the subject while Milne and Thompson (1970) state that a careful search of medical literature failed to reveal any reference to the condition. This is somewhat misleading as the literature since 1960 contains seven case reports and a number of earlier references have been encountered in the preparation of this paper. It would appear that gastro-bronchial fistulae may arise in one of four ways (Table 1). The largest group develop as a complication of a subphrenic abscess extending through the diaphragm to form an empyema, or lung abscess, which in turn drains into the bronchial tree. The formation of a bronchial fistula in this way is a well recognized complication of subphrenic abscess and occurs in about 10% cases (Ochsner and Graves, 1933; Wetterfors, 1960). Where the subphrenic abscess has arisen from perforation of the stomach, or when it causes necrosis of a part of the stomach wall, a gastro-bronchial fistula may ensue. A somewhat similar process accounts for the second group which develops as a result of the perforation of a stomach incarcerated in a diaphragmatic hernia. A perigastric abscess lying above the diaphragm occurs and extends into the lung until it eventually drains via the bronchial tree. A third group results from necrosis in an infiltrating carcinoma which may be either a primary tumour of the stomach or a tumour arising in a nearby site which infiltrates the stomach and also extends via the diaphragm into the lower lobe of the left lung. Tumours behaving in this way may also involve adjacent loops of bowel, particularly the colon, with the formation of even more complex fistula tracks. The fourth type of gastro-bronchial fistula is traumatic in origin resulting from rupture of the diaphragm associated with damage to both the lung and the stomach. The present case which was secondary to a carcinoma of the pancreas appears to be a considerable rarity and worthy of record on that account.