Case of post-primary tuberculosis and massive haematemesis

Tuberculous fistula of the esophagus

BACKGROUND

Tuberculous involvement of the esophagus has been extremely rare during the past 40 years. It will be, however, more frequently encountered in the future, as the number of immunocompromised patients is growing. This condition is usually secondary to infection in other thoracic sites, such as lungs, larynx, or mediastinum. The diagnosis is difficult if the suspicion of tuberculosis is not raised. Dysphagia and cough after ingestion of fluids and food are common symptoms without any other specific signs in these patients. Diagnosis is based on combination of esophagography, esophagoscopy, bronchoscopy, and computed tomographic scan.

METHODS

We present 3 patients with tuberculous fistulas of the esophagus. Two of our 3 patients were treated successfully with the combination of operation and antituberculous chemotherapy. Fistulas were resected and closed directly. Suture lines were secured with pedicled pleural flaps.

RESULTS

Both patients who underwent operation recovered without complications. One patient died without definitive diagnosis and treatment.

CONCLUSIONS

Treatment of tuberculous fistulas consists of operation and antituberculous chemotherapy, although antituberculous medication alone has been suggested to be effective if the diagnosis is early. However, operation is usually necessary to establish the correct diagnosis. Therefore, we believe that if the cause of the esophageal fistula cannot be verified, thoracotomy should be performed. If the fistula is left untreated the consequences are usually fatal.

Esophagoaortic fistula caused by esophageal tuberculosis: report of a case

We report herein the case of a 73-year-old woman who was urgently admitted to hospital with severe hematemesis. An emergency endoscopy revealed a protruding lesion 36 cm from the incisors; however, respiratory insufficiency precluded surgery and despite aggressive medical treatment, the patient's respiratory status continued to deteriorate, leading to death on the 36th hospital day. An autopsy revealed the source of the hemorrhage to be a fistula connecting the esophagus and the descending aorta. Histopathologic studies showed that this fistula was caused by esophageal tuberculosis.

Oesophageal tuberculosis: a review of eleven cases

Tuberculous infection of the oesophagus is rare. This is confirmed by our present review of cases managed in our teaching hospitals over a period of 18 years which uncovered only 11 patients. The main presentation is that of dysphagia whose algorithm of investigation should seek to differentiate tuberculosis from carcinoma, the more common cause of this symptom. Of the 11 patients, 9 presented with dysphagia while 2 had haemorrhage; 7 had an abnormal plain chest radiograph, of whom 4 had a mediastinal mass lesion (3 were lymphadenopathy and one an abscess). All but one had an abnormal radio-contrast oesophagogram, including a mediastinal sinus in two and a traction diverticulum in another two. The mainstay of investigation was oesophagoscopy through which diagnostic biopsy material was obtained 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 was established post-mortem in one patient. Treatment was primarily non-operative with standard anti-tuberculosis drug therapy. Two patients underwent a diagnostic thoracotomy and one a drainage of mediastinal abscess together with resection and repair of oesophago-mediastinal sinus during the early part of the series. Outcome of management was very rewarding in 9 patients and death occurred in 2 patients, one of whom had his anti-tuberculosis drug therapy interrupted by severe hepatitis B virus infection. The other death occurred in a patient whose haemorrhage from an aorta-oesophageal fistula was not established ante-mortem. It is recommended that when 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 be made to obtain biopsy material from associated lymph nodes, even by thoracotomy if necessary, or culture of biopsy from the radiologically abnormal part oesophagus and sputum for mycobacteria, in order to establish the diagnosis of this rare but eminently treatable cause of dysphagia. Clinicians should be aware of tuberculosis of the oesophagus as a possible cause of haematemesis in patients with otherwise unexplained upper gastrointestinal haemorrhage.

Aortoesophageal fistula: a comprehensive review of the literature

Aortoesophageal fistula (AEF) is a relatively rare but life-threatening cause of upper gastro-intestinal bleeding. The clinical characteristics of AEF are so unique that a presumptive bedside diagnosis can be made at the time of presentation. In the past decade, surgical management has improved to the point that cure is now possible. For these reasons, we have reviewed the literature. We summarize our findings with respect to the etiology and clinical characteristics of AEF. Further, we discuss the diagnostic modalities that may be used to confirm the diagnosis, and the therapeutic modalities available to slow the hemorrhage, so as to allow time to correct the anatomic defect.

Tuberculosis of the esophagus

Tuberculosis of the esophagus is rare. More cases of secondary tuberculosis of the esophagus have been reported compared to primary esophageal tuberculosis. An illustrative case of primary tuberculosis of the esophagus is presented and 54 published cases of esophageal involvement in tuberculosis are reviewed. There were eight primary and 46 secondary cases of esophageal tuberculosis. There were more male than female patients (M/F = 2.6:1) with an average age of 39.2 years (range 6 months to 75 years). Diagnosis can be difficult, being based on clinical, radiological, endoscopic, and histological features and on the response to chemotherapy. Most cases can be successfully treated with antituberculous chemotherapy even in the presence of fistulous tracts. Patients with esophageal tuberculosis in the presence of AIDS do not respond as well to antituberculous chemotherapy.

[Surgical treatment of esophageal tuberculosis]

Esophageal tuberculosis, being rare, traditionally has been treated by antituberculous drug therapy, respectively by esophagectomy. A 66-year-old women is reported showing a productive/caseous tuberculosis of the mid-esophagus without pulmonary lesions. In suspicion of a benign tumor thoracotomy was done, and an enlarged oval excision of the esophagus wall with a longitudinal closure was performed. Chemotherapy was applied for one year. 3 1/2 years postoperatively there is a free passage of the esophagus, and the patient seems to be healed.

Oesophago-aortic fistula

This report of oesophageal peptic ulceration communicating with the thoracic aorta, successfully treated, illustrates the importance of prompt recognition of major bleeding and early repair.

Oesophageal tuberculosis: four cases

Four Asian patients presented with dysphagia. In each case the oesophagus was involved by adjacent tuberculous subcarinal glands. The lungs were clear and symptoms of systemic illness were minimal. Findings at oesophagoscopy were non-specific and early diagnosis rested on a high index of suspicion and a strongly positive Mantoux test. Bacteriological proof was obtained early in only two of the cases.

Rupture of a tuberculous pseudoaneurysm of the innominate artery into the trachea and esophagus: report of a case and review of the literature

Spontaneous rupture of a tuberculous pseudoaneurysm of the innominate artery, undiagnosed until necropsy, occurred simultaneously into the trachea and the esophagus in a patient receiving anti-tuberculosis chemotherapy. This is the first reported instance of a tuberculous innominate artery aneurysm, the third tuberculous aneurysm with rupture into the trachea, the sixth into the esophagus, and the first with rupture into both structures. A review of the literature relating to tuberculous aneurysms of the major arteries is provided.