Presentation
Upper abdominal pain and discomfort following sleeve gastrectomy done about a year ago with recent history of cough and fever.
Patient Data
There is a large cavitary lesion with gas-fluid level and mottled gas foci seen at the left lower lung lobe associated with pulmonary infiltrates around it. It shows post-contrast wall enhancement in keeping with lung abscess. This lung abscess shows subdiaphragmatic extension through a defect in the left diaphragmatic copula.
Sutures for sleeve gastrectomy are seen. Lateral to the stomach, there are multiple hyperdense clumps and few gas foci. These changes are suspicious for leaks from a perforated bowel. The hyperdense clumps are mostly representing leaked contrast from the stomach as the patient had a previous CT study with oral contrast at another institute.
Hepatic hemangioma (confirmed by triphasic CT), small gall bladder stones (confirmed by ultrasound) and accessory splenule are also noted.
CT Image courtesy of Dr. Mahmoud Osman.
Chest radiograph was obtained following placement of drainage catheter for the lung abscess that appears as lung opacity with gas-fluid level.
Upper gastrointestinal contrast study was performed and revealed a contrast leak from the left aspect of the stomach to the left subdiaphragmatic region. The fluoroscopy study was terminated before the contrast seen in the left pleural space as the patient was liable for the risk of aspiration.
Case Discussion
Gastropleural fistula is a rare abnormal communication between the stomach and the pleural sac through the diaphragm. In this case; the underlying etiology was the previous sleeve gastrectomy that was complicated by the presence of a defect in the gastric wall. It is suggested that this defect led to the slow flow of the gastric acids that eroded the diaphragm and resulted in the formation of lung abscess.