Endoscopic balloon dilation of tuberculous duodenal strictures J. C. Vij, G. N. Ramesh, V. Chaudhary, V. Malhotra,
MD MD MD MD
Tuberculosis may affect any part of the gastrointestinal tract but duodenal involvement is distinctly unusual. The majority of patients with duodenal tuberculosis present with obstruction, and in spite of effective anti-tuberculous chemotherapy, a significant number of patients require surgery. Balloon dilation of duodenal strictures is an attractive alternative that has been performed successfully mainly for pyloroduodenal stenosis associated with peptic ulcer diseases. 1 We report successful dilation of duodenal strictures due to tuberculosis in two patients.
ture. Balloon dilation was performed with local pharyngeal anesthesia and 10 mg of intravenously administered diazepam. A 10-mm diameter balloon was used first, followed by a 15-mm balloon. The balloon was inflated with water and pressure was monitored according to the specifications recommended by the manufacturer. Successful dilation was confirmed by the ability to move an inflated balloon to and fro within the strictured area without difficulty. Following dilation, the patient's epigastric pain disappeared and vomiting stopped. Repeat barium study showed marked improvement in the stricture. The patient received a short course of chemotherapy consisting of 450 mg of rifampicin, 300 mg of isoniazid, and 1.0 g of pyrazinamide daily for 2 months followed by rifampicin and isoniazid for another 4 months. Endoscopy with biopsy was performed after completion of 6 months of chemotherapy. The histopathology of the mucosa showed disappearance of granulomas with minimal residual increase in inflammatory cells in the lamina propria. The patient has been free of symptoms for the last 10 months. Case 2
CASE REPORTS Case 1
A 34-year-old man was in good health until 6 months earlier when he began to experience epigastric pain and a low-grade daily temperature of 38 to 3WC. Two months later he developed vomiting, and he lost 8 kg of weight. He never complained of hematemesis or melena. Physical examination revealed an anemic and emaciated man. Abdominal examination showed epigastric tenderness. There was no organomegaly or ascites. Hemoglobin was 10.2 g/100 ml and white blood count was 1O.200/mm3 with 48% lymphocytes, 46% polymorphonuclear neutrophils, 2% monocytes, and 2% eosinophils. ESR was 60 mm/first hour Westergren. Serum albumin was 3.2 g/IOO ml. Urinalysis, stool examination, routine biochemistry were normal. Chest x-ray showed an infiltrating tubercular lesion in the right apical zone. Sputum examinations for AFB on two occasions were negative. An upper gastrointestinal series with barium revealed a narrowed segment with irregular mucosa in the post-bulbar duodenum. Ultrasound examination of the abdomen was normal; there was no evidence of lymphadenopathy. Fiberoptic endoscopy showed ulceration of the duodenal mucosa with a stricture. Multiple biopsies were obtained which on histopathology revealed granulomas with Langhans' giant cells. Tissue culture isolated Mycobacterium tuberculosis. The patient was treated with anti-tubercular drugs. Within 4 weeks of chemotherapy, fever subsided, appetite improved, and pain reduced somewhat, but vomiting persisted. A repeat endoscopy after 2 months showed that the ulceration had healed but the tight stricture persisted. At this stage balloon dilation was undertaken. Under direct vision, a deflated TTS balloon (Rigiflex; Microvasive, Milford, Mass) was passed through the biopsy channel of an Olympus XQlO endoscope and positioned within the stricFrom the Departments of Gastroenterology, Radiology, and Patho,logy, GB Pant Hospital, New Delhi, India, Reprint requests: J. C. V.U, MD, Gastroenterology, GB Pant Hospital, New Delhi 110 002, Indw. 510
A 26-year-old man presented with symptoms of abdominal pain and vomiting of 8 months' duration. The pain in the epigastrium was almost continuous, but worse about 1 hour after meals. He had frequent vomiting that usually reduced the abdominal pain. He was treated elsewhere with H2 receptor antagonists, antacids, and anticholincergics, but these drugs provided no improvement. He lost 6 kg of body weight. Physical examination showed an anemic and emaciated man weighing 46 kg. There was tenderness in the epigastrium and a succession splash 4 hours after meals, but no other abnormal physical findings. Hemoglobin was 9.2 g/ 100 ml and ESR was 32 mm/first hour Westergren. Total and differential leukocyte counts were within normal limits. Urinalysis, blood sugar, blood urea, serum electrolytes, serum protein levels, and chest x-ray were all normal. Barium meal study revealed narrowing of the post-bulbar region of the duodenum. Duodenoscopy showed a stricture with ulceration of the mucosa. Biopsy revealed changes consistent with tuberculosis. Mycobacterium tuberculosis was isolated on tissue culture. The patient was treated with a combination of rifampicin (450 mg), isoniazid (300 mg), and pyrazinamide (1.0 g) daily for 2 months followed by rifampicin and isoniazid for another 4 months. The patient's symptoms improved after 6 weeks of chemotherapy, but vomiting persisted. Endoscopic dilation of the stricture was performed in the same manner described in patient 1. Following dilation, the vomiting stopped and the abdominal pain disappeared. The patient gained 5 kg of weight in 2 months. After completion of an additional 6 weeks of chemotherapy, repeat biopsy of the duodenal mucosa revealed normal histology except for minimal increase in inflammatory cells in the lamina propria. He has been free of symptoms for the subsequent 8 months.
DISCUSSION
Tuberculosis of the gastrointestinal tract, although rare in Western countries, is still very common in India and other developing countries of the world. It GASTROINTESTINAL ENDOSCOPY
may involve any region of the gastrointestinal tract, but the most frequent site is the ileocecal/cecal region, which is affected in about 65% of patients. Other affected regions, in order of frequency, are the ascending colon, jejunum, appendix, transverse and descending colon, and anorectum. 2 In the past, abdominal tuberculosis was commonly associated with pulmonary tuberculosis. However, with the advent of potent anti-tuberculous drugs, around 75% of cases with abdominal tuberculosis have negative chest x-rays,3 and the majority of those with lung involvement have radiographic evidence of healed tuberculosis. 3 Tuberculous cavitating lesions in the lungs are seen in only 6% of patients presenting with abdominal tuberculosis. 4 Duodenal involvement with tuberculosis is very un~ common. 5 A total of 114 cases were reported by 1974, and in most of the subsequent series on gastrointestinal tuberculosis it accounts for only about 1 % of total cases. Duodenal tuberculosis on gross appearance presents with ulcerative, hypertrophic, and ulceroconstrictive lesions,6 similar to those seen in other portions of the intestinal tract. The most common manifestation of duodenal tuberculosis is obstruction, present in more than 50% of patients; hemorrhage, perforation, and fistula formation are other complications. 6 Duodenal obstruction may be secondary to lymph node enlargement or due to intrinsic stricture formation. Duodenal strictures are usually short but can involve large segments of the duodenum, affecting almost the entire C-Ioop.7 Anti-tuberculous chemotherapy is the most important aspect of treatment, but surgery has been performed in the majority of cases to relieve obstructive symptoms, as strictures often fail to resolve on medical treatment. Nair et al.,s in a recent study, reported that all four patients with tuberculous post-bulbar duodenal narrowing underwent surgery to relieve symptoms. The response of tuberculous strictures in the gastrointestinal tract to chemotherapy, however, IS a subject of controversy. Anand et al.,9 in a prospective study, reported resolution of tuberculous strictures in the gastrointestinal tract in 70% of cases (including one with duodenal stricture) after 1 year of chemotherapy. The presence of associated pulmonary tuberculosis did not influence the response to treatment. They suggested that patients with long strictures and
VOLUME 38, NO.4, 1992
with multiple areas of involvement are less likely to respond to drug therapy. However, other workers 10, II feel that once a stricture develops, it is unlikely to resolve with medical therapy and surgery will be required. Balloon dilation of tuberculous strictures is a convenient, fast, and safe alternative to surgery. Balloons have been successfully used for dilation of various stenoses in the esophagus, stomach, small intestine, and colon. 12,13 We used TTS balloons for dilation in both patients, which has the advantage of being performed under direct vision without the need for guidewires or fluoroscopy. Both patients tolerated the procedure very well and no complication occurred. Both have remained asymptomatic for 8 to 10 months. To the best of our knowledge this is the first report of balloon dilation of duodenal strictures due to tuberculosis. It is suggested that balloon dilation should be attempted before surgery in such patients.
REFERENCES 1. Schmudderch W, Harloff M, Riemann JF. Through-the-scope balloon dilatation of benign pyloric stenoses. Endoscopy 1989;21:7-10. 2. Paustian FF, Marshall JB. Intestinal tuberculosis. In: Bockus HL, ed. Gastroenterology. 4th ed. Philadelphia: WB Saunders, 1985:2018-36. 3. Haddad FS, Ghossain A, Sawaya E, Nelson AR. Abdominal tuberculosis. Dis Colon Rectum 1987;30:727-35. 4. Kolawole TM, Lewis EA. A radiologic study of tuberculosis of abdomen (gastrointestinal tract). AJR 1975;123:348-58. 5. Lockwood CM, Foster PM, Catto F, Stewart JS. A case of duodenal tuberculosis. Am J Dig Dis 1974;19:575-9. 6. Gleason T, Priuz RA, Kirsch EP, Jablokow V, Greenlee HB. Tuberculosis of the duodenum. Am J GastroenteroI1979;72:3640. 7. Gupta SK, Jain K, Gupta AP, et al. Duodenal tuberculosis. Clin RadioI1988;39:159-61. 8. Nair KV, Pai CG, Rajgopal KP, Bhat VN, Thomas M. Unusual presentations of duodenal tuberculosis. Am J Gastroenterol 1991;86:756-60. 9. Anand BS, Nanda R, Sachdev GK. Response of tuberculous stricture to antituberculous treatment. Gut 1988;29:62-9. 10. Elhence IP. Abdominal tuberculosis as observed by a surgeon. Indian J Tuberc 1970;26:59-61. 11. Bhansali SK. Abdominal tuberculosis: experience of 300 cases. Am J Gastroenterol 1977;67:324-37. 12. Kozarek RA. Hydrostatic balloon dilation of gastrointestinal stenosis: a national survey. Gastrointest Endosc 1986;32:15-9. 13. Graham DY, Tabibian N, Schwartz JT, Smith JL. Evaluation of the effectiveness of through the scope balloons as dilators of benign and malignant gastrointestinal strictures. Gastrointest Endosc 1987;33:432-5.
511
MD MD MD MD
Tuberculosis may affect any part of the gastrointestinal tract but duodenal involvement is distinctly unusual. The majority of patients with duodenal tuberculosis present with obstruction, and in spite of effective anti-tuberculous chemotherapy, a significant number of patients require surgery. Balloon dilation of duodenal strictures is an attractive alternative that has been performed successfully mainly for pyloroduodenal stenosis associated with peptic ulcer diseases. 1 We report successful dilation of duodenal strictures due to tuberculosis in two patients.
ture. Balloon dilation was performed with local pharyngeal anesthesia and 10 mg of intravenously administered diazepam. A 10-mm diameter balloon was used first, followed by a 15-mm balloon. The balloon was inflated with water and pressure was monitored according to the specifications recommended by the manufacturer. Successful dilation was confirmed by the ability to move an inflated balloon to and fro within the strictured area without difficulty. Following dilation, the patient's epigastric pain disappeared and vomiting stopped. Repeat barium study showed marked improvement in the stricture. The patient received a short course of chemotherapy consisting of 450 mg of rifampicin, 300 mg of isoniazid, and 1.0 g of pyrazinamide daily for 2 months followed by rifampicin and isoniazid for another 4 months. Endoscopy with biopsy was performed after completion of 6 months of chemotherapy. The histopathology of the mucosa showed disappearance of granulomas with minimal residual increase in inflammatory cells in the lamina propria. The patient has been free of symptoms for the last 10 months. Case 2
CASE REPORTS Case 1
A 34-year-old man was in good health until 6 months earlier when he began to experience epigastric pain and a low-grade daily temperature of 38 to 3WC. Two months later he developed vomiting, and he lost 8 kg of weight. He never complained of hematemesis or melena. Physical examination revealed an anemic and emaciated man. Abdominal examination showed epigastric tenderness. There was no organomegaly or ascites. Hemoglobin was 10.2 g/100 ml and white blood count was 1O.200/mm3 with 48% lymphocytes, 46% polymorphonuclear neutrophils, 2% monocytes, and 2% eosinophils. ESR was 60 mm/first hour Westergren. Serum albumin was 3.2 g/IOO ml. Urinalysis, stool examination, routine biochemistry were normal. Chest x-ray showed an infiltrating tubercular lesion in the right apical zone. Sputum examinations for AFB on two occasions were negative. An upper gastrointestinal series with barium revealed a narrowed segment with irregular mucosa in the post-bulbar duodenum. Ultrasound examination of the abdomen was normal; there was no evidence of lymphadenopathy. Fiberoptic endoscopy showed ulceration of the duodenal mucosa with a stricture. Multiple biopsies were obtained which on histopathology revealed granulomas with Langhans' giant cells. Tissue culture isolated Mycobacterium tuberculosis. The patient was treated with anti-tubercular drugs. Within 4 weeks of chemotherapy, fever subsided, appetite improved, and pain reduced somewhat, but vomiting persisted. A repeat endoscopy after 2 months showed that the ulceration had healed but the tight stricture persisted. At this stage balloon dilation was undertaken. Under direct vision, a deflated TTS balloon (Rigiflex; Microvasive, Milford, Mass) was passed through the biopsy channel of an Olympus XQlO endoscope and positioned within the stricFrom the Departments of Gastroenterology, Radiology, and Patho,logy, GB Pant Hospital, New Delhi, India, Reprint requests: J. C. V.U, MD, Gastroenterology, GB Pant Hospital, New Delhi 110 002, Indw. 510
A 26-year-old man presented with symptoms of abdominal pain and vomiting of 8 months' duration. The pain in the epigastrium was almost continuous, but worse about 1 hour after meals. He had frequent vomiting that usually reduced the abdominal pain. He was treated elsewhere with H2 receptor antagonists, antacids, and anticholincergics, but these drugs provided no improvement. He lost 6 kg of body weight. Physical examination showed an anemic and emaciated man weighing 46 kg. There was tenderness in the epigastrium and a succession splash 4 hours after meals, but no other abnormal physical findings. Hemoglobin was 9.2 g/ 100 ml and ESR was 32 mm/first hour Westergren. Total and differential leukocyte counts were within normal limits. Urinalysis, blood sugar, blood urea, serum electrolytes, serum protein levels, and chest x-ray were all normal. Barium meal study revealed narrowing of the post-bulbar region of the duodenum. Duodenoscopy showed a stricture with ulceration of the mucosa. Biopsy revealed changes consistent with tuberculosis. Mycobacterium tuberculosis was isolated on tissue culture. The patient was treated with a combination of rifampicin (450 mg), isoniazid (300 mg), and pyrazinamide (1.0 g) daily for 2 months followed by rifampicin and isoniazid for another 4 months. The patient's symptoms improved after 6 weeks of chemotherapy, but vomiting persisted. Endoscopic dilation of the stricture was performed in the same manner described in patient 1. Following dilation, the vomiting stopped and the abdominal pain disappeared. The patient gained 5 kg of weight in 2 months. After completion of an additional 6 weeks of chemotherapy, repeat biopsy of the duodenal mucosa revealed normal histology except for minimal increase in inflammatory cells in the lamina propria. He has been free of symptoms for the subsequent 8 months.
DISCUSSION
Tuberculosis of the gastrointestinal tract, although rare in Western countries, is still very common in India and other developing countries of the world. It GASTROINTESTINAL ENDOSCOPY
may involve any region of the gastrointestinal tract, but the most frequent site is the ileocecal/cecal region, which is affected in about 65% of patients. Other affected regions, in order of frequency, are the ascending colon, jejunum, appendix, transverse and descending colon, and anorectum. 2 In the past, abdominal tuberculosis was commonly associated with pulmonary tuberculosis. However, with the advent of potent anti-tuberculous drugs, around 75% of cases with abdominal tuberculosis have negative chest x-rays,3 and the majority of those with lung involvement have radiographic evidence of healed tuberculosis. 3 Tuberculous cavitating lesions in the lungs are seen in only 6% of patients presenting with abdominal tuberculosis. 4 Duodenal involvement with tuberculosis is very un~ common. 5 A total of 114 cases were reported by 1974, and in most of the subsequent series on gastrointestinal tuberculosis it accounts for only about 1 % of total cases. Duodenal tuberculosis on gross appearance presents with ulcerative, hypertrophic, and ulceroconstrictive lesions,6 similar to those seen in other portions of the intestinal tract. The most common manifestation of duodenal tuberculosis is obstruction, present in more than 50% of patients; hemorrhage, perforation, and fistula formation are other complications. 6 Duodenal obstruction may be secondary to lymph node enlargement or due to intrinsic stricture formation. Duodenal strictures are usually short but can involve large segments of the duodenum, affecting almost the entire C-Ioop.7 Anti-tuberculous chemotherapy is the most important aspect of treatment, but surgery has been performed in the majority of cases to relieve obstructive symptoms, as strictures often fail to resolve on medical treatment. Nair et al.,s in a recent study, reported that all four patients with tuberculous post-bulbar duodenal narrowing underwent surgery to relieve symptoms. The response of tuberculous strictures in the gastrointestinal tract to chemotherapy, however, IS a subject of controversy. Anand et al.,9 in a prospective study, reported resolution of tuberculous strictures in the gastrointestinal tract in 70% of cases (including one with duodenal stricture) after 1 year of chemotherapy. The presence of associated pulmonary tuberculosis did not influence the response to treatment. They suggested that patients with long strictures and
VOLUME 38, NO.4, 1992
with multiple areas of involvement are less likely to respond to drug therapy. However, other workers 10, II feel that once a stricture develops, it is unlikely to resolve with medical therapy and surgery will be required. Balloon dilation of tuberculous strictures is a convenient, fast, and safe alternative to surgery. Balloons have been successfully used for dilation of various stenoses in the esophagus, stomach, small intestine, and colon. 12,13 We used TTS balloons for dilation in both patients, which has the advantage of being performed under direct vision without the need for guidewires or fluoroscopy. Both patients tolerated the procedure very well and no complication occurred. Both have remained asymptomatic for 8 to 10 months. To the best of our knowledge this is the first report of balloon dilation of duodenal strictures due to tuberculosis. It is suggested that balloon dilation should be attempted before surgery in such patients.
REFERENCES 1. Schmudderch W, Harloff M, Riemann JF. Through-the-scope balloon dilatation of benign pyloric stenoses. Endoscopy 1989;21:7-10. 2. Paustian FF, Marshall JB. Intestinal tuberculosis. In: Bockus HL, ed. Gastroenterology. 4th ed. Philadelphia: WB Saunders, 1985:2018-36. 3. Haddad FS, Ghossain A, Sawaya E, Nelson AR. Abdominal tuberculosis. Dis Colon Rectum 1987;30:727-35. 4. Kolawole TM, Lewis EA. A radiologic study of tuberculosis of abdomen (gastrointestinal tract). AJR 1975;123:348-58. 5. Lockwood CM, Foster PM, Catto F, Stewart JS. A case of duodenal tuberculosis. Am J Dig Dis 1974;19:575-9. 6. Gleason T, Priuz RA, Kirsch EP, Jablokow V, Greenlee HB. Tuberculosis of the duodenum. Am J GastroenteroI1979;72:3640. 7. Gupta SK, Jain K, Gupta AP, et al. Duodenal tuberculosis. Clin RadioI1988;39:159-61. 8. Nair KV, Pai CG, Rajgopal KP, Bhat VN, Thomas M. Unusual presentations of duodenal tuberculosis. Am J Gastroenterol 1991;86:756-60. 9. Anand BS, Nanda R, Sachdev GK. Response of tuberculous stricture to antituberculous treatment. Gut 1988;29:62-9. 10. Elhence IP. Abdominal tuberculosis as observed by a surgeon. Indian J Tuberc 1970;26:59-61. 11. Bhansali SK. Abdominal tuberculosis: experience of 300 cases. Am J Gastroenterol 1977;67:324-37. 12. Kozarek RA. Hydrostatic balloon dilation of gastrointestinal stenosis: a national survey. Gastrointest Endosc 1986;32:15-9. 13. Graham DY, Tabibian N, Schwartz JT, Smith JL. Evaluation of the effectiveness of through the scope balloons as dilators of benign and malignant gastrointestinal strictures. Gastrointest Endosc 1987;33:432-5.
511
