October - LRS Institute of Tuberculosis & Respiratory Diseases

TUBERCULOSIS OF THE OESOPHAGUS 247
the skiagrams of chest, there were opacities in
the hilar region suggestive of an old tuberculous
lesion. His E.S.R. was 38 in 1st hour
(Westergren’s method). He was prescribed antitubercular
therapy. Follow up examination
after 8 weeks showed opening out of the narrowed
segment of the oesophagus, the dilated
proximal oesophagus showed regression in
size. Gastrostomy wound was closed. The patient
was advised to continue anti-tubercular therapy.
Discussion
Tuberculosis of the oesophagus is a rare
entity and its presence without active primary
lesion in the chest or elsewhere in a 50 year
old man makes the case interesting clinically.
Involvement of the oesophagus by tuberculosis
is usually secondary to already existing
disease in the lungs or other parts of the body,
although primary tuberculosis has been reported
(Fehmy, 1969). There have been many hypotheses
as to the mode of affection of the oesophagus.
Most of the cases are due to swallowing
of highly infectious sputum of cavitary disease
in the lungs. Sputum may get stagnated proximal
loan oesophageal stricture. Lymphatic (Fehmay,
1969) or hematogenous (Lockaward, 1913)
involvement is also possible and occasionally
oesophageal tuberculosis has been described in
miliary tuberculosis (Thomson and Negus,
1948). Involvement of the oesophagus also
occurs by continuity as in downward extension
or tubercular ulceration of the pharynx. Rarely
it may be affected by contiguity as in Pott’s
disease of spine and by tuberculous lyinphnodes
in the mediastinum and may be responsible for
traction diverticulum of the oesophagus.
Although there are many patients with
pulmonary tuberculosis, oesophageal tuberculosis
is not frequently met with (as against
frequent involvement of the intestinal tract)
inspite of the fact that the oesophagus is so
frequently exposed to tubercle bacilli from the
swallowed sputum of patient with pulmonary
tuberculosis. This local resistance of the oesophagus
is difficult to explain. However, it
might be due to difference in blood supply,
lymphatic drainage, mucous secretion and local
pH. A relative paucity of lymphoid tissue in
the oesophageal wall (for which tubercular
bacilli have a great affinity) could perhaps be an
additional factor responsible for the rare occurrence
of tubercular lesions in the oesophagus.
Both the gross and the microsopic pathology
of oesophageal tuberculosis are similar to that
of other tuberculous lesions in the gastrointestinal
tract, Endoscopic examination may
show an ulcer, gramiloma or at times tubercles
scattered here and there. The present case
revealed a tumour like lesion occluding the whole
of the circumference of the lumen. The most
common site for lesion is the mid-portion of the
oesophagus near the bifurcation of the trachea.
No characteristic symptoms are ascribable
to tubercular lesion of the oesophagus. Clinically,
the symptoms depend on the type of the lesion,
whether it is ulcerative or stenotic. Progressive
dysphagia and pain are common complaints
at the time of presentation (Wexels, 1954;
Rubinstein et al, 1958, Fehmay, 1969; Pradhan
et al. 1976). In the present case, complete
oesophageal obstruction required gastrostomy
for feeding.
Prognosis is usually favourable with recent
anti-tubercular drugs. Resection of the part is
usually not required. Drug therapy was found to
be beneficial in the present case.
This case reveals that a tubercular lesion of
the oesophagus should be kept in the mind
when dealing with oesophageal lesions. It may
pose a diagnostic problem when repeated biopsy
is negative for malignancy inspite of suggestive
clinical and radiological evidence. Biopsy is
essential for final diagnosis.
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Ind. J. Tub., Vol. XXIX, No. 4