Case Presentation 부산백병원소화기내과임상강사황진원
C.C: Dysphagia Present illness F / 43 10 일전부터갑자기시작된상기 C.C 로 LMC 방문하여 EGDS 시행후 mass lesion 발견되어 further evaluation 위해내원함. Past Hx.: DM/HTN/TB/Hepatitis ( - / - / - / - )
F / 43 Social Hx: Alcohol/Smoking ( - / - ) Op Hx.: Ut. Myoma로 Total Hysterectomy (2012년 8월 ) F/Hx.: N-S
Review of system General: Weakness/Faigue/Fever/Chill/Wt. loss (-/-/-/-/-) HEENT: Headache/Dizziness/Sore throat (-/-/-) C-P: Chest pain/dyspnea/palpitation/cough/sputum (-/-/-/-) G-I: Anorexia/Nausea/Vomiting/Diarrhea/Constipation (-/-/-/-/-) Heartburn/Epigastric soreness/abd. pain (-/-/-) G-U: Dysuria/Frequency/Hematuria (-/-/-) N-M: Tingling sense/paralysis pain (-/-)
V/S: 130/70mmHg - 76/min - 12/min 36.6 General appearance: Well being appearance HEENT: Not anemic conjunctivae, Anicteric sclerae Chest: RHB, CBS Abdomen: -Soft and flat abdomen -Normoactive bowel sound - T/RT ( - / - ) Physical examination Back & Extremities: N-S
EGDS: 2013-04 13(LMC)
EGDS: 2013-04 - 22
EGDS: 2013-04 - 22
EGDS: 2013-04 - 22
Diagnosis?
BFS: 2013-04 24
EBUS-TBNA: 2013-04 24
Granuloma Histology Esophagus, 27cm from incisor, endoscopic biopsy: Chronic granulation inflammation with inflammed granulation tissue Tb PCR: M. tuberculosis Inflamed granulation tissue
Granuloma Histology Lung, 4R, EBUS-TBNA: Chronic granulomatous inflammation with caseous necrosis; Tuberculosis Tb PCR: M. tuberculosis Caseous necrosis
Protective mechanism of Esophagus -Rapid transit time of swallowed materials -Stratified squamous epithelial lining -Coating of the mucosa by saliva -Peristalsis Esophageal tuberculosis Devarbhavi HC, Alvares JF, Radhikadevi M. Esophageal tuberculosis associated with esophagotracheal or esophagomediastinal fistula : report of 10 cases. Gastrointest Endosc 2003; 57:588-92.
Esophageal tuberculosis Primary esophageal tuberculosis -Inoculation swallowed contaminated saliva/bovine milk -Haematogenous or lymphatic spread Direct extension from adjacent mediastinal structures -Pulmonary focus, mediastinal LNs, -Vertebrae or upper laryngopharyngeal complex Nagi B, Lal A, Kochhar R, et al. Imaging of esophageal tuberculosis : a review of 23 cases. Acta Radiol 2003; 44:329-33. Rubenstein BM, Pastrana T, Jacobson HG. Tuberculosis of the esophagus. Radiology 1958; 70:401-3.
Midesophagus Esophageal tuberculosis -At the level of carina(from mediastinal lymph nodes) -Most common site of involvement Upper third of esophagus -Direct spread from tubercular laryngitis or pharyngitis Wilcox CM (1999) Esophagitis in the immunocompromised host. In: Castell DO, Richter JE (eds) The esophagus, 3rd edn. Lippincott-Raven, Philadelphia, pp 549 550
Esophageal tuberculosis Weight loss, cough, chest pain, fever Dysphagia, odynophagia, retrosternal discomfort or pain Subsequent complications -Bleeding, perforation, and fistula formation. -Bronchoesophageal fistula -Aortooesophageal fistula Devarbhavi HC, Alvares JF, Radhikadevi M. Esophageal tuberculosis associated with esophagotracheal or esophagomediastinal fistula : report of 10 cases. Gastrointest Endosc 2003; 57:588-92. Abid S, Jafri W, Hamid S, Khan H, Hussainy A. Endoscopic features of esophageal tuberculosis. Gastrointest Endosc.2003; 57:759-62.
Esophageal tuberculosis Endoscopic findings -Ulcerative lesions (most common lesion: tubercular ulcer) -Hyperplastic and granular type lesions -Tumor like growth with a stricture -Extrinsic compression Jain SK, Jain S, Jain M, Yaduvanshi A. Esophageal tuberculosis: is it so rare? Report of 12 cases and review of the literature. Am J Gastroenterol 2002; 97:287-91.
Esophageal tuberculosis Endoscopic findings 대한소화기내시경학회지 2002;25:192-197 경북대학교의과대학내과학교실이승엽ㆍ김은수ㆍ박수영ㆍ이영학ㆍ깅영탁ㆍ조창민ㆍ탁원영권성오ㆍ김성국ㆍ최용환ㆍ정준모
Esophageal tuberculosis Endoscopic findings 대한소화기내시경학회지 2002;24:147-151 한림대학교의과대학내과학교실백일현 김종혁 서중산 김지수 백광호 한태호박현주 이종민 박상훈 장웅기 김우중 박충기 대한소화기내시경학회지 2008;37:335-338 경희대학교의과대학내과학교실차재명ㆍ이정일ㆍ최재원ㆍ주광로ㆍ정성원ㆍ신현필ㆍ허우영
Esophageal tuberculosis Endoscopic findings 대한소화기내시경학회지 2005;30:80-85 연세대학교의과대학내과학교실, * 진단병리학교실최성우 박효진 이상배 정준표 이상인 홍순원 *
Esophageal tuberculosis Endoscopic findings 대한내과학회지 : 제 80 권제 3 호 2011 울산대학교의과대학울산대학교병원내과김세진 정석원 황세진 이영암 김종민 성시정 정인두
Radiology findings Esophageal tuberculosis -Nonspecific: lymphatic lesions or contiguous organs -Lung lesions/lymphatic lesions, B-E fistula -D/Dx: Esophageal cancer Mediastinal LN metastases(other malignancies) Nagi B, Lal A, Kochhar R, Bhasin DK, Gulati M, Suri S, et al. Imaging of esophageal tuberculosis: a review of 23 cases. Acta Radiol 2003;44:329 33. Patnayak R, Reddy MK, Parthasarathy S, Yootla M, Reddy V, Jena A. Unusual presentation of esophageal tuberculosis mimicking malignancy. J Gastroenterol 2008;14:103 4.
Histologic findings -Epithelioid granulomas -Langhans type multinucleated giant cells Isolation of tubercle bacilli -Biopsy specimens: AFB stain & culture -Tb-PCR Esophageal tuberculosis Gordon AH, Marshall JB. Esophageal tuberculosis: definitive diagnosis by endoscopy. Am J Gastroenterol 1990;85:174 7 Garg SK, Tiwari RP, Tiwari D, Singh R, Malhotra D,Ramnani VK, et al. Diagnosis of tuberculosis: available technologies, limitations, and possibilities. J Clin Lab Anal 2003;17:155 63..