UNUSUAL PRESENTATION OF HEMOPTYSIS IN A 78-YEAR-OLD WITH PREVIOUS NISSEN FUNDOPLICATION

A 78-year-old individual, who had a previous transthoracic Nissen fund oplication 20 years earlier, presented to our institution with hemopty sis. Initial workup included chest roentgenogram, upper gastrointestin al series, and upper endoscopy, all of which were nondiagnostic. A rep eat upper endoscopy diagnosed a gastrobronchial fistula by revealing a large gastric ulcer that penetrated into the lung parenchyma. The pat ient underwent surgery for takedown of the fistula. One of the most co mmon symptoms associated with gastrobronchial fistula is hemoptysis, a lthough insidious cough, recurrent pneumonia, or gastrointestinal blee ding are also observed. The most useful diagnostic study is an upper g astrointestinal series, which must be read with a high index of suspic ion. Gastrobronchial fistula is most commonly a long-term complication from hiatal hernia repair. The most frequently used procedure for rep air of this disorder is the Nissen fundoplication. This can be done fr om either an abdominal or transthoracic approach. When the procedure i s done such that the gastric wrap is left above the diaphragm, serious complications can occur. These include gastric ulceration, gastric he rniation with gastric outlet obstruction, slippage or perforation of t he wrap, and gastrobronchial fistula. Because of these serious complic ations, the Nissen fundoplication with the wrap left above the diaphra gm should only be used in certain situations, such as obesity and shor tened esophagus.