Vascular tethering of the megaoesophagus by the azygos arch masquerading as a malignancy.

We report the case of a 50-year-old male, a known case of achalasia cardia for 15 years, who after being successfully treated earlier by pneumatic dilatation, presented with recurrent dysphagia due to vascular tethering of the megaoesophagus by the azygos arch simulating a malignant oesophageal stricture. The patient underwent oesophagectomy because of our inability to rule out the possibility of a malignancy developing in the mid-portion of the long-standing megaoesophagus. We wish to highlight the existence of this new clinical entity and the diagnostic as well as therapeutic dilemmas posed by it.

Surgical management of obstructive gastroduodenal tuberculosis.

BACKGROUND: Gastroduodenal tuberculosis is a rare but potentially curable condition. The aim of the present study was to evaluate the clinical presentation, pre-operative status, management and outcome in patients with histologically proven diagnosis of gastroduodenal obstruction due to tuberculosis. METHODS: We retrospectively reviewed the records of 17 patients managed surgically for gastroduodenal obstruction due to tuberculosis. RESULTS: The site of obstruction was the pyloroduodenal canal in 53% of patients, second part of the duodenum in 24%, third part of the duodenum in 12% and duodenjojejunal flexure in 12%. The obstruction was caused by fibrotic stricture formation in 59% of patients and extrinsic compression by a lymph nodal mass in 41%. Endoscopic biopsy was diagnostic in only 29% of the patients in whom it was performed. Overall, a pre-operative diagnosis of gastroduodenal tuberculosis was suspected in only 35% of patients. All the patients underwent surgical drainage procedures and the diagnosis was confirmed by histopathological examination of biopsies taken at the time of laparotomy. CONCLUSIONS: In view of its rarity and non-specific findings on clinical, radiological and endoscopic evaluation, tuberculosis as a cause of gastroduodenal obstruction is seldom diagnosed pre-operatively. Hence, a high index of suspicion is required in young patients residing in endemic areas. Surgical intervention helps not only in relieving obstruction but also in confirming the diagnosis.