History

Fact Explanation
Dysphagia 90% of affected patients present with dysphagia. This may arise secondary to esophageal ulcers, tracheoesophageal fistula, extrinsic compression by the enlarged adjacent lymph nodes or stricture formation. Some patients may complain of associated odynophagia as well. [1,2,3]
Epigastric pain Epigastric pain and retrosternal chest pain are some presenting complains of tuberculous esophagitis. [1,2,3]
Fever Fever is associated with anorexia, malaise and weight loss. [1,2,3]
History of pulmonary tuberculosis (TB) Patients with pulmonary TB can acquire gastrointestinal TB by accidental swallowing of infected sputum. Some patients acquire it by hematogenous spread of primary pulmonary TB. Most of the esophageal TB occurs due to direct spread of TB from adjacent infected lymph nodes or pulmonary Ghon focus. [1,2]
Paroxysmal postprandial coughing This is due to the presence of trachea-esophageal fistula and aspiration of food particles into the airway. [2]
Recurrent respiratory tract infections Patients with tracheoesophageal fistula can have recurrent lower respiratory tract infections due to frequent aspiration. [2]
Hematemesis Patients with esophageal ulcers can present with hematemesis. Rarely patients with aorto-esophageal fistula and atrioesophageal fistula can also present with hematemesis. [2,3]
Immunocompromised patients Patients with human immunodeficiency virus infection and patients who are on immunosuppressive therapy are at risk of tuberculous infection. [4]
Contact history of pulmonary TB People who are not immunized against TB can present with extrapulmonary TB. [4]
References
  1. GOMES JOANA, ANTUNES ANA, CARVALHO AURORA, DUARTE RAQUEL. Dysphagia as a manifestation of esophageal tuberculosis: a report of two cases. Array [online] 2011 December [viewed 23 July 2014] Available from: doi:10.1186/1752-1947-5-447
  2. HUANG Y. Esophageal tuberculosis mimicking submucosal tumor. Interactive Cardiovascular and Thoracic Surgery [online] 2004 June, 3(2):274-276 [viewed 23 July 2014] Available from: doi:10.1016/j.icvts.2003.11.016
  3. JAIN SS, SOMANI PO, MAHEY RC, SHAH DK, CONTRACTOR QQ, RATHI PM. Esophageal tuberculosis presenting with hematemesis World J Gastrointest Endosc [online] 2013 Nov 16, 5(11):581-583 [viewed 23 July 2014] Available from: doi:10.4253/wjge.v5.i11.581
  4. CHANGAL KHALID HAMID, RAINA AB. HAMEED, PARRA REYAZ, KHAN MUSHTAQ AHMED. Esophageal tuberculosis; A rare cause of odynophagia: A case report. Egyptian Journal of Chest Diseases and Tuberculosis [online] 2013 April, 62(2):349-351 [viewed 23 July 2014] Available from: doi:10.1016/j.ejcdt.2013.06.005

Examination

Fact Explanation
Signs of lower respiratory tract infection Patients are febrile, and have evidence of pulmonary consolidation, commonly over the base of the right lung. The chest wall movements are reduced, over the affected area. Percussion note is dull, tactile vocal fremitus is increased and bronchial breath sounds are heard. [1]
Signs of pulmonary TB Patients with a history of pulmonary TB can have evidence of pulmonary consolidation (reduced chest wall movements, dull percussion note, increased tactile vocal fremitus and bronchial breath sounds). [2] Patients with a history of pulmonary TB can have signs of apical fibrosis (tracheal deviation to the opposite side of fibrosis, apical flattening, reduced chest expansion, fine inspiratory crackles). In miliary TB inspiratory crackles can be auscultated during the second half of inspiration.
Digital clubbing Digital clubbing is detected in severe pulmonary TB. [2]
Cervical lymphadenopathy Palpable cervical lymph nodes can be detected in some patients.
References
  1. KHAN AN, AL-JAHDALI H, AL-GHANEM S, GOUDA A. Reading chest radiographs in the critically ill (Part II): Radiography of lung pathologies common in the ICU patient Ann Thorac Med [online] 2009, 4(3):149-157 [viewed 23 July 2014] Available from: doi:10.4103/1817-1737.53349
  2. BESEN ALINE, STAUB GUILHERME JöNCK, SILVA ROSEMERI MAURICI DA. Manifestações clínicas, radiológicas e laboratoriais em indivíduos com tuberculose pulmonar: estudo comparativo entre indivíduos HIV positivos e HIV negativos internados em um hospital de referência. J. bras. pneumol. [online] 2011 December, 37(6):768-775 [viewed 24 July 2014] Available from: doi:10.1590/S1806-37132011000600010

Differential Diagnoses

Fact Explanation
Esophageal stricture Both benign and malignant esophageal strictures can cause dysphagia. History of ingestion of caustic material is also important because ingested caustic substances can result in esophageal strictures. [1,3]
Esophageal carcinoma Endoscopic appearance of the tuberculous polyps may mimic an esophageal carcinoma. Biopsy and histological examination is helpful in making the definitive diagnosis. Constitutional symptoms like fever, loss of weight and malaise can occur in both conditions. [1,2]
Crohn’s disease Crohn’s disease can affect the esophagus. Endoscopy will reveal the presence of mucosal ulcers. Histology will aid in making the definitive diagnosis. [3]
Esophageal candidiasis Esophageal candidiasis is another cause for dysphagia. It is commonly seen in patients with impaired immunity. [3,4]
Actinomycosis Actinomycosis is a chronic infection of the oropharynx, gastrointestinal tract, and urogenital tract. This is slowly progressive granulomatous disease. [3,5]
Syphilis Tertiary syphilis can affect the esophagus. Patients present with dysphagia and retrosternal chest pain. [3,6]
References
  1. GOMES JOANA, ANTUNES ANA, CARVALHO AURORA, DUARTE RAQUEL. Dysphagia as a manifestation of esophageal tuberculosis: a report of two cases. Array [online] 2011 December [viewed 23 July 2014] Available from: doi:10.1186/1752-1947-5-447
  2. HUANG Y. Esophageal tuberculosis mimicking submucosal tumor. Interactive Cardiovascular and Thoracic Surgery [online] 2004 June, 3(2):274-276 [viewed 23 July 2014] Available from: doi:10.1016/j.icvts.2003.11.016
  3. CHANGAL KHALID HAMID, RAINA AB. HAMEED, PARRA REYAZ, KHAN MUSHTAQ AHMED. Esophageal tuberculosis; A rare cause of odynophagia: A case report. Egyptian Journal of Chest Diseases and Tuberculosis [online] 2013 April, 62(2):349-351 [viewed 23 July 2014] Available from: doi:10.1016/j.ejcdt.2013.06.005
  4. SAMONIS GEORGE, SKORDILIS PANAGIOTIS, MARAKI SOFIA, DATSERIS GEORGE, TOLOUDIS PARASCHOS, CHATZINIKOLAOU IOANNIS, GEORGOULIAS VASSILIOS, BODEY GERALD P.. Oropharyngeal Candidiasis as a Marker for Esophageal Candidiasis in Patients with Cancer. CLIN INFECT DIS [online] 1998 August, 27(2):283-286 [viewed 23 July 2014] Available from: doi:10.1086/514653
  5. WONG V. K., TURMEZEI T. D., WESTON V. C.. Actinomycosis. BMJ [online] December, 343(oct11 3):d6099-d6099 [viewed 23 July 2014] Available from: doi:10.1136/bmj.d6099
  6. BUCHER CJ, ONO J. Tracheo-esophageal Fistula of Syphilitic Origin: Report of a Case Am J Pathol [online] 1934 May, 10(3):391-398.5 [viewed 23 July 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2062823

Investigations - for Diagnosis

Fact Explanation
Upper gastrointestinal endoscopy (UGEI) Tuberculous esophagitis can affect any part of the esophagus but it commonly involves the middle third of the esophagus. Presence of superficial esophageal ulcers with pale grey purulent base and esophageal polyps are macroscopic features suggestive of tuberculous esophagitis. UGEI can detect the presence of esophageal strictures. [1,2,3]
Esophageal biopsy Characteristic histological findings in tuberculous esophagitis are the presence of epithelioid granulomas with Langhans cells, and central necrosis (caseating granulomas). These lesions are surrounded by irregular margins. Acid-fast bacilli can be detected if stained with Ziehl–Neelsen stain. [1,2,3]
Sputum microscopy In primary TB and in patients with simultaneous pulmonary TB, sputum microscopy (Ziehl Nielsen stain) demonstrates the presence of tuberculous bacteria. [1]
Sputum culture Culture of sputum in Löwenstein–Jensen medium can isolate tuberculous bacilli.
Chest X-ray Chest X-ray is helpful in detecting calcified lymph nodes and apical fibrosis. Patients with pulmonary TB have fluffy shadows in the upper zones of the lungs. Most of those lesions show cavitation. In miliary TB small millet like calcifications can be seen. [3,4]
CT scan of the chest CT scan of the chest demonstrates the presence of enlarged periesophageal lymph nodes with hypo dense center and increased esophageal wall thickness. Pulmonary TB can also be diagnosed with CT scan of the chest. [2,3]
Enzyme-Linked ImmunoSorbent Assay (ELISA) ELISA is helpful in diagnosing gastrointestinal TB infection with about 80% sensitivity. [2]
Polymerase chain reaction (PCR) PCR can detect the presence of genetic material of tuberculous bacilli. [3]
References
  1. GOMES JOANA, ANTUNES ANA, CARVALHO AURORA, DUARTE RAQUEL. Dysphagia as a manifestation of esophageal tuberculosis: a report of two cases. Array [online] 2011 December [viewed 23 July 2014] Available from: doi:10.1186/1752-1947-5-447
  2. HUANG Y. Esophageal tuberculosis mimicking submucosal tumor. Interactive Cardiovascular and Thoracic Surgery [online] 2004 June, 3(2):274-276 [viewed 23 July 2014] Available from: doi:10.1016/j.icvts.2003.11.016
  3. JAIN SS, SOMANI PO, MAHEY RC, SHAH DK, CONTRACTOR QQ, RATHI PM. Esophageal tuberculosis presenting with hematemesis World J Gastrointest Endosc [online] 2013 Nov 16, 5(11):581-583 [viewed 23 July 2014] Available from: doi:10.4253/wjge.v5.i11.581FITNESS
  4. CAMPBELL IA, BAH-SOW O. Pulmonary tuberculosis: diagnosis and treatment BMJ [online] 2006 May 20, 332(7551):1194-1197 [viewed 24 July 2014] Available from: doi:10.1136/bmj.332.7551.1194

Investigations - Fitness for Management

Fact Explanation
Chest X-ray Aspiration pneumonia can be diagnosed with the use of chest X-ray. Pulmonary opacities are predominantly seen in the lower lung zones. Either lobar consolidation or segmental consolidation can be seen in aspiration pneumonia. [1]
References
  1. CHANGAL KHALID HAMID, RAINA AB. HAMEED, PARRA REYAZ, KHAN MUSHTAQ AHMED. Esophageal tuberculosis; A rare cause of odynophagia: A case report. Egyptian Journal of Chest Diseases and Tuberculosis [online] 2013 April, 62(2):349-351 [viewed 23 July 2014] Available from: doi:10.1016/j.ejcdt.2013.06.005

Investigations - Screening/Staging

Fact Explanation
Chest X-ray Some patients with tuberculous esophagitis can have pulmonary TB as well. Patients with pulmonary TB have fluffy shadows in the upper zones of the lungs. Most of those lesions show cavitation. In miliary TB small millet like calcifications can be seen. [1,2]
References
  1. GOMES JOANA, ANTUNES ANA, CARVALHO AURORA, DUARTE RAQUEL. Dysphagia as a manifestation of esophageal tuberculosis: a report of two cases. Array [online] 2011 December [viewed 23 July 2014] Available from: doi:10.1186/1752-1947-5-447
  2. HUANG Y. Esophageal tuberculosis mimicking submucosal tumor. Interactive Cardiovascular and Thoracic Surgery [online] 2004 June, 3(2):274-276 [viewed 23 July 2014] Available from: doi:10.1016/j.icvts.2003.11.016

Management - General Measures

Fact Explanation
Management of tracheo-esophageal fistula Pneumonectomy or pericardial patching of the fistula and esophagectomy are indicated in the management of tracheo-esophageal fistula. How ever this has significantly high mortality and morbidity. [1,2,3]
Management of aorto-esophageal fistula Immediate fluid resuscitation is indicated in patients with severe hemorrhage. Endoscopic insertion of a Sengstaken Blakemore tube is indicated in emergency situations. Aortic graft replacement and esophageal replacement is done which should be followed by anti-TB chemotherapy. [4]
References
  1. GOMES JOANA, ANTUNES ANA, CARVALHO AURORA, DUARTE RAQUEL. Dysphagia as a manifestation of esophageal tuberculosis: a report of two cases. Array [online] 2011 December [viewed 23 July 2014] Available from: doi:10.1186/1752-1947-5-447
  2. HUANG Y. Esophageal tuberculosis mimicking submucosal tumor. Interactive Cardiovascular and Thoracic Surgery [online] 2004 June, 3(2):274-276 [viewed 23 July 2014] Available from: doi:10.1016/j.icvts.2003.11.016
  3. JAIN SS, SOMANI PO, MAHEY RC, SHAH DK, CONTRACTOR QQ, RATHI PM. Esophageal tuberculosis presenting with hematemesis World J Gastrointest Endosc [online] 2013 Nov 16, 5(11):581-583 [viewed 23 July 2014] Available from: doi:10.4253/wjge.v5.i11.581
  4. PANDA SS, AGARWALA S, KABRA SK, RAY R, SUGANDHI N, BHAT AS, LODHA R, JOSHI P, BISOI AK, ARORA A, GUPTA AK. Aortoesophageal fistula in a child J Indian Assoc Pediatr Surg [online] 2013, 18(3):124-126 [viewed 24 July 2014] Available from: doi:10.4103/0971-9261.116051

Management - Specific Treatments

Fact Explanation
Antituberculous drugs Antituberculous drugs are used in the treatment of tuberculous esophagitis. Isoniazid, rifampicin, pyrazinamide and ethambutol are used during the first two months which is followed by combined therapy of isoniazid and rifampicin for four months thereafter. [1,2,3]
References
  1. GOMES JOANA, ANTUNES ANA, CARVALHO AURORA, DUARTE RAQUEL. Dysphagia as a manifestation of esophageal tuberculosis: a report of two cases. Array [online] 2011 December [viewed 23 July 2014] Available from: doi:10.1186/1752-1947-5-447
  2. HUANG Y. Esophageal tuberculosis mimicking submucosal tumor. Interactive Cardiovascular and Thoracic Surgery [online] 2004 June, 3(2):274-276 [viewed 23 July 2014] Available from: doi:10.1016/j.icvts.2003.11.016
  3. JAIN SS, SOMANI PO, MAHEY RC, SHAH DK, CONTRACTOR QQ, RATHI PM. Esophageal tuberculosis presenting with hematemesis World J Gastrointest Endosc [online] 2013 Nov 16, 5(11):581-583 [viewed 23 July 2014] Available from: doi:10.4253/wjge.v5.i11.581