Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 5, 2003, pp. 442-444

Indian Journal of Surgery, Vol. 65, No. 5, Sept-Oct, 2003, pp. 442-444

Case Report

Tracheo-oesophageal fistula - an unusual complication following celphos poisoning

Jitendra Tiwari, B. Lahoti, K. Dubey, P. Mishra, S. Verma

Department of Surgery, M.G.M. Medical college, Indore.
Address for correspondence: Dr. Jitendra Tiwari, Department of Surgery, M.G.M. Medical college, Indore.

Paper Received: April 2002. Paper Accepted: November 2002. Source of Support: Nil.

How to cite this article: Tiwari J, Lahoti B, Dubey K, Mishra P, Verma S. Tracheo-oesophageal fistula - an unusual complication following celphos poisoning. Indian J Surg 2003;65:442-4.

Code Number: is03092

ABSTRACT

Celphos is an aluminium phospate based pesticide commonly used for preserving wheat. We present a 32-year old man who consumed a celphos tablet with suicidal intent and subsequently developed a tracheo-oesophageal fistula. This case is presented as an unusual complication of celphos poisoning.

Key Words: Celphos, Poisining, Tracheo-oesophageal fistula.

INTRODUCTION

Celphos is an aluminium phosphide-based pesticide, which is commonly used for preserving wheat. It has emerged as a common poison used to commit suicide. Celphos poisoning usually presents with a gastrointestinal upset and shock followed by adult respiratory distress syndrome (ARDS) and central nervous system manifestations. Common complications of this poisoning include haemorrhage, acute renal failure, disseminated intravascular coagulation and arrythmias.¹ We report a case of tracheo-oesophageal fistula developing after celphos poisoning.

CASE REPORT

A 32-year-old male consumed a tablet of celphos under the influence of alcohol with a suicidal intent. The tablet got stuck in the mid-oesophagus. Incidentally, his 7-year-old daughter saw him consuming the tablet and reported the matter to his father-in-law. The old man put his fingers inside the patient's mouth and made him vomit the tablet. This process lasted about 8 to 10 minutes. The patient was shifted to the hospital immediately, where a thorough gastric lavage was done and he was treated. He was discharged from the hospital after complete recovery. On the 12^th day following the poisoning he noticed some difficulty in swallowing solids which gradually progressed to liquids. Three weeks after the episode, he could not swallow anything and any attempt to drink even water used to stimulate a severe cough reflex. He was hospitalised again in a different hospital, and a barium swallow was done. This showed the presence of a tracheo-oesophageal (TO) fistula with a oesophageal stricture below it. Oesophagoscopy revealed a tight stricture at 25-cm from the incisor teeth through which the endoscope could not be negotiated. Biopsy of the tissue from the lesion showed chronic non-specific inflammatory changes and without any evidence of malignancy.

Owing to the absolute dysphagia and non-negotiable stricture, he was offered surgery. The oesophagus was mobilised through a right lateral thoracotomy using an extra-plural approach. A 3-4 mm communication was identified between the oesophagus and the trachea at the level of the carina. This was associated with a 1-cm oesophagal striucture. The T-O fistula was disconnected below the stricture and the tracheal rent was repaired by 3- 0 polypropylene sutures. The oesophageal stricture was excised and an end-to-end oesophageal anastomosis was performed. An extraplural chest drain was placed and the thoracotomy closed. The postoperative recovery was uneventful with a gastrograffin swallow done on the 10^th postoperative day showing no leak from the anastomosis. The patient was then gradually allowed to have liquids and then progressed to solids.

DISCUSSION

The patient was in an inebrieted state before consuming the celphos tablet, which being large got stuck in the mid-oesophagus. It remained stuck there for some time making contact with the oesophageal mucosa and thus inducing severe corrosion. Celphos is known to liberate phosphine gas, specially when it comes into contact with moist surfaces.² Phosphine is a systemic poison, as has been found at autopsies and causes severe congestion and evokes a significant inflammatory response.³ This excessive inflammation and corrosion at the site of contact of the tablet with the oesophageal mucosa near the carina led to the occurrence of T-O fistula in our patient.

In conclusion, this appears to be an isolated case reported in the literature of T-O fistula, developing after celphos poisoning. Possibility of this occurrence should be kept in mind when dealing with patients with celphos poisoning.

REFERENCES

1. Siwach SB, Yadav DR, Arora B, Dalal S. Acute aluminium phosphide poisoning, an epidemiological, clinical, and histopathological study. JAssoc Phys India 1988;36:594-6.
2. Koley TF. Aluminium phosphoid poisoning. Indian J Clin Pract 1988;9:14-22.
3. Chung SN, Arora BB, Melhotra GC. Incidence and outcome of aluminium phosphoid poisoning in a hospital study. Indian J Med Res 1991;94:232-5.
4. Tan KK, Lee JK, Tan I, Sarvesvaran R. Acquired tracheo-oesophageal fistula following tracheal intubation in a burned patient. Burns 1993;19:360-1.
5. Soman RL, Sawani M. Plural effusion, a rare complication of Aluminium phosphide poisoning, Indian Paediatr 1999;36:1161-3.

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