Barium aspiration through a tracheo-oesophageal fistula caused by percutaneous tracheostomy.

Alqurashi MM, et al. BMJ Case Rep 2017. doi:10.1136/bcr-2017-220486 Description A healthy 43-year-old gravida 14, para 12+1 woman, developed Sheehan syndrome followed by disseminated intravascular coagulopathy and sepsis post-Caesarean section. Her postoperative course was further complicated by a hospital-acquired pneumonia for which she required endotracheal intubation and mechanical ventilation. Enteral feeding and medications were administered via a nasogastric tube (NGT). After three failed attempts at extubation, a tracheostomy was inserted percutaneously. Over the next 2 weeks, she improved and was successfully weaned off ventilatory support. She was transferred to a medical ward with the tracheostomy in situ with minimum oxygen requirement. Her rehabilitation progressed slowly while the NGT was kept in situ in view of recurrent aspiration with oral intake. A barium study was performed via the NGT after she developed severe vomiting and CT of the abdomen was reported as normal. This demonstrated mild gastritis and delayed gastric emptying due to ileus. No immediate complications were apparent during the barium study. A few hours after the barium study, the patient vomited and reported mild breathlessness. Although she did develop a slight tachypnoea, she did not desaturate and there was no increase in oxygen requirement. Rather unexpectedly, a chest X-ray revealed massive bilateral aspiration of barium that had affected the right lung more than the left (figure 1). The extent of the radiological abnormalities was significantly out of proportion to her mild symptoms and signs. Radio-opacities due to aspirated barium usually persist for many years due to slow clearance. Indeed, a chest X-ray performed 5 months after aspiration of barium (figure 2) still showed residual opacities.