Tuberculosis of the Esophagus

Abstract

Tuberculosis of the esophagus is rare (1–10). It occurs usually in association with acid-fast disease elsewhere in the body, most often in the terminal stage of pulmonary tuberculosis. The esophagus may be affected by tuberculosis through anyone of several mechanisms: 1. Infection of the esophageal mucosa from tuberculous sputum, with some type of pre-existing surface lesion as a prerequisite, i.e., esophageal mucosal tears, strictures, carcinoma, etc. It is doubtful that the normal esophagus is involved by tubercle bacilli swallowed in the sputum. 2. Extension from laryngeal and pharyngeal lesions by contiguity. 3. Contiguous extension from caseous hilar lymph nodes or tuberculous spondylitis. 4. Involvement in the course of generalized disseminated miliary tuberculosis. Lockard (4) and Carr and Spain (1) reported macroscopic esophageal lesions in only 0.14 per cent of 18,049 autopsied tuberculous patients. In over 1,400 autopsies on tuberculous patients performed at Bellevue Hospital in a ten-year period, only 1 case of involvement of the esophagus was described. Pathology: The most common site of esophageal involvement is in the midportion, near the bifurcation of the trachea. Lesions resulting from surface invasion when tubercle bacilli enter the esophageal wall from swallowed sputum, develop as superficial erosions with irregular borders. The ulcers remain superficial and are usually surrounded by small gray nodules; involvement of the muscularis propria is quite infrequent. Peri-esophageal tuberculosis of extrinsic origin, with resulting adhesions, may produce distortion and tenting of the esophagus. Lymphadenitis may lead to perforation with the formation of fistulae between the esophagus and portions of the adjacent respiratory tract. When the esophagus is involved in miliary tuberculosis, individual lesions appear as tiny gray translucent tubercles. Later, the small tubercles enlarge, become yellowish, and may caseate and break down. Although some strictures of the esophagus have been ascribed to healed tuberculous lesions, either through intrinsic infection or a peri-esophageal process, in most patients showing both esophageal stricture and tuberculosis the stricture was probably present initially (5). The relationship of carcinoma and tuberculosis of the esophagus must be mentioned. Pepper and Edsall (6) described a case in which tuberculous esophagitis was present before development of a carcinoma. Carr and Spain reported a case of squamous-cell carcinoma involving the outer wall of the esophagus. At necropsy, actual tubercles were found in the center of the ulcerating tumor. The reported material is obviously insufficient to warrant any statement of correlation between tuberculosis and carcinoma. Symptoms: The symptomatology is that referable to any ulcerating or stenosing lesion of the esophagus; dysphagia and pain behind the sternum are commonly noted.