Differential Diagnosis Of Ulcer Of The Esophagus

Simple ulcer requires the exclusion of lues, tuberculosis,

epithelioma, endothelioma, sarcoma, and actinomycosis. Simple ulcer of

the esophagus is usually associated with stenosis, spastic or organic.

Luetic ulcers commonly show a surrounding inflammatory areola, and

they usually have thickened elevated edges, generally free from

granulation tissue, with a pasty center not bleeding readily when

sponged. The Wassermann reaction may contribute to the diagnosis; but

if negative, a thorough and prolonged test with mercury is imperative.

It must be remembered that a person with lues may have a simple,

mixed, or malignant ulceration of the esophagus, or the three lesions

may even be combined. It may be in some cases possible to demonstrate

the treponema pallidum in scrapings taken from the ulcer.

The single tuberculous ulcer is usually pale, superficial, and

granular in base. If it is a continuation from more extensive

extra-esophageal tuberculous ulceration, pale cauliflower granulations

may be present. Slight cicatrices may be seen. Tuberculosis in other

organs can almost always be demonstrated by roentgenographic,

physical, or laboratory studies. Tuberculin tests and animal injection

with an emulsion of a specimen of tissue may be required. The specimen

must be taken very superficially to avoid risk of perforation.

Sarcomatous ulcers do not differ materially in appearance from those

of carcinoma, but they are much more rare.

Carcinomatous ulcer is usually characterized by the very vascular

bright red zone, raised edges, fungations, granulation tissue that

bleeds freely on the lightest touch, and above all, it is almost

invariably situated on an infiltrated base which communicates a

feeling of hardness to the pressure of sponges or the esophagoscope

itself. A scar may be from the healing of an ulcer from stasis, or one

of specific or precancerous character. It may be a cancerous process

developing on the site of a scar, so that the presence of scar tissue

does not absolutely negative malignancy. As a rule, however, scars are

absent in cancer of the esophagus. The firm and sometimes prominent

ridge of the crossing of the left bronchus must not be mistaken for

infiltration, and the esophagoscopist must be familiar with the normal

rigidity of the cricopharyngeus.

[242] Mixed infection gives to all esophageal ulceration a certain

uniformity of appearance, so that laboratory studies of smears or

histologic and bacteriologic study of tissue specimens taken from

fungations or thickened edges are often required to confirm the

endoscopic diagnosis. If the edges are thin and flat, the taking of a

specimen involves some risk; fungations can be removed without risk;

so can nodules, but care must be taken that projecting folds are not

mistaken for nodules. It is always wise to push the therapeutic test

with potassium iodid and especially mercury in any case of esophageal

ulceration unassociated with stasis.

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