 |
       |
|
|
PRIMARY OESOPHAGEAL TUBERCULOSISHK Parikh*,DM Parikh*
*Department of liurgical Oncology, Tata Memorial Hospital,Dr.E.Borges Marg, Parel,Mumbai-400 012.
A case with primary tuberculosis of the oesophagus presenting with features mimicking carcinoma of the oesophagus with mediastinal fistulae, is presented.Primary oesophageal tuberculosis is rare; the incidence of this condition is reported to be 0.14% of all tubercular diseases! Secon dary involvement of the oesophagus due to primary pulmonary tuberculosis, tubercular lym phadenopathy or miliary tuberculosis and their complications is known. Since the prevalence of tuberculosis is still high in India, the possibility of oesophageal tuberculosis, should perhaps still be considered. Isolated cases of oesophageal tubercu losis are also reported in western literature.[2],[3]
CASE REPORT
USK, a female aged 56 years, was first seen in August 1983 with dysphagia of 4 years duration, becoming worse for 6 months. The patient had no history of fever, significant weight loss, chronic cough, or of exposure to tuberculosis. There were no positive clinical findings. A barium swallow revealed irregularity and narrowing of the lower third of the oesophagus. An oesophago-gastroduodenoscopy revealed oesophagitis with oedematous mucosal folds and gastro-oesophageal reflux. A biopsy from the lower end of the oesophagus yielded no positive diagnosis. Antacids for 6 weeks resulted in complete symptomatic improvement.
She was again seen in April 1989, with features of dysphagia and occasional cough on swallowing solids, of 7 months duration. Barium swallow showed a delay 'in passage at the lower end of the oesophagus with narrowing and two blind fistulous tracts into the posterior mediastinum. Flexible oesophagoscopy revealed an "outpouching" of the ocsophageal wall at 31 cm and a stricture at 34 cm which could not be negotiated. Brush cytology and biopsies from this area did not yield a positive diagnosis. Rigid oesophagoscopy revealed a tight stricture at 31 cm with no mucosal abnormality. CT scan revealed a 3.5 cm long soft tissue mass in the region of the cardio-oesophageal junction, thickening of the oesophageal walls, with luminal irregularity and para-oesophageal extravasation of' the oral contrast; suggesting carcinoma of the lower end of the oesophagus with posterior mediastinal fistulae.
Haernatological and biochemical parameters and ECG were within normal limits. Chest X-ray showed no tubercular lesion, active or healed. Her pulmonary function tests showed a restrictive type of defect. (FVC = 48.3% of predicted value; FEVI 47.6% of predicted value).
Laparotomy through a midline incision revealed normal liver and other abdominal viscera. Oesophageal hiatus and the abdominal oesophagus showed dense fibrotic adhesions. Hard nodules, the largest being about 1 cm, were noted on the serosa of the funclus of the stomach and the abdominal oesophagus. A solitary left gastric lymphnode was enlarged. One of the nodules and the left gastric lymphnode were subjected to frozen section and showed tuberculous granuloma and tuberculous lymphadenopathy respectively.
On account of poor pulmonary function and radiological findings suggestive of mediastinal fistulae, a thoracotomy was deferred. The stomach and duodenum were mobilised. A pyloroplasty was performed and the stomach was sectioned at the level of the cardio-oesophageal junction, with a part of the funclus being left behind. The mucosa of* the remnant stomach and oesophagus were stripped and sent for histopathological examination. The muscular coat of' the remnant stomach was closed with interrupted sutures. A subcutaneous antesternal gastric pull-up was performed with an oesophago-gastric anastomosis in the left neck, with single layer interrupted 3/0 silk. The upper end of the oesophagus was sutured and dropped into the superior mediastinum. The patient had an uneventful Postoperative recovery and was put on anti-tubercular chernotherapy on the 7th postoperative day.
The histopathology report of the mucosa of the oesopha,(us and the funclus of the stomach and the left gastric lymphnode confirmed tuberculosis.
A barium swallow, two months after surgery showed smooth passage of barium with normal emptying of the stornach.
DISCUSSION
The term "primary oesophageal tuberculosis" implies absence of tubercular disease elsewhere. Secondary involvement of the oesophagus in intrathoracic tuberculosis is well known. [2],[3] We have had one such other case of oesophageal tuberculosis. [4]
Autopsy diagnosis of tuberculosis of the oesophagus was first made in 1837 and the first antemortern diagnosis in 1907. [5] Until 1950, no case of primary oesophageal tuberculosis is on record. [6] Mechanisms of secondary tubercular involvement of the oesophagus are : (1) Swallowed sputum in patients having advanced open tuberculosis; (2) direct involvement from tuberculosis involving the lungs, mediastinal lymph nodes or thoracic spine; (3) retrograde lymphatic spread; and (4) blood borne; superimposed on local devitalization due to trauma and general debility. [6]
Three macroscopic types are recognized: hypertrophic, granular and ulcerative. The hypertrophic type usually affects the middle and lower thirds of the oesophagus and may involve long segments. [6] It risembles the hypertrophic form of the disease in the ileo-caccal region and causes obstruction of the lumen. Common symptoms are pain and dysphagia, often mimicking those of carcinoma. A barium swallow frequently shows diminished motility, stricture formation and mucosal irregularity. [7] Oesophagoscopy and biopsy may clinch the diagnosis in the granular and ulcerative varieties, but could be misleading in the hypertrophic type. [2] Oesophageal tuberculosis may present with complications like traction diverticula, mediastinal perforation, fistula forination (bronchial, pleural or cutaneous), recurrent laryngeal nerve palsy or malignant change. [6]
Our patient had no identifiable primary focus of tuberculosis on investigations or at surgery, hence the label of "primary tuberculosis of the oesophagus".
In view of her poor pulmonary function, mediastinal fistulae and the dense adhesions at the oesophageal hiatus, we deferred a thoracotomy and performed an oesophageal bypass akin to the Krishchner's procedure for carcinoma of the oesophagus. [8] Another suggested method of treatment is that the stomach be brought up by the transthoracic route in the posterior mediastinum to form an anastomosis in the neck. [6] Colon too has been suggested as a means for bypass. [9] However, no case report exists describing the procedure performed by us. Our surgical procedure resembles the Krishchner's operation; [8] the difference being that we preferred to strip and remove all the fundic and oesophageal mucosa of the remnant without anastomosis with the jejunum. No clear guidelines for the surgical management of oesophageal tuberculosis exist. Antitubercular chemotherapy remains the mainstay of treatment, with surgical intervention being imperative when symptoms become progressive or when complications arise.
REFERENCES
1. Shreckurnar S. Tuberculosis of the oesophagus. Am J Gastroenterol 1972; 57:166-8.
2. Ito Y, Kobayashi S, Kasugai T. Tuberculosis of the oesophagus. Am J Gastr6enterol 1976~ 65 : 453-6.
3. Dow CJ. Oesophageal tuberculosis : Four cases. Gut 1981; 22 : 234-6.
4. Pradhan SA, Mehta AR, Sampat MB. Tuberculosis of the oesophagus. A case report. Ind J Cancer 1976~ 13 : 383-5.
5. Terracol J, Sweet RH. Diseases of the oesophagus. Saunders, Philadelphia. 1958; 341.
6. Fahrny AR, Guirdi R, Farid A. Tuberculosis of the oesophagus. Thorax 1969; 24 : 254-6.
7. Rubenstein BM, Pasterna T, Jacobson HG. Tuberculosis of the oesophagus. Radiology 1958; 79 : 401.
8. Mannel A. The Krishchner operation for cancer of the oesophagus. Ann Royal Coll of Surg of Eng 1992~ 64 : 256-9.
9. Monies 1, Larson E, Haiderer 0, Kennedy JM. Tuberculous stricture of the oesophagus : Report of a patient successfully treated by colon interposition. Chest 1971; 60 (No. 2): 194-5.
 |