Amphoric abdomen: An unusual finding.

Sir,

A 62-year-old male, a known case of squamous cell carcinoma of esophagus (status postchemoradiotherapy), presented to the emergency department with history of cough with copious expectoration of 15-day duration and worsening breathlessness of 5-day duration. Examination revealed diffuse crackles over bilateral lung fields. The patient was intubated and mechanically ventilated for respiratory failure. Few hours after intubation, there was gradual distension of the abdomen, and auscultation over the left hypochondrium revealed amphoric sounds. Esophageal intubation was ruled out by laryngoscopic examination and capnometry; a possibility of bronchoesophageal fistula was considered. Pre- and post-intubation radiographs were reviewed that revealed gaseous distension of the abdomen postintubation [Figure 1]. Flexible bronchoscopy at bedside revealed a fistulous communication between the left main bronchus and the esophagus. A metallic Y-stent insertion was planned; however, the patient succumbed to his illness within few hours of presentation to the intensive care unit.

Figure 1

Left panel: Chest radiograph (preintubation) revealing nonhomogeneous opacification in bilateral lower zone (right>>left) suggestive of aspiration pneumonia; Right panel: Supine radiograph of the abdomen revealing gaseous distension of the stomach and the small and large bowel

Amphoric type of bronchial breath sounds has been classically described in the presence of a superficial large cavity that has smooth walls and a communicating patent bronchus. It can also be appreciated in an open pneumothorax.[1] However, amphoric type of 'breath' sound over the abdomen has not been described previously. In the index case, the setting was perfect for producing an amphoric breath sound during positive airway pressure ventilation where a superficial cavity with smooth walls (stomach) was communicating with a patent airway (fistula).

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