Obstrucción duodenal y hemorragia digestiva alta como presentación inicial de una tuberculosis duodenal aislada / Duodenal obstruction and upper gastrointestinal bleeding as the initial presentation of an isolated duodenal tuberculosis

Resumen La tuberculosis duodenal primaria es muy infrecuente, incluso en regiones endémicas. El diagnóstico plantea un gran reto, y requiere un alto índice de sospecha, apoyado en estudios de imágenes, microbiología, e histopatología obtenida por biopsia endoscópica o quirúrgica. Presentamos el caso de un varón de 31 años, sin infección por VIH ni antecedente de tuberculosis, que debutó con una obstrucción duodenal. Posterior a una laparatomía exploradora presentó una estenosis duodenal y una hemorragia digestiva alta. Luego de varias biopsias no concluyentes, sólo la última, realizada con la técnica "biopsia sobre biopsia", demostró la presencia de granulomas con bacilos ácido-alcohol resistentes. El diagnóstico de tuberculosis fue confirmado por reacción de polimerasa en cadena de tejido duodenal. No se evidenció compromiso de otros órganos. La respuesta terapéutica fue excelente.

Primary duodenal tuberculosis is rare, even in endemic regions. The diagnosis poses a major challenge and requires a high index of suspicion, supported by imaging studies, microbiology, and histopatology obtained by endoscopic or surgical biopsy. We report the case of a 31-year-old man, without HIV infection or any previous history of tuberculosis, who presented with duodenal obstruction. After exploratory laparotomy, he presented a duodenal stenosis and upper gastrointestinal bleeding. A total of four diagnostic procedures (one laparotomy and three endoscopies) were performed, all of which included biopsies. Only the last endoscopy made with the technique "biopsy upon biopsy" showed the presence of acid fast bacilli and granulomas. The diagnosis of tuberculosis was confirmed by polymerase chain reaction in duodenal tissue. There was no evidence of involvement of other organs by tuberculosis. The patient had an excellent therapeutic response.

An Interesting Case of Tuberculous Colitis Mimicking Crohn's Disease.

Intestinal tuberculosis is a rare disease in western countries and may mimic a variety of gastrointestinal disorders. Here, we report the case of a 29-yr-old male patient who presented with loose motions, loss of appetite and loss of body weight since two years. On colonoscopy transverse colon, ascending colon, caecum and ileocaecal mucosa was inflamed, swollen and showed multiple superficial longitudinal ulcerations. Crohn’s disease was suspected based on colonoscopic finding. However histopathological examination of biopsies from colonic mucosa then revealed caseating granulomas in the colonic mucosa typical for mycobacterium tuberculosis infection. Our diagnosis is supported by raised serum IgM levels.The patient responded nicely to antitubercular therapy. This case emphasizes the need to include intestinal tuberculosis in the initial differential diagnosis of ulcerative colorectal lesions.

Gallbladder Tuberculosis: CT Findings with Histopathologic Correlation

OBJECTIVE: We wanted to describe the computed tomography (CT) findings of gallbladder tuberculosis (TB) and to correlate them with pathologic findings. MATERIALS AND METHODS: There were seven patients (M:F = 3:4; mean age, 46.3 years; age range, 32 to 78 years) in whom gallbladder TB was eventually diagnosed. All of them underwent cross-sectional imaging with CT, a pathologic examination and a retrospective review. CT imaging evaluation was done in each case, including the findings of a mass versus nodule, wall thickening (uniform or irregular) and the enhancement patterns (homogeneous or heterogeneous). RESULTS: All the cases of gallbladder TB revealed the following three different CT findings: micronodular lesion of the gallbladder wall (n = 1), a thickened wall (n = 4) and a gallbladder mass (n = 2). There were three cases of homogeneous enhancement of the lesions, including homogeneous enhancement with nodular lesion, homogeneous uniform thickness enhancement and homogeneous thickness enhancement in one case each, and these cases pathology showed tuberculous granuloma with a little caseating necrosis in one case and tuberculous granuloma with rich fibrous tissue, but little or no evident caseating necrosis in two cases. Four cases of heterogeneous enhancement of the lesions, including heterogeneous uniform-thickness enhancement in two cases, heterogeneous enhancement with a local mass lesion in one case and heterogeneous enhancement with a mass that replaced the gallbladder in one case; in these cases, pathology showed tuberculous granuloma with marked caseation or liquefaction necrosis in three cases and tuberculous granuloma by fibrous and calcifications accompanied by caseating necrosis in one case. Among the seven cases of gallbladder TB, six cases were accompanied by abdominal extra-gallbladder TB, including abdominal lymph node TB in five cases and hepatic TB in four cases. CONCLUSION: Gallbladder TB has various CT manifestations, and the enhanced CT findings are well matched with pathological features. An irregularly thickened gallbladder wall or a gallbladder wall mass with multiple-focus necrosis or calcifications accompanied by the typical CT findings of abdominal extra-gallbladder TB should suggest the diagnosis of gallbladder TB.

Úlcera tuberculosa intestinal como causa de hemorragia digestiva baja masiva exanguinante / Intestinal tuberculosis causing a severe gastrointestinal bleeding: report of one case

We report a 27 years old woman presenting with hematochezia. An upper endoscopy and colonoscopy did not reveal the bleeding site. Due to persistence of bleeding, the patient was operated, finding a fibrinous secretion surrounding bowel loops and a hyper vascularized concentric papular lesion. The involved bowel loop was excised. The pathological study of the surgical piece revealed intestinal tuberculosis. The patient started treatment for extra pulmonary tuberculosis.

Reportamos el caso de una paciente de 27 años con tuberculosis extrapulmonar gastrointestinal que se manifestó clínicamente como una hemorragia digestiva baja masiva exanguinante requiriendo cirugía de urgencia, donde se realizó laparotomía exploradora con entero y colonoscopía intraoperatoria localizando lesión a nivel de intestino delgado, resecando segmento comprometido con anastomosis primaria, evolución satisfactoria sin complicaciones postoperatorias.

Tuberculosis intestinal / Intestinal tuberculosis

La tuberculosis (TBC) es una enfermedad infecciosa crónica, de tipo granulomatosa, producida por el Mycobacterium tuberculosis. En Chile es endémica, con tasas de 18 casos por 100.000 habitantes. La forma extrapulmonar constituye el 24 por ciento de los casos totales, siendo el compromiso intestinal uno de los más frecuentes, destacando la región ileo-cecal como la más afectada (90 por ciento de los casos). El diagnóstico es complejo ya que las manifestaciones clínicas son inespecíficas y el bacilo difícil de aislar, lo que muchas veces retrasa el inicio del tratamiento aumentando la morbimortalidad. Las manifestaciones clínicas habituales son: dolor abdominal, fiebre, baja de peso y compromiso ileal, siendo frecuente la duda diagnóstica con otras enfermedades que afectan el íleon distal, principalmente la enfermedad de Crohn. El diagnóstico definitivo sólo puede ser realizado a través de la histología o la detección directa del bacilo. La notificación de los casos de TBC es obligatoria en nuestro país; el tratamiento estándar con drogas antituberculosas es altamente efectivo y está garantizado para toda la población chilena.

Tuberculosis (TBC) is a chronic infectious disease of granulomatous type, caused by Mycobacterium tuberculosis. In Chile, the disease is endemic with rates of 18 cases per 100,000 inhabitants. The extrapulmonary form accounts for 24 percent of the total cases. Of these, intestinal tuberculosis is the most frequent, being the ileo-colonic region the most affected (90 percent of cases). Diagnosis is complex because the clinical manifestations are non specific and the bacteria is difficult to isolate, which often delays the onset of treatment thus increasing morbidity and mortality. The most common clinical manifestations are abdominal pain, fever, weight loss and ileal disease, increasing the diagnostic uncertainty in relation to other diseases affecting the distal ileum, mainly Crohn’s disease. A definitive diagnosis can only be made through histology or direct detection of the bacillus. Notification of TBC cases is mandatory in our country; standard treatment with antituberculosis drugs is highly effective and is guaranteed for the entire Chilean population.

Gastrointestinal Histoplasmosis Mimicking Abdominal Tuberculosis.

We report an elderly male who presented with history of chronic diarrhoea. The patient underwent colonoscopy and CT scan of the abdomen which strongly suggested tuberculosis; however histopathology showed presence of budding forms of Histoplasma capsulatum. The patient was started on oral itraconazole on which he improved remarkably. ©

Apresentação de tuberculose com hemorragia digestiva alta: relato de caso / Tuberculosis presenting as upper gastrointestinal bleeding: case report

Tuberculose pode envolver qualquer parte do trato gastrointestinal, entretanto a localização gástrica é extremamente rara. Tuberculose gástrica pode mimetizar úlcera péptica ou neoplasia gástrica maligna, porém hemorragia digestiva alta é manifestação extremamente incomum da tuberculose gástrica. Nós relatamos um caso de tuberculose disseminada, em uma paciente com SIDA com repetidos episódios de melena e hematêmese. A biópsia realizada evidenciou micobacteriose antral, com presença de bacilos álcool-ácido resistentes na área ulcerada (AU)

Tuberculosis may involve any part of the gastrointestinal (GI) tract. However gastric involvement is extremely rare. Gastric tuberculosis may simulate peptic ulcer or gastric malignancy, but upper GI bleeding is an extremely uncommon manifestation. We report a case of disseminated tuberculosis in a patient with AIDS, with repeated episodes of melena and hematemesis. A biopsy revealed antral mycobacteriosis with the presence of acidfast bacilli in the ulcerated area (AU)

Clinicopathological profile and surgical management outcomes in patients suffering from intestinal tuberculosis

To determine the mode of presentation in intestinal tuberculosis and effectiveness of various surgical procedures adopted in our set up. A descriptive study. Liaquat University Hospital, Hyderabad from June 1996 to May 1998 and Muhammad Medical College Hospital Mirpurkhas, Sindh from April 2002 to March 2004. One hundred-twelve cases of intestinal tuberculosis were studied, which were operated and diagnosis was confirmed on biopsy. Data collection included detailed history particularly duration of symptoms, respiratory complains, dietary habits and bowel habits. At Liaquat University Hospital, 1872 patients were admitted, 386 [20.61%] were operated for abdominal complains [acute, sub-acute or chronic intestinal obstruction or perforation] and 80 [4.27%] were diagnosed as having intestinal tuberculosis. Meanwhile, 624 patients were admitted in Muhammad Medical College Hospital Mirpurkhas. Of these, one hundred-seventy [27.24%] were operated for abdominal pathology and 32 [5.12%] cases were proved as intestinal tuberculosis on histopathology. Out of total 112 cases of intestinal tuberculosis, 64 [57.20%] were male and 48 [42.80%] females. Age ranged from 8 to 55 years with majority in 2nd and 3rd decades. Resection and anastomosis of small gut, limited right hemicolectomy, right hemicolectomy, stricturoplasty, ileostomy, adhenolysis and evacuation of pus were the procedures adopted for management. Post-operative complications were seen in 30.65% of patients with wound infection on top, however, mortality remained 3.57%. The mortality of intestinal tuberculosis is high due to delay in diagnosis and under dosage or irregular anti-tuberculous treatment. In complicated cases, surgery is indicated. When multiple strictures or perforations are present, resection and end to end anastomosis is required. In case of caecal mass [fungating type], right hemicolectomy can be performed and in cases where extensive adhesions are present and there is fear of iatrogenic perforation, in attempts to mobilize right colon, limited right hemicolectomy shall be performed

Skip lesions in intestinal tuberculosis

A young lady of 20 years presented with profuse vomiting and absolute constipation of three days duration. She had history of recurrent abdominal pain with vomiting associated with intermittent constipation, abdominal distension and weight loss for the last one year. Conservative management led to no improvement. There was no past history of diarrhea, bleeding per rectum, cough or hemoptysis. General physical examination showed her to be emaciated, afebrile and moderately dehydrated. Her weight was 38 kg. Abdomen was grossly distended with tinkling bowel sounds. No other general or specific physical abnormality was found. Her ESR was 25 mm at the end of 1st hour [Westergren method]; hemoglobin was 9.3 gm% with a hematocrit of 30%; TLC was 8500/cm with 25% lymphocytes and the plain x-ray abdomen showed multiple air-fluid levels in small intestine confirming the diagnosis of intestinal obstruction. She was prepared for emergency surgery, which revealed seven tight strictures in the jejunum and ileum starting at 6 inches from the duodenojejunal flexure and ending 4 inches from the ileocaecal junction. Although the proximal jejunum was dilated, the intervening segments of intestine between strictures were absolutely normal in shape and thickness of wall, colour and texture varying in length from 7 to 18 inches. Gross examination of the mucosa showed transversely placed fibrous strictures causing stenosis without adjacent ulceration, edema or congestion. Mesenteric lymph nodes were enlarged. The rest of the gut was normal. All strictures were managed by stricturoplasties. A piece of the involved gut and an enlarged lymph node from the mesentery was taken as biopsy. Postoperative recovery was smooth. Considering the history and the gross appearance of the intestinal mucosa, anti-tuberculous [TB] chemotherapy was started. Histopathology revealed caseation and Langhan's type of multinucleate giant cells in both the specimens. Ziehl Nielson [ZN] staining of the intestinal biopsy showed acid-fast bacilli, confirming the clinical diagnosis of tuberculosis. Anti-TB drugs were continued for 9 months. During this period her weight increased to 60 kg and abdominal symptoms disappeared. She was asymptomatic 6 months after cessation of drugs

Toxic amebic colitis coexisting with intestinal tuberculosis

A patient with a fulminant amebic colitis coexisting with intestinal tuberculosis had a sudden onset of crampy abdominal pain, mucoid diarrhea, anorexia, fever and vomiting with signs of positive peritoneal irritation. Fulminant amebic colitis occurring together with intestinal tuberculosis is an uncommon event and may present an interesting patho-etiological relationship. The diagnosis was proven by histopathologic examination of resected specimen. Subtotal colectomy including segmental resection of ileum, about 80 cm in length, followed by exteriorization of both ends, was performed in an emergency basis. Despite all measures, the patient died on the sixth postoperative day. The exact relationship of fulminant amebic colitis and intestinal tuberculosis is speculative but the possibility of a cause and effect relationship exists. Fulminant amebic colitis may readily be confused with other types of inflammatory bowel disease, such as idiopathic ulcerative colitis, Crohn's disease, perforated diverticulitis and appendicitis with perforation. This report draws attention to the resurgence of tuberculosis and amebiasis in Korea, and the need for the high degree of caution required to detect it.

Tuberculosis gastrointestinal: revisión y actualización / Gastrointestinal tuberculosis: concepts and update

La tuberculosis gastrointestinal (TBGI)ha aumentado su incidencia últimamente debido a la epidemia del SIDA, los grupos marginales en las sociedades desarrolladas y al incremento de la longevidad en las sociedades modernas. Etiología: la ruta de infección puede ser: ingestión de bacilos, vía linfática, extensión directa de zonas contíguas y hematógena. El 85-90 por ciento de los casos de TBGI afectan el tramo ileo-cecal debido a éstasis de heces y a la mayor absorción presentes. Patología: variedades, ulcerativa (60 por ciento de los casos), hipertrófica (10 por ciento), ulcerohipertrófica. El 74 por ciento de los casos presenta granulomas no caseificantes en la biopsia. Cuadro clínico: dolor abdominal, pérdida...

Tuberculous colo-appendicular fistula

A case of tuberculous fistula between the appendix and sigmoid colon is being presented. Appendicectomy with resection of the part of sigmoid colon having the fistula was performed. Histopathology report of the appendix and mesenteric lymph nodes revealed chronic granulomatous appendicitis and lymphadenitis with caseation. To the best of our knowledge it has not been reported in literature before

Mesenteric vasculopathy in intestinal tuberculosis.

BACKGROUND: Involvement of mesenteric vessels in intestinal tuberculosis and its role in the pathogenesis of the intestinal changes have not been studied histologically. AIM: To study mesenteric vessels in patients undergoing surgery for complications of intestinal tuberculosis. METHODS: Resected intestinal specimens from 68 patients presenting with intestinal perforation and intestinal obstruction were examined; involvement of the major mesenteric vessels was evaluated. RESULTS: Granulomas were seen in the vessel wall in one case and near the vessel wall in 11 cases, intraluminal thrombi were seen in 23 cases, and subintimal fibrosis in nine cases. Perivascular cuffing was seen in intramural and subserosal vessels in ten cases. CONCLUSIONS: Changes in the vessel wall may lead to gut ischemia, which may contribute to the development of strictures and stercoral perforation in intestinal tuberculosis.

Inguinal hernia incarceration as a form of intestinal tuberculosis

We report the case of a 41 year-old male who came to the emergency room with a complaint of abdominal pain, and was diagnosed to have an acute obstructive abdomen due to a right inguinal hernia incarceration. During surgery, an intestinal granulomatous inflammation was observed adhered to the hernial sac. The histopathologic study confirmed the diagnosis of tuberculosis. We present a review of the different clinical forms of intestinal tuberculosis and the difficulties encounted in the differential diagnosis of such, emphasizing the uncommon presentation described in our patient.

Envolvimento intestinal na tuberculose / Intestinal involvement in tuberculosis

É feita uma revisäo sobre o envolvimento intestinal na tuberculose, analisando-se os aspectos clínicos, epidemiológicos, histopatológicos e radiológicos