Colopleural fistula: a rare case of diverticulitis induced lung abscess formation

초록

Fistulas between the abdomen and pleura are very rare, and not many cases have been reported. Colopleural fistula (CF) has a very high mortality rate and requires surgery upon diagnosis. Here we present a case of a patient whose CF progressed to a lung abscess due to diverticulitis. A 63-year-old male patient was transferred to our hospital due to epistaxis during antibiotic therapy at a local hospital with a diagnosis of sepsis and pneumonia with lung abscess of Left lower lobe (LLL). The patient was diagnosed with diabetes mellitus and atrial fibrillation as comorbidities and had a history of primary repair for gastric ulcer perforation. Antibiotics were Piperacillin/tazobactam 4.5 grams 4 times and levofloxacin daily for 5 days, but the infection persisted and pancytopenia and metabolic acidosis progressed. After hospitalization, the antibiotic was changed to intravenous cefepime. On the 6th day of hospitalization, a follow-up computed tomography revealed a colopulmonary fistula between the LLL and splenic flexure (SF) colon. In addition, a colonoscopy showed a diverticulum in the SF and a connection to a lung abscess. In response, left hemicolectomy, small bowel adhesiolysis, video-assisted thoracic LLL, and diaphragm primary repair of the fistula site were performed in the thoracic surgery department. When exploratory laparotomy was performed due to pus like drainage around postoperative day 10, irrigation was performed for intraabdominal abscess. The patient underwent emergency EGD for hematemesis around 15 days after reoperation, and bleeding control for huge gastric ulcer was performed. The patient was discharged after 2 weeks without further complications. Lung abscesses caused by CF are rare and almost always diagnostically challenging. However, pneumonia with a lung abscess that does not respond to prolonged antibiotic therapy should be the first suspicion for CF and should be diagnosed quickly and treated surgically.