Successful Multidisciplinary Treatment of Small Bowel Obstruction With an Ileal Stricture Resulting in Bowel Perforation in the Setting of Multidrug-Resistant Gastrointestinal Tuberculosis: A Case Report.

We present the case of a male in his 40s who recently emigrated from Russia and was actively undergoing treatment for multidrug-resistant (MDR) pulmonary tuberculosis (TB) with the BPaL-M (bedaquiline, pretomanid, linezolid, moxifloxacin, and pyridoxine) regimen who presented to the emergency department (ED) with abdominal pain, vomiting, and no bowel movements. A computed tomography (CT) scan of the abdomen and pelvis revealed a small bowel obstruction (SBO) from ileal stricture consistent with gastrointestinal (GI) TB. He did not require an emergent surgical intervention and was managed conservatively via bowel rest and initiation of total parenteral nutrition (TPN). An oral BPaL-M regimen was held and an intravenous (IV) regimen consisting of linezolid, moxifloxacin, meropenem, and ampicillin/sulbactam was started per infectious disease (ID) recommendations. He improved clinically over the next several days and was started on a diet that was initially well tolerated. Shortly after transitioning to a regular diet, he developed severe abdominal pain. A CT scan of the abdomen and pelvis revealed pneumoperitoneum and he was taken emergently to the operating room (OR) for exploratory laparotomy (ex-lap). A perforation was found in the terminal ileum and he underwent a right hemicolectomy. He returned to the OR two days later for ileocolic anastomosis and fascial closure. A diet was initiated once again which was tolerated well. He was then transitioned back to his oral BPaL-M regimen which was also tolerated well. He was discharged home on an oral diet after a 23-day hospital course with follow-up appointments with acute care surgery (ACS) and ID.

Recognizing and addressing the challenges of gastrointestinal tuberculosis.

In this editorial, we comment on the article by Ali et al published in the recent issue of the World Journal of Clinical Cases. This case report shed light on a particularly rare manifestation of this disease-primary gastrointestinal tuberculosis (GTB) presenting as gastric outlet obstruction. GTB presents diagnostic challenges due to its nonspecific symptoms and lack of highly accurate diagnostic algorithms. This editorial synthesizes epidemiological data, risk factors, pathogenesis, clinical presentations, diagnostic methods, and therapies to raise awareness about GTB. GTB constitutes 1%-3% of all tuberculosis cases globally, with 6%-38% of patients also having pulmonary tuberculosis. Pathogenesis involves various modes of Mycobacterium tuberculosis complex entry into the gastrointestinal system, with the terminal ileum and ileocecal valve commonly affected. Clinical presentation varies, often resembling other intra-abdominal pathologies, necessitating a high index of suspicion. Diagnostic tools include a combination of biochemical, microbiological, radiological, and endoscopic assessments. Anti-tubercular medication remains the cornerstone of treatment, supplemented by surgical intervention in severe cases. Multidisciplinary management involving gastroenterologists, surgeons, pulmonologists, and infectious disease specialists is crucial for optimal outcomes. Despite advancements, timely diagnosis and management challenges persist, underscoring the need for continued research and collaboration in addressing primary GTB.

Primary gastroduodenal tuberculosis presenting as gastric outlet obstruction: A case report and review of literature.

BACKGROUND: Mycobacterium tuberculosis (TB) is the causative agent of TB, a chronic granulomatous illness. This disease is prevalent in low-income countries, posing a significant global health challenge. Gastrointestinal TB is one of the three forms. The disease can mimic other intra-abdominal conditions, leading to delayed diagnosis owing to the absence of specific symptoms. While gastric outlet obstruction (GOO) remains a frequent complication, its incidence has declined with the advent of proton pump inhibitors and Helicobacter pylori eradication therapy. Gastroduodenal TB can cause upper gastrointestinal hemorrhage, obstruction, and malignancy-like tumors. CASE SUMMARY: A 23-year-old male presented with recurrent epigastric pain, distension, nausea, vomiting, and weight loss, prompting a referral to a gastroenterologist clinic. Endoscopic examination revealed distorted gastric mucosa and signs of chronic inflammation. However, treatment was interrupted, possibly owing to vomiting or comorbidities such as human immunodeficiency virus infection or diabetes. Subsequent surgical intervention revealed a dilated stomach and diffuse thickening of the duodenal wall. Resection revealed gastric wall effacement with TB. CONCLUSION: Primary gastric TB is rare, frequently leading to GOO. Given its rarity, suspicions should be promptly raised when encountering relevant symptoms, often requiring surgical intervention for diagnosis and treatment.

Rare Case of Lower Gastrointestinal Bleeding Secondary to Miliary Tuberculosis in the United States.

Tuberculosis (TB) remains a significant global health challenge. Miliary TB is a rare manifestation of TB that involves systemic lymphohematogenous dissemination of infection and presents diagnostic challenges due to its often asymptomatic or non-specific nature. This case report documents a rare occurrence of gastrointestinal (GI) bleeding secondary to miliary TB without pulmonary symptoms in an 81-year-old Filipino-American male living in the United States. Extensive imaging studies revealed a mass in the right colon with multiple bleeding vessels draped around it; it was not amendable to treatment with embolization and required right hemicolectomy with end ileostomy. The pathology report of the excised mass demonstrated miliary TB with necrotizing granulomas and granulomatous lymphadenopathy involving 23 lymph nodes. The patient was started on anti-tuberculosis medical management; however, the patient remained clinically unstable and expired on postoperative day 39. This case highlights the importance of the heightened clinical awareness required during times of globalization and in regions with dense immigrant populations. We aim to delineate the clinical understanding of gastrointestinal TB (GITB) and review possible indications for surgical management. We aim to help reduce diagnostic delay, therefore improving patient outcomes and limiting the spread of disease.

Antibiotics for inflammatory bowel disease: Current status.

There is abundant literature reporting about the use of antibiotics in inflammatory bowel disease (IBD), but their role in the management of IBD is not entirely clear. Diverse infectious organisms have been implicated in the pathogenesis of Crohn's disease. Also, infections are believed to be a trigger for flares of ulcerative colitis. The benefit of the routine use of antibiotics in IBD is equivocal. However, there are certain situations, where antibiotics have a clear role and evidence of benefit: perianal fistula, intra-abdominal abscesses in Crohn's disease, acute pouchitis and infection-related flares. However, there is a lack of supportive evidence for the routine use of antibiotics in all disease-related flares. Evidence indicates a lack of benefit of intravenous antibiotics in acute severe ulcerative colitis and only limited benefit in active ulcerative colitis. Limited evidence suggests the role of a combination of oral antibiotics in pediatric ulcerative colitis. Certain targeted antibiotic regimens have been used in IBD. In ulcerative colitis, limited evidence suggests the benefit of the use of an antibiotic cocktail directed against Fusobacterium varium. Therapy directed against Escherichia coli does not seem to have a benefit in inflammatory Crohn's disease. In Crohn's disease, antimycobacterial therapy may result in symptomatic improvement but no durable benefit. Antitubercular therapy (ATT), on the contrary, may result in fibrotic transformation, suggesting a need to avoid misdiagnosis and limit the duration of ATT in Crohn's disease. This review assesses the published literature with respect to antibiotic use and provides guidance to clinicians in appropriate antibiotic use in various situations in the setting of IBD.

Imaging of infra-thoracic tuberculosis.

Tuberculosis (TB) is a potentially curable disease that is a leading cause of death globally. While it typically affects the lungs, this disease may involve many extra-pulmonary sites, particularly in patients with risk factors. Extra-pulmonary TB often mimics a variety of different diseases, posing a diagnostic dilemma. Imaging aids in early diagnosis of TB, especially in patients with non-specific or atypical symptoms found at extra-pulmonary infra-thoracic locations. Imaging also helps guide appropriate laboratory investigation, monitor disease progress, and response to treatment. This review aims to highlight the imaging spectrum of TB affecting the infra-thoracic region, that is, gastrointestinal tract, abdominal lymph nodes, peritoneal cavity, intra-abdominal solid organs, and urogenital system.

Artificial intelligence for discrimination of Crohn's disease and gastrointestinal tuberculosis: A systematic review.

BACKGROUND AND AIM: Discrimination of gastrointestinal tuberculosis (GITB) and Crohn's disease (CD) is difficult. Use of artificial intelligence (AI)-based technologies may help in discriminating these two entities. METHODS: We conducted a systematic review on the use of AI for discrimination of GITB and CD. Electronic databases (PubMed and Embase) were searched on June 6, 2022, to identify relevant studies. We included any study reporting the use of clinical, endoscopic, and radiological information (textual or images) to discriminate GITB and CD using any AI technique. Quality of studies was assessed with MI-CLAIM checklist. RESULTS: Out of 27 identified results, a total of 9 studies were included. All studies used retrospective databases. There were five studies of only endoscopy-based AI, one of radiology-based AI, and three of multiparameter-based AI. The AI models performed fairly well with high accuracy ranging from 69.6-100%. Text-based convolutional neural network was used in three studies and Classification and regression tree analysis used in two studies. Interestingly, irrespective of the AI method used, the performance of discriminating GITB and CD did not match in discriminating from other diseases (in studies where a third disease was also considered). CONCLUSION: The use of AI in differentiating GITB and CD seem to have acceptable accuracy but there were no direct comparisons with traditional multiparameter models. The use of multiple parameter-based AI models have the potential for further exploration in search of an ideal tool and improve on the accuracy of traditional models.

Gastrointestinal tuberculosis: An autopsy-based study.

Background: Tuberculosis is a disease of great relevance since it is one of the leading causes of morbidity and mortality worldwide. Gastrointestinal tuberculosis is an unusual presentation. It is defined as the involvement of any segment of the digestive tract, associated viscera, and peritoneum. The study's main objective is to collect information from autopsies of patients diagnosed with gastrointestinal tuberculosis in a Pathology reference center in Colombia. Methods: This is a retrospective and descriptive study of autopsy reports. A total of 4,500 autopsies were performed between January 2004 and December 2020. The inclusion criteria were authorization of a family member following local law regulations and a final autopsy diagnosis of gastrointestinal tuberculosis using microscopic visualization. Results: Forty-eight patients with gastrointestinal tuberculosis autopsies were included in our study. Most of the patients were male (n = 35, 72.9%) with a median age of 40.5 years old. Human immunodeficiency virus infection history was reported in 28 cases (58.33%). The most affected gastrointestinal tract site was the terminal ileum. Ulcers and thickened epithelium were common autopsies macroscopic findings. Tuberculosis multiorgan compromise was a relevant finding in patients with gastrointestinal tuberculosis. Conclusions: Gastrointestinal tuberculosis is a disease of great importance, being its diagnosis a clinical challenge. Underdiagnosis can be reported in a high percentage of cases, so autopsy diagnosis can help reveal more accurate data about this condition.

Gastroduodenal and Colorectal Tuberculosis: Report of 2 Cases.

Introduction: Tuberculosis remains a public health concern in developing countries, as well as in developed countries as a result of immigration from endemic areas. Gastroduodenal and colorectal tuberculosis are rare manifestations of gastrointestinal infection. Case Presentation: We present 2 cases of gastric, duodenal, and colorectal tuberculosis. The first case, a 17-year-old male with no medical record, presented with chronic diarrhea and abdominal pain. At endoscopy, he had multiple ulcers in the stomach, colon, and rectum, which were positive to Mycobacterium tuberculosis. The second case was a 43-year-old HIV-positive male, with a history of intermittent fever, nausea, and vomiting. Upper gastrointestinal endoscopy revealed a deep ulcer on gastric fundus that tested positive to M. tuberculosis in the acid-fast bacilli staining. Discussion/Conclusion: Gastroduodenal and colorectal tuberculosis, although rare, should be considered in the differential diagnosis in both immunosuppressed and immunocompetent patients. An adequate tissue sample and appropriate diagnostic tests are essential for the diagnosis and prompt start of first-line antituberculosis agents.

Introdução: A tuberculose continua sendo um problema de saúde pública nos países em desenvolvimento, bem como nos países desenvolvidos, em decorrência da imigração. A tuberculose gastroduodenal e colorretalsão manifestações raras de infecção gastrointestinal. Apresentação do Caso: Apresentamos dois casos de tuberculose gástrica, duodenal ecolorretal. O primeiro caso, um jovem de 17 anos, apresentou diarreia crônica e dor abdominal. Na endoscopia, tinha múltiplas úlceras no estômago, cólon e reto que foram positivas para Mycobacterium Tuberculosis. O segundo caso foi um homem de 43 anos, HIV positivo, com relato de febre intermitente, náuseas e vômitos. A endoscopia digestiva alta revelou úlcera profunda do fundo gástrico positivo para Mycobacterium tuberculosis na coloração de bacilos álcool-ácido resistentes. Discussão/Conclusão: Tuberculosegastroduodenal e colorretal, embora raras, deve ser considerada como diagnóstico em pacientes imunossuprimidos e imunocompetentes. Uma amostra de tecido adequada e testes diagnósticos apropriados são essenciais para o diagnósticoe início imediato dos tuberculostáticos de primeira linha.

First case of primary appendiceal tuberculosis presented as stump appendicitis.

Tuberculosis (TB) remains as a significant global public health issue, especially in developing and underdeveloped nations. Extrapulmonary TB comprises 20% of the TB cases; of which 34.4% were in the lymphatics, 25.2% pleural, followed by 12.8% gastrointestinal and 9.4% in the central nervous system. Ileocecal involvement is the most common among gastrointestinal TB. Although it can cause secondary damage to the appendix, primary type of appendicular TB is rare and can occur with no other signs of the disease. A high index of suspicion is necessary for early diagnosis and treatment of TB. Similarly, stump appendicitis (SA) is a rare and delayed complication of appendectomy. Here we report a case of primary appendicular TB in a patient presented to a multi-specialty hospital in Kerala, India, with SA.

Esophageal anthracosis occurred after treatment of esophageal tuberculosis secondary to mediastinal tuberculous lymphadenitis: a rare case report.

BACKGROUND: Anthracosis is a disease generally considered to be in the lungs resulting from exposure to industrial dust in the workplace. Esophageal anthracosis is a fairly rare phenomenon and shows a strong correlation with tuberculosis. Moreover, esophageal involvement in tuberculosis is also rare. We here present an extremely rare case in which follow-up gastroesophageal endoscopy revealed a mass with a sunken, black area in the center and raised ring-like pattern in the surrounding mucosa resembling malignant melanoma. Uncovering the patient's tuberculosis history finally avoided a misdiagnosis or overtreatment. CASE PRESENTATION: A 67-year-old male patient was admitted to the hospital due to "repeated chest pain for 1 month". Endoscopic ultrasonography and contrast-enhanced CT scans revealed a mass adjacent to the esophageal wall with unclear boundaries. Aspiration biopsy confirmed that esophageal tuberculosis was caused by nearby mediastinal tuberculous lymphadenitis. After a standard anti-tuberculosis treatment regimen, the patient achieved a favorable prognosis. The follow-up gastroesophageal endoscopy showed a sunken black lesion with elevated peripheral mucosa replacing the original tuberculous mass, which was thought to be anthracosis, a disease that rarely occurs in the esophagus. CONCLUSION: The diagnosis of tuberculosis should be taken into consideration when a submucosal mass appears in the middle part of the esophagus. Endoscopic ultrasonography can effectively contribute to a definite diagnosis. Moreover, this is the first case of esophageal anthracosis observed only 1 year after the treatment of tuberculosis, indicating esophageal anthracosis can be a short-term disease. The traction of the reduction of tubercular mediastinal lymph nodes after anti-tuberculosis treatment may create a circumstance for pigmentation or dust deposition.

Evidence-based approach to diagnosis and management of abdominal tuberculosis.

Abdominal tuberculosis is an ancient problem with modern nuances in diagnosis and management. The two major forms are tuberculous peritonitis and gastrointestinal tuberculosis (GITB), while the less frequent forms are esophageal, gastroduodenal, pancreatic, hepatic, gallbladder and biliary tuberculosis. The clinicians need to discriminate the disease from the close mimics: peritoneal carcinomatosis closely mimics peritoneal tuberculosis, while Crohn's disease closely mimics intestinal tuberculosis. Imaging modalities (ultrasound, computed tomography, magnetic resonance imaging and occasionally positron emission tomography) guide the line of evaluation. Research in diagnostics (imaging and endoscopy) has helped in the better acquisition of tissue for histological and microbiological tests. Although point-of-care polymerase chain reaction-based tests (e.g. Xpert Mtb/Rif) may provide a quick diagnosis, these have low sensitivity. In such situations, ancillary investigations such as ascitic adenosine deaminase and histological clues (granulomas, caseating necrosis, ulcers lined by histiocytes) may provide some specificity to the diagnosis. A diagnostic trial of antitubercular therapy (ATT) may be considered if all diagnostic armamentaria fail to clinch the diagnosis, especially in TB-endemic regions. Objective evaluation with clear endpoints of response is mandatory in such situations. Early mucosal response (healing of ulcers at two months) and resolution of ascites are objective criteria for early response assessment and should be sought at two months. Biomarkers, especially fecal calprotectin for intestinal tuberculosis, have also shown promise. For most forms of abdominal tuberculosis, six months of ATT is sufficient. Sequelae of GITB may require endoscopic balloon dilatation for intestinal strictures or surgical intervention for recurrent intestinal obstruction, perforation or massive bleeding.

Frequency, outcomes, and need for intervention in stricturing gastrointestinal tuberculosis: a systematic review and meta-analysis.

BACKGROUND: Gastrointestinal strictures impact clinical presentation in abdominal tuberculosis and are associated with significant morbidity. AIM: To conduct a systematic review of the prevalence of stricturing disease in abdominal and gastrointestinal tuberculosis and response to antitubercular therapy (ATT). METHODS: We searched Pubmed and Embase on 13th January 2022, for papers reporting on the frequency and outcomes of stricturing gastrointestinal tuberculosis. The data were extracted, and pooled prevalence of stricturing disease was estimated in abdominal tuberculosis and gastrointestinal (intestinal) tuberculosis. The pooled clinical response and stricture resolution (endoscopic or radiologic) rates were also estimated. Publication bias was assessed using the Funnel plot and Egger test. The risk of bias assessment was done using a modified Newcastle Ottawa Scale. RESULTS: Thirty-three studies reporting about 1969 patients were included. The pooled prevalence of intestinal strictures in abdominal tuberculosis and gastrointestinal TB was 0.12 (95%CI 0.07-0.20, I2 = 89%) and 0.27 (95% CI 0.21-0.33, I2 = 85%), respectively. The pooled clinical response of stricturing gastrointestinal tuberculosis to antitubercular therapy was 0.77 (95%CI 0.65-0.86, I2 = 74%). The pooled stricture response rate (endoscopic or radiological) was 0.66 (95%CI 0.40-0.85, I2 = 91%). The pooled rate of need for surgical intervention was 0.21 (95%CI 0.13-0.32, I2 = 70%), while endoscopic dilatation was 0.14 (95%CI 0.09-0.21, I2 = 0%). CONCLUSION: Stricturing gastrointestinal tuberculosis occurs in around a quarter of patients with gastrointestinal tuberculosis, and around two-thirds of patients have a clinical response with antitubercular therapy. A subset of patients may need endoscopic or surgical intervention. The estimates for the pooled prevalence of stricturing disease and response to ATT had significant heterogeneity.

Massive gastrointestinal bleeding as a clinical manifestation of miliary tuberculosis

Tuberculosis is still a public health problem today and can have acute and chronic manifestations challenging clinics for various medical specialties. Because it's a disease of multisystem potential, it is often overlooked when outside the respiratory clinical context. As a result, a clinical case report was carried out at the Hospital de Clínicas de Porto Alegre, in 2020, of a patient with voluminous gastrointestinal bleeding as severe acute clinical manifestation of Miliary and Intestinal Tuberculosis. Due to the potential severity of undiagnosed and untreated tuberculosis, high suspicion is suggested at all levels of health systems (whether public or private) with a view to early diagnosis, treatment and prevention of complications resulting from the disease.

Comparative evaluation of interleukin-10, transforming growth factor-ß, and interleukin-17 in gastrointestinal tuberculosis and crohn's disease.

Background: Gastrointestinal tuberculosis (GITB) and Crohn's disease (CD) are close mimickers and difficult to discriminate. Recent work has focused on the immunological differences between GITB and CD based on cytokines related to T-regulatory cells and Th17 cells. In the present cross-sectional study, suspected cases of GITB or CD underwent extensive clinical, radiological, endoscopic, histological, and microbiological assessment. The diagnosis was based on standard criteria and response to antitubercular therapy endoscopically. Methods: Interleukin (IL)-10, transforming growth factor-ß (TGF-ß), and IL-17 were measured and compared between GITB and CD along with other parameters. Fisher's exact test and Mann-Whitney U test were used as per the data type. Results: Of the 27 patients, 11 had CD, 9 had GITB, and 7 had other conditions. Chronic diarrhea, involvement of left and long segments of the colon, and aphthous ulcers were significantly more frequent in CD; however, transverse ulcers were in GITB. IL-10 was reduced in both GITB (median-interquartile range [IQR] 9.54 [3.65-24.04]) and CD (median-IQR 13.28 [6.91-22.50]) compared to control (median-IQR 26.72 [10.34-35.43]). TGF-ß showed little variation, but IL-17 was below the detection limit in most cases. None of these cytokines were significantly different between CD and GITB. The sensitivity and specificity of multiplex Mycobacterium tuberculosis-polymerase chain reaction were 44.44% and 100%, respectively. Conclusion: Serum cytokine profiling (IL-10, IL-17, and TGF-ß) could not significantly differentiate GITB and CD. Moreover, extensive molecular, transcriptomic, chemokines, and cytokine analyses may shed light on these aspects.

Rosai-Dorfman disease mimicking gastrointestinal tuberculosis and fungal sinusitis: A case report.

Every organ can be affected by Rosai-Dorfman disease, the most common being skin and soft tissue, bone and upper respiratory tract. Here we present a Rosai-Dorfman disease patient who manifested with multiple organ involvement. A 33-year-old male presented with multiple joint pain, diarrhea, a purulent nasal discharge and sinus pain. After having serials of investigations he was misdiagnosed as having tuberculosis and fungal sinusitis. Finally, cytology from lymph node aspiration suggested Rosai-Dorfman disease. The sino nasal presentation of Rosai-Dorfman disease can be misdiagnosed as fungal sinusitis and the gastrointestinal manifestation can mimic gastrointestinal tuberculosis. Diffuse joint involvement could also be an initial manifestation of Rosai-Dorfman disease.