Postgrad Med J (1992) 68, 110- 115 © The Fellowship of Postgraduate Medicine, 1992

Oesophageal tuberculosis: a review of eleven cases

T. Mokoenal, D.M. Shama2, H. Ngakanel and J.V. BryerlDepartments of'General Surgery and 2Thoracic Surgery, University ofNatal Medical School, Durban,Republic ofSouth Africa

Summary: Tuberculous infection of the oesophagus is rare. This is confirmed by our present review ofcases managed in our teaching hospitals over a period of 18 years which uncovered only 11 patients. Themain presentation is that of dysphagia whose algorithm of investigation should seek to differentiatetuberculosis from carcinoma, the more common cause of this symptom. Of the 11 patients, 9 presentedwith dysphagia while 2 had haemorrhage; 7 had an abnormal plain chest radiograph, of whom 4 had amediastinal mass lesion (3 were lymphadenopathy and one an abscess). All but one had an abnormalradio-contrast oesophagogram, including a mediastinal sinus in two and a traction diverticulum in anothertwo. The mainstay of investigation was oesophagoscopy through which diagnostic biopsy material wasobtained in half of the patients. In the other half diagnosis was by either biopsy of associated mediastinal(3) or cervical (1) lymph node masses or by acid fast bacilli positive sputum (1). The diagnosis wasestablished post-mortem in one patient.

Treatment was primarily non-operative with standard anti-tuberculosis drug therapy. Two patientsunderwent a diagnostic thoracotomy and one a drainage ofmediastinal abscess together with resection andrepair of oesophago-mediastinal sinus during the early part of the series. Outcome of management wasvery rewarding in 9 patients and death occurred in 2 patients, one ofwhom had his anti-tuberculosis drugtherapy interrupted by severe hepatitis B virus infection. The other death occurred in a patient whosehaemorrhage from an aorta-oesophageal fistula was not established ante-mortem. It is recommended thatwhen biopsy material of the oesophagus is unobtainable or non-diagnostic in patients with dysphagia,especially with an abnormal chest radiograph or human immunodeficiency virus infection, effort should bemade to obtain biopsy material from associated lymph nodes, even by thoracotomy if necessary, or cultureof biopsy from the radiologically abnormal part of oesophagus and sputum for mycobacteria, in order toestablish the diagnosis of this rare but eminently treatable cause of dysphagia. Clinicians should be awareof tuberculosis of the oesophagus as a possible cause of haematemesis in patients with otherwiseunexplained upper gastrointestinal haemorrhage.

Introduction

Tuberculosis (TB) of the oesophagus is rare.',When present, it is usually secondary to current orprevious tuberculous infection in other anatomicalsites. Most reported cases have been secondary torespiratory tract infection.`5 Some have showninvolvement of the thoracic aorta.6'7 The principalpresentation has been dysphagia but many hadpain- and few presented with haematemesis.67Because of the rarity of TB as a cause of symp-tomatic oesophageal disease, the diagnosis hasoften been missed as diagnostic efforts weredirected at the more common causes such ascarcinoma and peptic ulceration and, in cases of

haemorrhage, at oesophageal varices. However,unlike these other diseases, TB is eminently curableand therefore it is imperative that clinicians shouldbear it in mind when managing patients withoesophageal disease symptoms. Although TBoesophagus is rare worldwide, it is not confined todeveloping countries where TB is endemic, but isbeing seen increasingly in developed countries withsignificant immigrant populations and would beexpected in native populations with the increase ofacquired immunodeficiency syndrome (AIDS)which is often complicated by mycobacterial infec-tions. TB is prevalent in our environment andtherefore it would be expected that the oesophagealdisease would be relatively less uncommon. Areview of records of patients with TB of theoesophagus was undertaken in order to uncoverpatterns of presentation and outcome in manage-ment of this disease at the teaching hospitals of theUniversity of Natal Medical School.

Correspondence: T. Mokoena, Department of Surgery,Faculty of Medicine, University of Natal, PO Box 17039,Congella 4013, Durban, RSA.Accepted: 27 September 1991

copyright. on 5 M

arch 2019 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.68.796.110 on 1 F

ebruary 1992. Dow

nloaded from

OESOPHAGEAL TUBERCULOSIS 111

Material and methods

Available case records of those patients who havebeen diagnosed as having TB with oesophagealinvolvement from 1972 to 1990 were studied.

Results

There were 11 patients whose records were suffi-ciently complete to permit a suitable analysis to becarried out (Table I). There were 6 male and 5female patients whose mean ( ± s.d.) age was 37.9( ± 14.7) years. The main presenting symptom wasdysphagia in 9 patients. Two patients presentedwith haematemesis. Hoarseness of the voice waspresent in 2 patients. A plain chest radiograph wasabnormal in 7 patients (64%), where 4 had paratra-cheal or mediastinal mass lesions, one of whichturned out to be a tuberculous abscess at operativeexploration and one each had pleural effusion andextensive old fibrosing pulmonary lesion.An oesophagogram showed external compres-

sion in 4 patients (36%) and these were the patientswith mass lesions of the mediastinum (Figure 1). Amediastinal sinus was demonstrated in 2 (18%), atraction diverticulum in 2, and in one each apolypoid tumour, an ulcer (Figure 2) and anirregularity of the mucosa. One patient with prox-imal oesophageal TB had a normal oesophago-gram.

All patients underwent oesophagoscopy. Thisconfirmed the oesophagogram findings ofa sinus in2 patients, a traction diverticulum in one, a poly-poid tumour in another and uncovered an ulcerat-ing mass in a patient whose oesophagogram merelyshowed extrinsic compression (patient no. 5, TableI). It also demonstrated the ulcer in one of thehaematemesis patients as well as showing proximalinvolvement of the oesophagus in a patient withlaryngeal TB. It failed to reveal the aorta-oeso-phageal fistula in the other haematemesis patientwhose clinical details have been reported pre-viously.7The definitive diagnosis of TB was made on

histological demonstration of the classical caseousTB granuloma or acid fast bacilli in 8 patients(72%), on clinical grounds in 2 patients and atautopsy in one. Three patients who were attendedto during the early 1970s period were managedoperatively for procurement of mediastinal lymphnode biopsy in 2 and drainage of a mediastinalabscess in one who also had resection of anoesophageal sinus and repair of the oesophagus.All patients were managed by standard anti-TBdrug treatment.

There were 2 deaths, one in a patient whoseeffective anti-TB therapy was interrupted by type Bviral hepatitis with jaundice and convulsions. This

patient also had severe cor pulmonale and he died 8months after diagnosis. The other death occurredin a patient with a missed aorta-oesophageal fistulawho had a fatal haemorrhage after two weeks ofhospitalisation and a fruitless gastroduodenal ex-ploration, vagotomy and pyloroplasty. The other 9patients were well at the last time of medicalattendance which varied from three months to 12years.

Discussion

Tuberculosis is capable ofmimicking many diseaseprocesses and may affect any anatomical structure.Whereas in developing countries where tubercul-osis is common the diagnosis is often made, in themore sophisticated countries TB may not be con-sidered in a primary list of differential diagnoses.Although the oesophagus is a rare site for TB to

cause symptoms, the problem is well recognized, asattested to by many sporadic case reports in theliterature.'-5 Our experience with 11 patients span-ning a period of 18 years further illustrates the lowfrequency of this disease in an environment inwhich TB is otherwise endemic.The most common presenting symptom is dys-

phagia, and haematemesis the least common.Occassionally patients present with oesophago-bronchial fistulae whose symptoms include cough-ing after ingestion of liquids.3 These symptoms aresimilar to those produced by carcinoma of theoesophagus which is much more prevalent.2 Theapproach to their clinical investigation thereforefollows the same guidelines used in carcinoma ofthe oesophagus and, among others, seeks to obtaintissue diagnosis.A plain chest radiograph is taken as part of the

routine work for patients with dysphagia. If thisshows abnormality, especially ifa mediastinal massor an apical lesion suggestive of present or past TBis noted, the possibility of oesophageal TB shouldbe strongly suspected. However, it is common tonote mediastinal lymphadenopathy in patientswith pulmonary TB but only rarely is this assoc-iated with dysphagia. A rare feature seen on chestX-ray is a mediastinal abscess which results frombreakdown of TB lymph nodes forming a 'cold'abscess or less frequently from a breach of theoesophageal wall integrity and contamination bypyogenic organisms. All the plain radiographchanges associated with TB may be seen in car-cinoma of the oesophagus although pulmonarychanges in carcinoma tend to affect the base of thelungs due to repeated aspiration. However a caveatthat the two diseases may co-exist needs to beadded and this should be kept in mind especially inour environment where both are endemic.A radio-contrast oesophagogram is obtained as

copyright. on 5 M

arch 2019 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.68.796.110 on 1 F

ebruary 1992. Dow

nloaded from

112 T. MOKOENA et al.

z I-~~~~~~~~~40 I >~~~~~~~~~~~~~~~~~~~*

o .= .U( 0

d

-

. d0U -0~~ ~~ 0~gzcd 0

>C(S~~4 .0 00>U0, =o'Z (2

~~ -~~ IOD .I=0, 0 00 _:-L

co~ CC0 O3

0 ~~~~~~

ODMcd 0 0 0 6H -0 ~~~-~~~~~~00~~~~=

00~ ~ ~ d el 00_ .

0~~~ +

C *- 0.0 >.*- a- o* U- L0- .C0

C13 0~~~~~~~~~~~~~.C00 Z- 0 0~~~~~~0-o -1+ Z

0 0 0 0~~~00 ~ 0U) 0 bX _ 00 0 t 0 0 COC

U C 0CO 0 0bo 0 0 *- > C

0 0 *,~~~~~~~~~~~~~~~~~C.-O

0 0~~~~~~~~~~~~~~~~~~~~CO0~~~~~~~~~~~~~~~~~~~~~~~~ ~~Oc

00U) U)U)~~~~~~C. 0O~~~~~ 0~~~~~~0 ~ ~ ~ ~ ~ ~ ~ ~ ~ ~0)~~~~~~

0 0 - ~~~~~ 0 0 -~~~~ 4 000 0 0~~x o- l

4- cq~~~~0U).CO - 0

Cd 0 r. 0 ~ 0 00 0~ 42

Z~0 Z - t O en~cZ4- I.. 0 0 ~ ~ ~ ~ ~ ~ 0 Icl~~~~~~~~~~~

0 -~~~~dnc 0 0A

~~~ U~O U)C>U

-~~~ cO~~~cO4 4- 0 Cd0c

CO

0 CO CO ~ U CO COel C O CO Cel 0ZCd rUCOAo b 0 0 00 S.U U 0

0d 0)0) 0 0) 0) 0) )00 0 ~~~~~~~~~~~0 r

0 -~~~1

copyright. on 5 M

arch 2019 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.68.796.110 on 1 F

ebruary 1992. Dow

nloaded from

OESOPHAGEAL TUBERCULOSIS 113

Figure 1 An illustrative barium oesophagogram of a

patient presenting with dysphagia shows the frequentexternal compression of the oesophagus by enlargedmedisatinal lymph nodes. Note a small diverticulum intothe compressing mass (arrow). This patient had a 'nor-mal' oesophagoscopic examination but biopsy of hercervical lymph nodes which were also enlarged proved tobe TB. She responded well to anti-TB treatment.

Figure 2 A barium oesophagogram of a patient present-ing with haematemesis and melaena demonstrates anulcerating lesion (arrow) which on oesophagoscopicexamination showed stigmata of recent bleeding. Biopsyof the lesion showed TB.

a prelude to oesophagoscopy. The most commonfeature is extrinsic compression of the oesophagususually by a mass of tuberculous lymph nodes.Although the oesophageal mucosa is often intact insuch cases, the adventitia is usually implicated andthis may produce a classical traction diverticulumdemonstrated on the oesophagogram (Figure 1).When the process involves the oesophageal mucosaan exuberant tumorous lesion or an ulcer may-esult, both of which are radiographically indistin-

copyright. on 5 M

arch 2019 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.68.796.110 on 1 F

ebruary 1992. Dow

nloaded from

114 T. MOKOENA et 'at.

guishable from carcinoma. The contrast oesopha-gogram may demonstrate a sinus into the media-stinum or a fistula into the tracheobronchial tree.Finally a constrictive lesion may result which maybe radiographically indistinguishable from themore common causes of benign oesophageal struc-ture."3 This latter presentation was not seen in our11 cases.An oesophageal endoscopy is the key investiga-

tion in evaluation of dysphagia for procurement ofbiopsy material. The preliminary radio-contrastoesophagogram assists the endoscopists in direct-ing particular attention to the area of interest. It isour practice to perform a tracheo-bronchoscopy aswell in all patients with dysphagia as part ofstagingof the more common oesophageal carcinoma. Thispractice is well suited to cases of suspected oeso-phageal TB as well since endotracheal or laryngealTB may coexist,8 as was illustrated by 2 patients inthis series. We prefer to use a rigid oesophagoscopeand a rigid bronchoscope which require a generalanaesthetic. Unlike some workers9 a flexible endo-scope is only used on haematemesis patients andwhen the general condition of the patient precludesgeneral anaesthetics. There are no specific endo-scopic features upon which a firm diagnosis of TBmay be rested. Indeed in many patients the oeso-phageal mucosa remains macroscopically clear andtherefore the requisite biopsy material unob-tainable as random mucosal biopsy is not recom-mended. Fortunately these patients sometimespresent with cervical lymphadenopathy, fromwhich biopsy material should be obtained. In a fewpatients the enlarged lymph nodes are only locatedin the mediastinum where they may be indistin-guishable from mediastinal tumours or cysts andthe diagnosis is then only made after mediastino-scopy, where appropriate, or exploratory thora-cotomy and biopsy. This is illustrated by 3 of ourcases where exploratory thoracotomy was utilizedduring the earlier part of the series when media-stinoscopy was less frequently performed - nowa-days mediastinoscopic lymph node biopsy wouldhave been offered before exploratory surgery unlessa cyst or an abscess was very strongly suspected.An especially challenging presentation is that of

haematemesis where TB of the oesophagus is un-likely to be part ofthe initial differential diagnosis. Inthese patients flexible endoscopy is usually the firstinvestigation and when the usual causes and sites ofupper gastrointestinal tract bleeding are not demon-strated a more careful oesophageal examination isnecessary. It might be necessary to resort to rigidendoscopy. An abnormal chest radiograph shouldalert the clinician to the possibility of TB of theoesophagus as the cause of haemorrhage; this cluewas missed in the case reported by Hancock andBarnett.6 An early oesophagogram might also give aclue to the diagnosis. Sadly, this and an abnormal

chest radiograph were overlooked in one of ourpatients who subsequently underwent fruitless vag-otomy and pyloroplasty and died 2 weeks afterhospitalization following haemorrhage from aorta-oesophageal fistula.7 Radio-contrast oesophago-gram and endoscopy complement each other ininvestigation of proximal alimentary tract diseaseand therefore when one is negative the other shouldbe used before the patient is dismissed. We haveoften had to repeat each one in quick successionbefore we could establish a diagnosis in difficultcases.The diagnosis of TB rests on the demonstration

of a classical caseous lesion or acid fast bacilli(AFB) in the lesion. This is also made where thesputum is AFB positive and the oesophagealbiopsy material equivocal, but excludes otherknown causes of the lesion, especially carcinoma.Some authors have resorted to culturing of thebiopsy material in order to establish the diagnosis.9Although to date we have not done this in ourpractice, a repeat biopsy taken from the area ofoesophagogram abnormality should be submittedfor mycobacteria culture in diagnostically difficultcases. We have found a Mantoux test unreliable indiagnosis of TB in endemic areas like ours. How-ever, this remains a useful indicator in non-endemicareas. In a few instances where neither biopsy, TBculture nor sputum examination succeeds in estab-lishing an otherwise strong clinical suspicion ofTB,a successful therapeutic trial often does. However,caution must be exercised in order not to overlookother causes ofgranulomatous diseases which mayalso present with dysphagia (such as histoplasmo-sis'0) in areas where these are endemic.Treatment of oesophageal TB is primarily medi-

cal with the usual multiple anti-TB drug therapyfor an average duration of 12 months. Whendysphagia is severe enough to preclude effectiveoral intake, parenteral anti-TB drug administra-tion is mandatory. In South Africa, rifampicin andstreptomycin are readily available in a parenteralform but not isoniazid which was withdrawnrecently for economic reasons. Isoniazid is pivotalin anti-TB chemotherapy. It was in the effort tomeet this deficiency that a novel isoniazid suppo-sitory preparation was made as an alternative tothe oral route (submitted for publication). Symp-toms subside fairly rapidly with specific anti-TBdrug therapy and the oesophagogram reverts tonormal within 3 months of treatment in most cases.Even the patients with sinuses heal well, with oftena small diverticulum as the only remaining evidenceof previous disease. However, this apparent rapidresolution should not tempt the clinician or thepatient to cut short the duration of full therapy.The outcome of medical treatment is very reward-ing. Of the 10 patients who received anti-TBtreatment, 9 had an uneventful recovery. Death

copyright. on 5 M

arch 2019 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.68.796.110 on 1 F

ebruary 1992. Dow

nloaded from

OESOPHAGEAL TUBERCULOSIS 115

occurred in a patient whose treatment was inter-rupted by severe hepatitis B viral infection.

Surgical intervention is reserved for thosepatients in whom the diagnosis cannot be reachedby endoscopy or biopsy of accessible associatedlymph nodes such as mediastinal masses not suit-able for mediastinoscopy and in those patients inwhom complications demand surgery, for examplea mediastinal abscess seen to be unresponsive tonon-operative management. Although radicalresection has sometimes been inadvertently per-formed,' planned resection has been infrequent.8"'The oesophageal lesion was tackled directly in onlyone case in this series. This was a patient in whom amediastinal sinus had lead to abscess formationwho underwent surgical drainage of the abscesstogether with successful resection of the sinus andoesophageal repair.Although total dysphagia is uncommon, the

usual strategies for nutritional support should beemployed until swallowing improves with anti-TBdrug therapy. We have recently used short tomedium term total parenteral nutrition in selectedcases of dysphagia, but a feeding gastrostomy is asuitable and more widely available alternative. It isin this type of case that we would recommend theuse of our recently described INH suppositories(submitted for publication) together with parenteralstreptomycin and rifampicin during the period oftotal parenteral nutrition. While dysphagia usuallyresolves with effective anti-TB treatment and nutri-tional support, troublesome stricture formation

has occasionally led to radical resection and coloninterposition.8

In summary, that oesophageal tuberculosis israre has been borne out by this study whichuncovered only 11 patients over a period of 18years in an environment in which TB in general isstill highly prevalent. However, with worldwideincrease in human immunodeficiency virus (HIV)infection, which is often complicated by myco-bacterial infections, its prevalence is expected toincrease likewise. The main presenting symptomwas dysphagia and as such the patients weresubjected to an algorithm used for the morecommon carcinoma of the oesophagus. This is asuitable course as both rely on tissue biopsy fordiagnosis. If endoscopic material is not obtainablethen associated lymph nodes may provide thediagnostic material. When biopsy is not histo-logically diagnostic, material from areas of oeso-phagogram abnormality should be cultured formycobacteria. Rarely, patients may present withhaemorrhage where the algorithm followed is thatof upper gastrointestinal bleeding. When gastro-intestinal tract endoscopy fails to establish themore common sites and causes of bleeding, aradio-contrast oesophagogram should be consider-ed. The plain chest radiograph is often abnormaland this should serve to alert the clinician to thediagnosis of TB, as should the presence of HIVinfection. Once diagnosed, treatment relies firmlyon anti-TB drug action, with surgery reserved forunresolving complications.

References

1. Fahmy, A.R., Guindi, R. & Farid, A. Tuberculosis of theoesophagus. Thorax 1969, 24: 254-256.

2. Damtew, B., Frengley, D., Wolinsky, E. & Spagnuolo, P.J.Esophageal tuberculosis: mimicry of gastrointestinal malig-nancy. Rev Inf Dis 1987, 9: 140-146.

3. Dow, C.J. Oesophageal tuberculosis: Four cases. Gut 1981,22: 234-236.

4. Savage, P.E. & Grundy, A. Oesophageal tuberculosis: anunusual cause ofdysphagia. Br J Radiol 1984,57:1153 - 1155.

5. McNamara, M., Williams, C.E., Brown, T.S. & Gopichand-ran, T.D. Tuberculosis affecting the oesophagus. Clin Radiol1987, 38: 419-422.

6. Hancock, B.W. & Barnett, D.B. Case of post-primarytuberculosis and massive haematemesis. Br Med J 1974, 3:722-723.

7. Robbs, J.V. & Baker, L.W. Tuberculosis involving majorarteries. J R Coll Surg Edinb 1976, 21: 353-358.

8. Montes, I., Larsen, E., Haiderer, 0. & Kennedy, J.H.Tuberculous stricture of the oesophagus: report of a patientsuccessfully treated by colon interposition. Chest 1971, 60:194-195.

9. Gordon, A.H. & Marshall, J.B. Oesophageal tuberculosis:definitive diagnosis by endoscopy. Am J Gastroenterol 1990,85: 174-177.

10. Wain, J.C. Jr & Mark, E.J. A 48-year-old man with dys-phagia, chest pain, fever and subcarinal mass. N Engl J Med1991, 324: 1049-1056.

11. Sinha, S.N., Tesar, P., Seta, W. & Sengupta, S.K. Primaryoesophageal tuberculosis. Br J Clin Pract 1988, 42: 391-394.

copyright. on 5 M

arch 2019 by guest. Protected by

http://pmj.bm

j.com/

Postgrad M

ed J: first published as 10.1136/pgmj.68.796.110 on 1 F

ebruary 1992. Dow

nloaded from