A 56-year-old woman with severe acute respiratory syndrome (SARS) in May 2003, was intubated and put on a mechanical ventilator because of persistent pulmonary inflammation with respiratory failure. After a 2-month intubation, tracheostomy was performed. Mechanical ventilation was weaned gradually; however, there was extensive bowel distention, as shown by plain radiography of the abdomen (A). Additional regular episodic hyperactive bowel sounds were audible at the epigastric area. Suspecting a tracheoesophageal fistula, endoscopy was performed; an orifice, measuring 1.0 cm in diameter, at 18 cm below the incisors, with part of the endotracheal tube balloon visible at the orifice (B) was found with intermittent air bubbles emanating from it. Bronchoscopy also revealed a 1.0-cm orifice at 6 cm below the vocal cord (C). The patient was referred for surgical repair of the fistula. Endoscopists should recognize the possibility of a tracheoesophageal fistula in patients with a distended abdomen and prolonged use of an endotracheal tube with mechanical ventilation support.
