Esophageal tuberculosis

Tuberculosis of the esophagus is extremely rare, because the rapid passage of infected sputum does not promote fixation of the pathogen in the mucosa, in addition, the mucosa of the esophagus is poor in lymphatic vessels, which also does not contribute to infection of the latter.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10]

Causes of tuberculosis of the esophagus

In all cases, esophageal tuberculosis is a secondary disease that occurs as a complication in pulmonary tuberculosis or as a result of infection from peribronchial or tracheal lymph nodes. Contribute to the emergence of tuberculosis of the esophagus abrasions, burns of the mucous membrane with caustic liquids, strictures, tumors, which create favorable conditions for fixing tuberculosis infection in these places. Cases of primary tuberculosis of the esophagus have not been described. The invasion of tuberculosis infection into the esophagus wall takes place in various ways: hematogenous, lymphogenous and in direct contact with infected sputum from the lungs.

Most often, tuberculosis of the esophagus occurs at the levels of the tracheal bifurcation (up to 50%), somewhat less frequently in the upper and less often in the lower third of the esophagus and is described macroscopically in two forms:

1. superficial or deeper ulcers of small size, oval in shape with thin uneven edges and a bottom covered with pale granulations;
2. sclerosing infiltrates of a limited or diffuse nature, sealing the esophagus wall and narrowing its lumen.

Pathomorphologically distinguish miliary, ulcerative and proliferative forms of tuberculosis of the esophagus.

The miliary form occurs extremely rarely and is observed in the generalized mil form of tuberculosis. Miliary eruptions are localized under the mucous membrane and represent typical tuberculous tubercles of gray color.

Ulcerous form is characterized by localization at the level of tracheal bifurcation and can proceed:

1. in the form of a typical single superficial tuberculous ulcer with scalloped edges and a dirty-gray septic gland purulent liquid; The ulcer is often surrounded by small yellowish nodules at different stages of development, including ulcers;
2. in the form of multiple merging ulcers, located at different stages of development, an oval shape, the major axis of which coincides with the axis of the esophagus. Around the ulcer, the mucosa is hyperemic and infiltrated. Ulcers do not spread deeper than the submucosa and do not affect the muscular layer. In rare cases, especially in patients with low level of immune defense weakened by a common tuberculosis infection, ulcers can affect all layers of the esophagus with the formation of esophageal-tracheal fistula.

In the proliferative form of tuberculosis of the esophagus, the tuberculosis granuloma is usually located above the bifurcation of the trachea, rapidly increases and obturates the lumen of the esophagus, causing its obstruction. With this form, the length of tuberculous granulomas is from 1 to 12 cm of the inner surface, their location is regular and concentric. The walls of the esophagus under the granulomas are thickened and sclerosed (sclerotic form), because of which the lumen of the esophagus completely breaks. The proliferative process affects the entire thickness of the esophageal wall and reaches the trachea and mediastinum, affecting these anatomical formations. Above the stricture caused by tuberculosis granuloma, the mucosa is usually pale, supple, covered with superficial ulcers.

[11], [12], [13], [14]

Evolution of esophageal tuberculosis

Tuberculosis of the esophagus, in the absence of timely etiological treatment, develops in the direction of the spread and deepening of pathomorphological changes in the esophageal wall, often with the damage of neighboring organs with a significant and rapid deterioration of the general condition due to dysphagia (alimentary dystrophy) and general toxic damage to the body. Clinical development of esophageal tuberculosis is aggravated by complications such as the formation of esophageal tracheal fistulas, aortic wall erosion (perforation leads to immediate death of the patient), hematogenic tuberculous meningitis, etc.

The prognosis for the initial forms of tuberculosis of the esophagus is cautious, largely dependent on the guilt, severity and localization of the primary tuberculosis. With neglected forms, manifested by extensive and deep lesions of the esophagus, accompanied by patient's cachexia and progression of the primary process, unfavorable.

[15], [16], [17], [18], [19], [20]

Symptoms and clinical course of esophageal tuberculosis

Actually, tuberculosis of the esophagus is not characterized by such severe symptoms as, for example, acute or chronic nonspecific esophagitis, and is determined mainly by the form of lesion of the esophagus. So, the presence of ulcers is accompanied by a burning sensation and pain when swallowing food, disappearing in between the swallowing acts. With sclerotic form, dysphagia predominates, worsening the general condition of the patient, since the primary process (in the lungs, lymph nodes) is aggravated due to the inability of adequate nutrition, causing a decline in strength and a decrease in the overall resistance of the organism. However, at the initial stage of the proliferative form, the general state of the patient remains for some time satisfactory, the act of swallowing is painless, but then as the esophagus lumen narrows and especially when the granule becomes ulcerated and disintegrates, strong spontaneous pain and rapid deterioration of the general condition occur.

Progression of the ulcerative process in the esophagus with simultaneous damage to tuberculous infection of the pharynx leads to a sharp violation of the act of swallowing and the appearance of severe spontaneous pain, especially at night, not being stopped by conventional analgesics. These pains irradiate into one or both ears, accompanied by a burning sensation behind the sternum, which increases with swallowing.

Diagnosis of esophageal tuberculosis

Diagnosis of tuberculosis of the esophagus is very difficult, especially with erased forms of primary tuberculosis, which was the source of the esophagus. At the initial stage, one can only assume the presence of this disease. It can be established with a certain probability only with esophagoscopy, which must be performed by all patients suffering from pulmonary tuberculosis, complaining of the difficulty of swallowing. Esophagoscopy, even when using a fibroscope, should be performed with great care, especially with ulcerative necrotic forms of esophageal lesions and with emerging difficulties with the advancement of the instrument, because of the deep lesions of the esophageal wall, its perforation and fatal bleeding are possible. With such difficulties, esophagoscopy should not be carried out, and in the case history it is necessary to justify the reason for the impossibility of realizing this procedure.

When esophagoscopy is successful, macroscopic signs of esophageal wall involvement and, presumably, the form of esophageal tuberculosis, are revealed, and a biopsy of tuberculous infiltrates is performed. The detection of epithelioid and giant cells in the biopsy specimen among the decoction and the remains of esophageal tissues and neutrophils of pus makes the diagnosis of tuberculosis of the esophagus authentic.

With ulcer forms, the pathological process is usually located in the middle and upper part of the esophagus, while in the case of infiltrative sclerotic - in the lower third of the organ. Here, a significant thickening of the esophagus wall, characteristic tuberculosis granulomas, stenosis, in which the lumen of the esophagus does not exceed several millimeters, and whose extent can reach 10-12 cm, is determined. When biopsy, a significant density of proliferative-sclerotic formations is determined. Above the stenosis, the dilatation site of the esophagus is usually found, filled with food residues and a puffy mass. Sometimes, in the tuberculous process in the lungs, which develops in the immediate vicinity of the esophagus and spreads to it, its secondary displacements and deformations due to the primary process arise.

Differential diagnosis is carried out with syphilis and neoplasms.

[21], [22], [23], [24], [25]

Treatment of esophageal tuberculosis

Treatment of tuberculosis of the esophagus is divided into general and local. At the general or common treatment appoint specific antituberculous preparations, as well as at other forms of a tuberculosis (aminoglycosides Kanamycin, Streptomycin, Rifabutin, Rifamycin, Rifampicin, PASK), and also nonspecific agents (biologically active additives to food Vetoron, Vetoron-E, Vetoron TC) and vitamins and vitamin-like agents (Retinol, Ergocalciferol). It is also possible to use glycopeptides (Capriomycin) and glucocorticoids (hydrocortisone, dexamethasone, Methylprednisolone), as well as drugs that increase immunity.

Local treatment with esophagoscopy, as a rule, will not yield positive results. Cauterization of silver ulcers with nitrate or lactic acid exacerbates the destructive process, and prolonged use of this treatment can lead to malignancy of affected areas. With severe pain, oral novocaine, anesthesin, cocaine are administered orally. With sclerotic forms, positive results are obtained by bougie, conducted against a background of general intensive antituberculous treatment. In some cases, temporary gastrostomy is used to exclude the esophagus from the swallowing act and to exercise adequate nutrition.