Tuberculosis of the esophagus

A case of tuberculosis of the esophagus is presented in a patient with pulmonary tuberculosis. The patient, complaining of dysphagia, had esophagoscopic examination which showed a submucosal tumor with central ulceration. Tissue biopsy, under direct vision from the tumor mass, confirmed the diagnosis of tuberculosis. The patient has been asymptomatic under treatment. Both esophageal and pulmonary lesions are largely improved.     

Long esophageal stricture in Crohn's disease: a case report

Crohn's disease of the esophagus is rare, and it is very unusual for it to be located only in the esophagus. We report a case of Crohn's disease confined to the esophagus in a 26-year-old female. The patient was admitted because of progressive dysphagia, odynophagia and weight loss. A barium-swallow examination showed an irregular narrowing of the esophagus below the level of the aortic arch which was 15 cm long, with marginal ulcers and a pseudopolypoid appearance of the mucosa; a computed tomographic scan of the thorax revealed a thickened esophageal wall. Esophagoscopy revealed an esophageal stricture 25 cm distal to the incisor teeth, 2 mm in diameter, with "punched out" ulcers and pseudopolypoid mucosa. Endobiopsy specimens showed chronic lymphocytic infiltration into the corion in the absence of neutrophils, basal-cell hyperplasia and elongation of the stromal papillae. The patient underwent an esophagectomy through a combined cervico-abdominal approach followed by a cervical esogastrostomy. The specimen was 18 cm long, the thickness of the wall was 1.7 cm with fibrosis involving all layers of the esophageal wall and a cobblestone appearance of the mucosa. A heavy lymphoplasmocytic infiltrate extended from the mucosa deep into the muscularis, fibrosis and granulomas were found transmurally. Crohn's disease of the esophagus is a rare and specific entity which can present in various ways; strictures resembling those from reflux esophagitis or a tumor are common. Diagnosis may be suggested by the presence of a chronic lymphocytic infiltrate with or without non-caseating granulomas, and no histologic evidence of chronic reflux esophagitis.     

A pedunculated intraluminal foregut reduplication cyst of the proximal esophagus

A 66-year-old woman with a 3-month history of progressive dysphagia underwent transoral excision of a pedunculated cyst arising in the proximal esophagus. Histologic examination confirmed a pedunculated intraluminal foregut reduplication cyst. She remains well 1 year after excision with no recurrence of dysphagia.     

Subclavian arterio-esophageal fistula secondary to fish bone impaction: report of a case

A 48-year-old Indian man swallowed a fish bone and presented 1 week later with dysphagia, following a single episode of fresh hematemesis. A barium swallow demonstrated a horizontal mucosal tear at the level of the aortic arch, and computed tomography (CT) showed mediastinal emphysema and a bleeding point medial to the left subclavian artery which appeared to be contained by a surrounding hematoma. Subsequently, he developed sudden massive hematemesis and collapsed. Despite emergency surgery, the patient died. At the postmortem examination, a 1.2-cm fistula tract was found connecting the esophagus to the left subclavian artery. This case report emphasizes that a diagnosis of arterio-esophageal fistula should be considered if a patient presents with fresh hematemesis and a recent history of foreign body ingestion.     

Technique for repair of Descemet membrane detachment

Tuberculous infection of the esophagus is a rare disease and usually occurs secondary to tuberculous mediastinal lymphadenopathy. We report a 74-year-old woman presenting with dysphagia and weight loss. The chest radiograph showed punctuated calcifications lining from the right hilar region to the paracardiac region. Upper gastrointestinal endoscopy revealed a 0.5 x 5 cm lesion localized in the 25th cm of the esophagus covered partly with normal mucosa, partly demonstrating ulcerous areas. Biopsy revealed granulomatous infiltrates being tuberculoid in type. Thorax CT showed a calcified lymph node at the right hilum. The patient did not give consent to therapy and died 1 month later.     

Hypomagnesemia and smooth muscle contractility: diffuse esophageal spasm in an old female patient

The aim of this paper is to describe and discuss, on the basis of the available literature, the case of an old female patient, admitted to our university hospital because of a severe dysphagia for solid foods, in whom laboratory data showed a marked hypomagnesemia. She reported a long history (20 years) of allergic bronchial asthma treated with theophylline. Esophagography evidenced a disorder of esophagus motility with diffuse multiple spasm, reminiscent of the 'corkscrew esophagus'. A link with the severe hypomagnesemia (Mg 1.1 mEq/l, normal range 1.6-2.1) was suspected, and a therapy with oral pidolate of Mg (1.5 g/twice a day) was started and continued for 4 months. This was associated with a slow progressive normalization of the Mg plasma level and reverted radiographic esophageal findings with disappearance of dysphagia. Mg is an important element for health and disease, and today Mg deficiency in man has become an accepted medical problem which might complicate many diseases. Neuromuscular disorders, as laryngeal spasm, are recognized complications of hypomagnesemia, but until now only 1 case of motor esophageal disorder associated with a low Mg plasma level was briefly reported in the literature, even if dysphagia is generally included in the symptomatological pattern of hypomagnesemia. Our observation of a severe form of esophageal spasm, associated with hypomagnesemia, in an aged female patient underlines the pathophysiological meaning of the plasma Mg level and suggests the need for routine Mg determination in the clinical setting.     

Upper esophageal stenosis: two case reports

Esophageal stenosis caused by an intrinsic congenital deformity is uncommon in infants and children. The main forms of stenosis are congenital esophageal web congenital stricture caused by tracheobronchial remnants, and congenital idiopathic muscular hypertrophy. The authors report on two patients who were successfully treated and managed after being diagnosed as having upper esophageal stenosis. One patient underwent resection of the web and primary anastomosis of the esophagus and was discharged 6 days after surgery. After 1 year, this patient has had no symptoms of dysphagia or other postoperative difficulties. The second patient underwent balloon dilatation of the esophageal stricture and was discharged on the day of surgery; however, this patient required numerous repeat dilatations.     

High signal in the adenohypophysis on T1-weighted images presumably due to manganese deposits in patients on long-term parenteral nutrition

Hypermanganesaemia is reported in patients on long-term parenteral nutrition. Deposition of manganese, giving high signal on T1-weighted images, may involve the basal ganglia. MRI in nine patients (mean age 51 years, range 31-75 years) on long-term parenteral nutrition (mean duration 30 months, range 6-126 months), demonstrated high signal in the anterior pituitary gland on T1-weighted sagittal and coronal images. The gland appeared normal on T2-weighted images. Signal intensity in the basal ganglia on T1-weighted images was increased in all patients. Endocrine assessment showed no significant abnormality. Neurological examination showed a mild parkinsonian movement disorder in one patient. Hypermanganaesemia was present in all nine (1.3-2.8 micromol/l, mean 1.87 micromol/l). The high signal in the anterior pituitary gland was probably related to deposition of paramagnetic substances, especially manganese.     

Ultrasonographic imaging of neoplasms of the cervical esophagus

BACKGROUND/AIMS: We studied the effectiveness of ultrasonography in evaluating the cervical esophagus for the presence of large masses arising from the esophageal wall and consequently, the modifications of the visceral lumen. MATERIALS AND METHODS: The cervical esophagus can be evaluated by ultrasound with longitudinal and axial scans, using the left thyroid lobe as an acoustic window. The cervical esophagus can be visualized from the C5 to D2 vertebrae. From November 1992 to July 1996, 220 patients with esophageal cancer and 120 subjects without esophageal disease (control group) were examined with ultrasonography. Examination of the cervical esophagus was performed with a linear high definition small parts probe with a frequency of 7.5-10 Mhz. RESULTS: In all 31 patients with cancer of the cervical esophagus, ultrasonography of the cervical region showed the presence of an expanding mass from the esophageal wall as well as the modifications in the visceral lumen. The neoplasm of the cervical esophagus was visualized when its diameter exceeded 5 mm. CONCLUSIONS: The experience of the authors shows that, during ultrasound examination of the cervical region, it is possible to accurately evaluate the cervical esophagus, either morphologically or functionally.     

Small angiomyolipoma of the liver diagnosed by fine-needle aspiration biopsy under ultrasound guidance

The first reported case of small hepatic angiomyolipoma to be diagnosed by fine-needle aspiration biopsy (FNAB) is described. A 53 year old man presented with a tumour in segment VI of the liver measuring 0.9 x 0.8 cm. The tumour was hyperechoic on ultrasound examination, showed relatively low density (+ 33 Hounsfield units) on computed tomography (CT), and was hypervascular on angiography. Computed tomography during arterial portography demonstrated a perfusion defect. Magnetic resonance imaging (MRI) revealed high intensity by both T1- and T2-weighted imaging. Diagnosis could not be obtained by these imaging modalities, but it was established successfully by FNAB under ultrasound guidance. Histologically, the tumour was an angiomyolipoma made up of three components: blood vessels, smooth muscle and fatty tissue. Surgery is unnecessary for this benign condition, and the patient has been followed up. Ten months later, the patient is currently doing well without growth of the hepatic angiomyolipoma.     

Follow-up of children after fetal treatment for obstructive uropathy

We report a 6-year-old girl with Japanese B encephalitis. The initial symptoms were high fever, headache and vomiting. On the second day of illness, she developed hemiconvulsion and was admitted to our hospital. Physical examination demonstrated a stiff neck. C-reactive protein elevated to 22.7 mg/dl. CSF examination showed a marked increase in the cell count (10,896/3 mm3). During the course of the treatment, she showed transient hemiparesis and dysphagia, followed by akinetic mutism lasting for about a month. The patient was left with severe cognitive and memory impairment and complex partial seizures but no motor dysfunction. Japanese B encephalitis was diagnosed by means of serological examination. Magnetic resonance imaging revealed cystic lesions in the medial and posterior thalamus and substantia nigra and severe atrophy of the hippocampus. Despite the involvement of substantia nigra, the patient had no parkinsonism. The cognitive impairment may in part be explained by the lesions in the medical and posterior thalamus.     

Severe dysphagia associated with major tranquillizer treatment

A 56 year old patient with psychiatric complications of systemic lupus erythematosus developed severe dysphagia complicated by weight loss and aspiration. Following investigation it was concluded that the addition of haloperidol to her treatment was the major precipitating cause and withdrawal of the drug was followed by an objective improvement in swallowing. Patients taking major transquillizers may be at increased risk of severe dysphagia; regular observation of swallowing is suggested as a useful addition to the clinical examination of these patients.     

Expression of a synthetic gene for human angiogenin in a recombinant vaccinia virus

A 67-year-old man with a long history of achalasia underwent pneumatic dilation of the lower esophageal sphincter due to increasing dysphagia. During the procedure, a small perforation of the thoracic part of the distal esophagus occurred. Since the rupture was small, well-confined, and detected immediately, the lesion was closed using endoscopically applied metallic clips. The patient did very well, and a contrast swallow three days later showed no leakage of the esophagus. This procedure has not yet been described for the esophagus in the literature, but it may be considered in selected cases of small and well-defined instrumental perforations.     

Percutaneous endoscopic gastrostomy to treat upside-down stomach before stent insertion in a patient with distal esophageal carcinoma

A 89-yr-old woman presenting with dysphagia due to an obstructing adenocarcinoma of the distal esophagus was additionally diagnosed to have an upside-down stomach creating a sharp angulation at the esophagogastric junction. Gastric anatomy had to be restored before palliative stent insertion. As the patient was judged unfit for surgery, the stomach was repositioned endoscopically and fixed to the abdominal wall by percutaneous endoscopic gastrostomy. In the same sitting, a metal stent was placed. Effective palliation of dysphagia was achieved until the patient died of an unrelated cause 5 months later.     

Parathyroid carcinoma: diagnosis and management

A patient with severe hypercalcemia and a palpable neck mass is presented. The highest calcium was 18.8 mg/dL. A left lower neck mass was felt on examination. The trachea was deviated to the right side on a chest film. A barium swallow demonstrated an indentation on the left side of the esophagus. An en-bloc resection of the mass including the thyroid lobe, the strap muscles, and the recurrent laryngeal nerve was done. The pathologic specimen revealed parathyroid carcinoma with dense fibrous septae, invasion of the capsule, and vascular invasion. The patient is alive and without evidence of hypercalcemia or recurrence of the disease 23 years after surgery, probably the longest survivor with carcinoma of the parathyroid gland. Parathyroid carcinoma should be suspected in any patient with severe hypercalcemia and a palpable mass. The best chance for cure is obtained by performing a wide surgical excision during the initial operation.     

Esophageal conduit in nearly hopeless corrosive esophageal stricture patient

The case report of a 28 year old woman with strictured esophagus from corrosive esophagitis for 4 months is presented. Barium swallowing showed a strictured esophagus extending from T2 to the aortic knob and needed frequent dilatations. The patient had a perforated thoracic esophagus and mediastinitis on last dilatation. Cervical esophagostomy, transabdominal esophageal bandaging and jejunostomy feeding were done along with intravenous broad spectrum antibiotics. On esophagoscopy, there was complete stenosis of the cervical esophagus 2 cm from the postcricoid area. The large intestine from the caecum, transverse colon and descending colon was chosen as the esophageal conduit because of adequate length to pass subcutaneously. The caecum was anastomosed to the cervical esophagus and descending colon to the stomach. Seven days postoperatively, the patient could take liquids and soft porridge orally. There was a small leakage from the cervical anastomosed, spontaneous closure was achieved 3 weeks postoperatively. We chose the right side colon as the esophageal conduit because of adequate length to pass subcutaneously. Mediastinal and transhiatal routes could not be passed because of previous mediastinitis from thoracic esophageal perforation. This may be an alternative choice of operation for high cervical esophageal stenosis with previous mediastinitis.     

A 61-year-old man with progressive gait disturbance, freezing, and vertical gaze paresis who developed esophagus cancer

We report a 61-year-old Japanese man who died of complications of esophagus cancer surgery. He was well until his 55 years of the age, when he had an onset of speech disturbance and hand writing. He was seen by a neurologist who prescribed Menesit 600 mg/day. His symptoms improved with this medication. In 1993, three years after the onset, he started to show gait disturbance and easy to fall. In 1995, he noted difficulty in eye opening. He visited our clinic on October 26, 1996. On examination, he showed vertical gaze paresis, masked face, nuchal rigidity, small step gait, freezing phenomena, and festination. His mental status was normal. He was treated with 800 mg/day of Menesit, 800 mg/day of L-dops, and 10 mg/day of bromocriptine with little improvement in his symptoms. Cranial CT scan revealed some dilatation of the third ventricle. Subsequent clinical course was one of the slow progression of his parkinsonism. In September of 1997, he noted difficulty in swallowing. He was admitted to the gastrointestinal service of our hospital on October 14, 1997. On admission, neurologic status was essentially similar to the previous one, but he showed more advanced state of his parkinsonism. Upper gastrointestinal series revealed a mass lesion of about 11.5 cm in length protruding into the lower esophagus lumen. Subtotal esophagus resection including the mass was performed on December 2, 1997. The stomach was elevated for anastomosis with the upper esophagus. No metastases were found in the mediastinum except for two lymph nodes in the para-esophageal region. The subsequent course was complicated by marked elevation of GOT, GPT, LDH, total bilirubin as well as direct bilirubin, alkaliphosphatase, and amylase starting in the evening of the surgery. On December 7, leukocytosis and pneumonic shadow were seen involving his right lung. On December 10, he developed cardiopulmonary arrest. He was once resuscitated; however, he developed cardiac arrest again seven hours later and pronounced dead. He was discussed in a neurologic CPC. The chief discussant arrived at the conclusion that the patient had PSP and the cause of the death was ascribed to circulatory disturbance to the liver. The discussant also thought that the terminal course was complicated by cholangitis or cholecystitis, sepsis, and pulmonary embolism. Surgical specimen of the esophagus tumor revealed carcinosarcoma. Postmortem examination revealed yellowish discoloration of the peritoneum and mesenterium, and accumulation of clouded ascites indicating the presence of peritonitis. Inflammatory change extended to the mediastinum. On microscopic examination, various kinds of bacilli and candida spores were seen. The liver was enlarged and a perforation was noted in the gallbladder causing biliary necrosis in the adjacent liver. An extensive infarct was seen in the left lobe of the liver; this was found to be due to obstruction of the hepatic artery at the site of the duodenohepatic mesenterium and obstruction of intrahepatic portal vein secondary to retrograde intrahepatic cholangitis in the left lobe. A piece of surgical threads was seen adjacent to the hepatic artery; foreign body granulomatous reaction was seen surrounding the surgical thread. The rupture of the gallbladder appeared to be due to the obstruction of the left branch of the hepatic artery. Neuropathologic examination revealed extensive degeneration of the pallidum, the substantia nigra, and the subthalamic nucleus and presence of neurofibrillary tangles in the remaining neurons. The neuropathologic findings were consistent with progressive supranuclear palsy, although the pathologic changes in the midbrain tegmentum was only mild gliosis.     

Severe dysphagia, dysmotility, and unusual saccular dilation (diverticulum) of the esophagus following excision of an asymptomatic congenital cyst

Iatrogenic dysmotility syndromes, particularly achalasia-like conditions, occasionally complicate esophageal and paraesophageal surgery. We describe a patient who developed a very unusual (and as far as we know unreported) syndrome characterized by severe dysphagia, esophageal dysmotility (segmental simultaneous contractions of the distal esophagus), and very large saccular outpouching (diverticulum) involving the right wall of the distal half of the esophagus as a consequence of excision of an asymptomatic congenital cyst. The cyst had been discovered as an incidental finding on a preemployment chest x-ray. Our patient's dysphagia did not improve with nonsurgical treatments that are usually successful for idiopathic and iatrogenic achalasia.     

Intramedullary tuberculoma: a case report

A fifty-year-old Portuguese man presented with a six-month history of low back pain, which initially was mechanical and slowly became inflammatory. Secondarily, he complained of right atypical sciatalgia. He did not report any fever, loss of weight, cough nor personal or familial history of tuberculosis. General examination was normal. Neurologic examination showed weakness of the extensors of the right leg, with a symmetric increased reflexes of the lower extremities suggesting a pyramidal syndrome without Babinski's sign. Laboratory data were normal as well as chest radiographs. Dorsolumbar gadolinium enhanced MRI revealed an intramedullary ringlike enhancing mass at T12 level. Lumbar puncture showed 11 WBC/mm3 (95 p. 100 lymphocytes), a normal protein and glucose content. PCR and culture for Mycobacterium tuberculosis were negative. Within a few days, he developed meningoencephalitis with fever, CSF examination revealed then 360 WBC/mm3 (65 p. 100 lymphocytes and 17 p. 100 neutrophils), a protein content of 7 g/l and a glucose level of 1.7 mmol/l. The clinical picture was then suggestive of tuberculosis and a specific therapy with rifampin, izoniazid, pyrazinamid, ethambutol and steroids was started. Clinical improvement and a second CSF culture that revealed one month later Mycobacterium tuberculosis complex confirmed this diagnosis. Ten months later, the patient was asymptomatic with a normal MRI. To our knowledge, this is the first total recovery of an intramedullary tuberculoma on medical therapy alone, confirmed by MRI normalization. We reviewed also 19 recent cases of tuberculomas in the literature, intending a therapeutic attitude when discovering an intramedullary ringlike enhancing mass on MRI.     

Diurnal variation of adrenocortical activity in chronic fatigue syndrome

The nutcracker esophagus, a primary motor disorder, is frequently associated with noncardiac chest pain. However, there are no data on whether its diagnosis, as in other esophageal motility disorders, is delayed. Since the disorder is frequently heralded by alarming symptoms such as chest pain and dysphagia, diagnosis should be made as soon as possible. In this study we assessed the diagnostic delay, if any, in patients with the nutcracker esophagus. Moreover, we were interested in whether the abnormalities described in the distal esophagus could also involve the entire viscus. Fifty-four subjects (age range 23-78 yr) with the nutcracker esophagus were assessed for clinical and manometric variables as an overall group and after dividing them into subgroups according to their symptoms. The manometric variables were compared with those obtained in 61 controls (age range 21-67 yr). Overall, a diagnosis of nutcracker esophagus was made after an average period of 36 +/- 6 months, and surprisingly, this was not different in the various subgroups complaining of either chest pain, dysphagia, or both. Analysis of manometric variables showed that the mean amplitude of contractions was significantly higher in the patients' group at all esophageal body levels, even in the proximal portions. Again, there were no significant differences among the subgroups of nutcracker esophagus with respect to the symptoms. Notwithstanding the presence of alarming symptoms, such as chest pain and dysphagia, the nutcracker esophagus is diagnosed on average after 3 years from the onset of symptoms. Manometric assessment seems to confirm that this entity may indeed represent a primary esophageal motor disorder. The major dysfunction is due to an abnormal increase of contraction amplitude of the entire esophageal body.