Esophageal tuberculosis

Tuberculosis of the esophagus occurs extremely rarely, since the rapid passage of infected sputum does not contribute to the fixation of the pathogen in the mucous membrane; in addition, the mucous membrane of the esophagus is poor in lymphatic vessels, which also does not contribute to infection of the latter.

[ 1 ], [ 2 ]

Causes of Esophageal Tuberculosis

In all cases, esophageal tuberculosis is a secondary disease that occurs as a complication of pulmonary tuberculosis or as a result of the infection spreading from the peribronchial or tracheal lymph nodes. Abrasions, burns of the mucous membrane with caustic liquids, strictures, and tumors contribute to the development of esophageal tuberculosis, which create favorable conditions for the fixation of tuberculosis infection in these areas. Cases of primary esophageal tuberculosis have not been described. Invasion of tuberculosis infection into the esophageal wall occurs in various ways: hematogenous, lymphogenous, and through direct contact with infected sputum coming from the lungs.

Most often, tuberculosis of the esophagus occurs at the level of the tracheal bifurcation (up to 50%), somewhat less often in the upper and least often in the lower third of the esophagus and is macroscopically described 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, thickening the wall of the esophagus and narrowing its lumen.

Pathologically, miliary, ulcerative and proliferative forms of esophageal tuberculosis are distinguished.

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

The ulcerative form is characterized by localization at the level of the tracheal bifurcation and can occur:

1. in the form of a typical single superficial tuberculous ulcer with scalloped edges and a dirty gray bottom secreting purulent fluid; the ulcer is often surrounded by small yellowish nodules in various stages of development, up to ulcers;
2. in the form of multiple merging ulcers at different stages of development, oval in shape, the major axis of which coincides with the direction of the axis of the esophagus. Around the ulcer, the mucous membrane is hyperemic and infiltrated. Ulcers do not extend deeper than the submucosal layer and do not affect the muscular layer. In rare cases, especially in patients weakened by general tuberculosis infection with a low level of immune protection, ulcers can affect all layers of the esophagus with the formation of esophageal-tracheal fistulas.

In the proliferative form of esophageal tuberculosis, the tuberculous granuloma is usually located above the bifurcation of the trachea, quickly increases and occludes the lumen of the esophagus, causing its obstruction. In this form, the length of the 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), due to which the lumen of the esophagus is completely interrupted. The proliferative process affects the entire thickness of the esophageal wall and reaches the trachea and mediastinum, affecting these anatomical structures as well. Above the stricture caused by the tuberculous granuloma, the mucous membrane is usually pale, pliable, covered with superficial ulcers.

[ 3 ], [ 4 ], [ 5 ], [ 6 ]

Evolution of esophageal tuberculosis

Esophageal tuberculosis, in the absence of timely etiologic treatment, develops in the direction of spreading and deepening of pathomorphological changes in the esophageal wall, often with damage to adjacent organs with significant and rapid deterioration of the general condition due to dysphagia (alimentary dystrophy) and general toxic damage to the body. The clinical development of esophageal tuberculosis is aggravated by complications such as the formation of esophageal-tracheal fistulas, erosion of the aortic wall (its perforation leads to immediate death of the patient), hematogenous tuberculous meningitis, etc.

The prognosis for initial forms of esophageal tuberculosis is cautious, largely depending on the severity, severity and localization of primary tuberculosis. In advanced forms, manifested by extensive and deep lesions of the esophagus, accompanied by cachexia of the patient and progression of the primary process, it is unfavorable.

[ 7 ], [ 8 ], [ 9 ]

Symptoms and clinical course of tuberculosis of the esophagus

Esophageal tuberculosis itself is not characterized by such pronounced symptoms as, for example, acute or chronic non-specific esophagitis, and is determined mainly by the form of esophageal lesion. Thus, the presence of ulcers is accompanied by a burning sensation and pain when swallowing food, which disappears in the intervals between swallowing acts. In the sclerotic form, dysphagia prevails, worsening the general condition of the patient, since the primary process (in the lungs, lymph nodes) is aggravated due to the impossibility of adequate nutrition, causing a decline in strength and a decrease in the general resistance of the body. However, at the initial stage of the proliferative form, the general condition of the patient remains satisfactory for some time, the act of swallowing is painless, but then, as the lumen of the esophagus narrows and especially with ulceration and disintegration of granulomas, severe spontaneous pain and a rapid deterioration in the general condition occur.

Progression of the ulcerative process in the esophagus with simultaneous tuberculosis infection of the pharynx leads to a sharp disruption of the act of swallowing and the appearance of severe spontaneous pain, especially at night, not relieved by conventional analgesics. These pains radiate to one or both ears, accompanied by a burning sensation behind the breastbone, intensifying when swallowing.

Diagnosis of esophageal tuberculosis

Diagnosis of esophageal tuberculosis is very difficult, especially in latent forms of primary tuberculosis, which is the source of the esophageal lesion. At the initial stage, one can only assume the presence of this disease. It can be established with a certain probability only by esophagoscopy, which must be performed on all patients suffering from pulmonary tuberculosis who complain of difficulty swallowing. Esophagoscopy, even when using a fibroscope, must be performed with great caution, especially in ulcerative-necrotic forms of esophageal lesion and in the event of difficulties in advancing the instrument, since perforation and fatal bleeding are possible due to deep lesions of the esophageal wall. In such difficulties, esophagoscopy should not be performed, and the reason for the impossibility of implementing this procedure must be substantiated in the medical history.

If esophagoscopy is successful, macroscopic signs of damage to the esophageal wall and a presumed form of esophageal tuberculosis are revealed, and a biopsy of tuberculous infiltrates is performed. The detection of epithelioid and giant cells in the biopsy among the caseous decay and remnants of esophageal tissue and neutrophils of pus makes the diagnosis of esophageal tuberculosis reliable.

In ulcerative forms, the pathological process is usually localized in the middle and upper part of the esophagus, while in infiltrative-sclerotic forms, it is in the lower third of the organ. Here, significant thickening of the esophageal wall, characteristic tuberculous granulomas, and stenosis are determined, in which the lumen of the esophagus does not exceed several millimeters, and the length of which can reach 10-12 cm. Biopsy reveals a significant density of proliferative-sclerotic formations. Above the stenosis, a dilated area of the esophagus is usually detected, filled with food debris and a purulent mass. Sometimes, with a tuberculous process in the lungs, developing in close proximity to the esophagus and spreading to it, its secondary displacements and deformations occur, caused by the primary process.

Differential diagnosis is carried out with syphilis and neoplasms.

[ 10 ], [ 11 ], [ 12 ], [ 13 ]

Treatment of tuberculosis of the esophagus

Treatment of esophageal tuberculosis is divided into general and local. General treatment involves prescribing specific anti-tuberculosis drugs, as with other forms of tuberculosis (aminoglycosides Kanamycin, Streptomycin, Rifabutin, Rifamycin, Rifampicin, PAS), as well as non-specific agents (biologically active food supplements Vetoron, Vetoron-E, Vetoron TK) 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 enhance immunity.

Local treatment using esophagoscopy, as a rule, will not give positive results. Cauterization of ulcers with silver nitrate or lactic acid aggravates the destructive process, and long-term use of this treatment can lead to malignancy of the affected areas. In case of severe pain, novocaine, anesthesin, and cocaine are prescribed orally. In sclerotic forms, bougienage, carried out against the background of general intensive anti-tuberculosis treatment, gives positive results. In some cases, temporary gastrostomy is used to exclude the esophagus from the act of swallowing and to ensure adequate nutrition.