Br. J. Surg. Vol. 62 (1975) 618620
Primary gastric tuberculosis : a case report R . E. PAGE, R . E. W I L L I A M S A N D E. A . BENSON * SUMMARY
A case ojprimary gastric tuberculosis is reported in a
34-year-old Negro male. The difficulty in diagnosis is emphasized. Surgical resection with postoperative arrtituberculosis chemotherapy was followed by satisfactory recovery. Case report A 34-year-old West Indian labourer, resident in the United Kingdom for 13 years, attended his general practitioner complaining of dyspepsia, and was treated with antacids for a year before a small haematemesis resulted in a surgical outpatients’ consultation. A barium meal examination failed to demonstrate any abnormality and the patient was given a further supply of antacids. He was followed u p in the outpatients’ clinic and continued to complain, and 10 months later when reviewed he had obviously lost weight and examination revealed a gastric succussion splash. A repeat barium meal study (Fig. 1) now showed a constant filling deformity in the antral region; no ulcer crater could be identified. A chest X-ray was normal. The patient was admitted to hospital, and at gastroscopy a flat sloughing lesion in the pyloric antrum was visualized but its nature was obscure. Laparotomy revealed a firm infiltrating lesion, low on the lesser curve of the stomach in association with marked lymph node enlargement around the coeliac axis and the left gastric artery; similar enlarged nodes were found in the subpyloric region. In the terminal ileum an infiltrating lesion measuring slightly less than 1 cm in width encircled the bowel. An operative diagnosis of carcinoma of the stomach with secondaries in the terminal ileum was made, and what was felt to be palliative surgery took the form of partial gastrectomy (resecting the gastric lesion but leaving many involved glands around the coeliac axis) together with a small bowel resection. The pathologist submitted the following report: ‘Two specimens were received, firstly a funnel of stomach 11 x 11 cm bearing an ulcer 2 cm in diameter. The adjacent lymph nodes were enlarged and contained creamy material. Secondly, a tube of small intestine 35 cm long x 5 cm diameter with a haemorrhagic fusiform swelling 1 cm in diameter encircling and extending through the wall. ‘Microscopy of both specimens showed an acute and chronic inflammatory reaction with, in places, collections of epithelioid cells and Langhans’s giant cells (Fig. 2). In addition, the lymph nodes showed caseous necrosis (Fig. 3). ‘Staining of the sections by an auramine phenol fluorescent technique (Greenwood and Fox, 1973) showed the presence of tubercle bacilli in the lesion. These were not confirmed using the Ziehl-Neelsen method. ‘Inview of the histological picture and fluorescent microscopy a diagnosis of tuberculosis was made. Unfortunately, bacteriological confirmation was not possible as only formalin-fixed material was received (Walter and Israel, 1974): The patient was started on streptomycin 0.750g daily and Mynah 250 (ethambutol and isoniazid) 1 tablet t.d.s., and postoperatively made satisfactory progress and was discharged to a convalescent hospital on the twelfth day. A Mantoux test performed postoperatively was positive, but stool examination did not show any acid-fast bacilli. A repeat chest X-ray failed to demonstrate any pulmonary tuberculosis, and three early morning specimens failed to produce any tubercle bacilli. The patient was well and gaining weight when seen 4 months after his operation.
618
Discussion Primary tuberculosis of the stomach is surpassed in rarity only by a primary lesion involving the oesophagus. Isolated cases of tuberculosis limited to the stomach have appeared in the Russian (Kuzionov and Polinkova, 1973) and Indian (Wig et al., 1961) literature, but in the Western world the condition is extremely rare. The only case of primary gastric tuberculosis to be reported in the Western literature has been by Stirk (1968). Palmer (1950), in 20 585 post-mortem examinations performed on patients dying with pulmonary tuberculosis, found the stomach to be involved in only 0.5 per cent, and in a recent series from South Africa (Novis et al., 1973) only 1 of 59 patients with gastro-intestinal tubercle had involvement of the stomach. Tuberculosis of the stomach is usually secondary to a primary focus involving another organ, invariably the lungs (Palmer, 1950), and tends to be a feature of widespread disease. The case presented in this communication had no pulmonary or pharyngeal involvement. The incidence of pulmonary disease diagnosed radiologically in patients with established gastrointestinal tuberculosis varies from series to series. Hamandi and Thamer (1965), in a study of 86 patients with gastro-intestinal tuberculosis, found only 10 with pulmonary involvement, whereas Novis et al. (1973) demonstrated a pulmonary lesion in 20 out of 56 patients. Abrams and Holden (1964) showed that 56 per cent of patients with pulmonary tuberculosis also have involvement of some part of the gastro-intestinal tract. The factors protecting the stomach against invasion by tubercle bacilli have been listed by Good (1931). It has, however, been suggested by Kossick (1969) that the organism gains entry to the submucosa of the stomach via a pre-existing ulcer. The patient presented in this communication might conceivably be an example of this. The radiological appearance of gastric tuberculosis is very similar to that of neoplasia. Indeed, Gaines et al. (1952) felt that radiology had little to offer in arriving at a specific diagnosis of gastric tuberculosis. Our case supports this opinion. Aird (1958) stated that gastric tuberculosis may rarely be the seat of a carcinoma, and Rentschler and Travis (1934) reported a case of gastric tuberculosis with a sarcoma. In the patient presented here there
* The General
Infirmary, Leeds.
Primary gastric tuberculosis
Fig. 1. Barium meal films showing a filling deformity in the antral region (arrows).
Stirk (1968) suggested treatment by partial gastrectomy where the lesion exists as a solitary ulcer. This procedure was followed, with success, in our patient. A course of anti-tuberculous drugs should be commenced as soon as the diagnosis is made, otherwise complications may ensue (Iles and Emerson, 1974).
References ABRAMS J. s. and HOLDEN w. D. (1964) Tuberculosis of the gastro-intestinal tract. Arch. Surg. 89, 282-293. (1 958) A Companion in Surgical Studies, 2nd ed. Edinburgh, Livingstone, p. 745. GAINES w., STEINBACH H. L. and LOWENHAUPT E. (1952) Tuberculosis of the stomach. Radiology 58, 808-81 8. GOOD R. w. (1931) Tuberculosis of stomach; analysis of cases recently reviewed. Arch. Surg. 22, 415425. GREENWOOD N. and FOX H. (1973) A comparison of methods for staining tubercle bacilli in histological sections. J. Clin. Pathol. 26, 253-257. HAMANDI w. J. and THAMER M. A. (1965) Tuberculosis of the bowel in Iraq: a study of 86 cases. Dis. Colon Rectum 8, 158-1 64. ILES P. B. and EMERSON P. A. (1974) Tuberculous lymphadenitis. Br. Med. J . 1, 143-145. KOSSICK P. (1969) Gastric tuberculosis. 5.Afr. Med. J. 43, 18-20. KUZIONOV P. V. and POLINKOVA G. A. (1973) Multiple perforations of T.B. stomach ulcers. Vestn Khir. 110, 134-135. NOVIS B. H., BANK S. and MARKS I. N. (1973) Gastrointestinal and peritoneal tuberculosis. S. Afr. Med. J. 47, 365-372. PALMER E. D. (1950) Tuberculosis of stomach and stomach in tuberculosis; review with particular reference to gross pathology and gastroscopic diagnosis. Am. Rev. Tuberc. Pulm. Dis. 61, I 16-1 30. AIRD I.
Fig. 2. Photomicrograph of stomach necrosis showing an inflammatory infiltrate with giant cells. ( x 90.)
Fig. 3. Photomicrograph of subserosal gastric lymph node showing giant cells, epithelioid cells and central caseation. ( x 90.)
was no histological evidence of neoplasia. The association is of interest, however, in that gastric neoplasia produces a state of debilitation, and in the presence of achlorhydria conditions would be theoretically ideal for t ubercu 1ous infection.
619
R. E. Page et al.
and TRAVIS R . C. (1934) Sarcoma and tuberculosis of the stomach. JAMA 102, 686-688. STIRK D. I. (1968) Primary tuberculosis of the stomach, caecum, and appendix treated with antituberculus drugs. Br. J. Surg. 55, 230-235. RENTSCHLER C. B.
620
and ISRAEL M. S. (1974) GeneralPathology, 4th ed. Edinburgh, Churchill Livingstone. p. 243. WIG K. L., CHITKAVA N. L., GUPTA P . S., KISHORE K. and MANCHANDA R. L. (1961) Ileocaecal tuberculosis with particular reference to isolation of Mycobacterium tuberculosis. Am. Rev. Resp. Dis. 24, 169-178. WALTER J. B.
Primary gastric tuberculosis : a case report R . E. PAGE, R . E. W I L L I A M S A N D E. A . BENSON * SUMMARY
A case ojprimary gastric tuberculosis is reported in a
34-year-old Negro male. The difficulty in diagnosis is emphasized. Surgical resection with postoperative arrtituberculosis chemotherapy was followed by satisfactory recovery. Case report A 34-year-old West Indian labourer, resident in the United Kingdom for 13 years, attended his general practitioner complaining of dyspepsia, and was treated with antacids for a year before a small haematemesis resulted in a surgical outpatients’ consultation. A barium meal examination failed to demonstrate any abnormality and the patient was given a further supply of antacids. He was followed u p in the outpatients’ clinic and continued to complain, and 10 months later when reviewed he had obviously lost weight and examination revealed a gastric succussion splash. A repeat barium meal study (Fig. 1) now showed a constant filling deformity in the antral region; no ulcer crater could be identified. A chest X-ray was normal. The patient was admitted to hospital, and at gastroscopy a flat sloughing lesion in the pyloric antrum was visualized but its nature was obscure. Laparotomy revealed a firm infiltrating lesion, low on the lesser curve of the stomach in association with marked lymph node enlargement around the coeliac axis and the left gastric artery; similar enlarged nodes were found in the subpyloric region. In the terminal ileum an infiltrating lesion measuring slightly less than 1 cm in width encircled the bowel. An operative diagnosis of carcinoma of the stomach with secondaries in the terminal ileum was made, and what was felt to be palliative surgery took the form of partial gastrectomy (resecting the gastric lesion but leaving many involved glands around the coeliac axis) together with a small bowel resection. The pathologist submitted the following report: ‘Two specimens were received, firstly a funnel of stomach 11 x 11 cm bearing an ulcer 2 cm in diameter. The adjacent lymph nodes were enlarged and contained creamy material. Secondly, a tube of small intestine 35 cm long x 5 cm diameter with a haemorrhagic fusiform swelling 1 cm in diameter encircling and extending through the wall. ‘Microscopy of both specimens showed an acute and chronic inflammatory reaction with, in places, collections of epithelioid cells and Langhans’s giant cells (Fig. 2). In addition, the lymph nodes showed caseous necrosis (Fig. 3). ‘Staining of the sections by an auramine phenol fluorescent technique (Greenwood and Fox, 1973) showed the presence of tubercle bacilli in the lesion. These were not confirmed using the Ziehl-Neelsen method. ‘Inview of the histological picture and fluorescent microscopy a diagnosis of tuberculosis was made. Unfortunately, bacteriological confirmation was not possible as only formalin-fixed material was received (Walter and Israel, 1974): The patient was started on streptomycin 0.750g daily and Mynah 250 (ethambutol and isoniazid) 1 tablet t.d.s., and postoperatively made satisfactory progress and was discharged to a convalescent hospital on the twelfth day. A Mantoux test performed postoperatively was positive, but stool examination did not show any acid-fast bacilli. A repeat chest X-ray failed to demonstrate any pulmonary tuberculosis, and three early morning specimens failed to produce any tubercle bacilli. The patient was well and gaining weight when seen 4 months after his operation.
618
Discussion Primary tuberculosis of the stomach is surpassed in rarity only by a primary lesion involving the oesophagus. Isolated cases of tuberculosis limited to the stomach have appeared in the Russian (Kuzionov and Polinkova, 1973) and Indian (Wig et al., 1961) literature, but in the Western world the condition is extremely rare. The only case of primary gastric tuberculosis to be reported in the Western literature has been by Stirk (1968). Palmer (1950), in 20 585 post-mortem examinations performed on patients dying with pulmonary tuberculosis, found the stomach to be involved in only 0.5 per cent, and in a recent series from South Africa (Novis et al., 1973) only 1 of 59 patients with gastro-intestinal tubercle had involvement of the stomach. Tuberculosis of the stomach is usually secondary to a primary focus involving another organ, invariably the lungs (Palmer, 1950), and tends to be a feature of widespread disease. The case presented in this communication had no pulmonary or pharyngeal involvement. The incidence of pulmonary disease diagnosed radiologically in patients with established gastrointestinal tuberculosis varies from series to series. Hamandi and Thamer (1965), in a study of 86 patients with gastro-intestinal tuberculosis, found only 10 with pulmonary involvement, whereas Novis et al. (1973) demonstrated a pulmonary lesion in 20 out of 56 patients. Abrams and Holden (1964) showed that 56 per cent of patients with pulmonary tuberculosis also have involvement of some part of the gastro-intestinal tract. The factors protecting the stomach against invasion by tubercle bacilli have been listed by Good (1931). It has, however, been suggested by Kossick (1969) that the organism gains entry to the submucosa of the stomach via a pre-existing ulcer. The patient presented in this communication might conceivably be an example of this. The radiological appearance of gastric tuberculosis is very similar to that of neoplasia. Indeed, Gaines et al. (1952) felt that radiology had little to offer in arriving at a specific diagnosis of gastric tuberculosis. Our case supports this opinion. Aird (1958) stated that gastric tuberculosis may rarely be the seat of a carcinoma, and Rentschler and Travis (1934) reported a case of gastric tuberculosis with a sarcoma. In the patient presented here there
* The General
Infirmary, Leeds.
Primary gastric tuberculosis
Fig. 1. Barium meal films showing a filling deformity in the antral region (arrows).
Stirk (1968) suggested treatment by partial gastrectomy where the lesion exists as a solitary ulcer. This procedure was followed, with success, in our patient. A course of anti-tuberculous drugs should be commenced as soon as the diagnosis is made, otherwise complications may ensue (Iles and Emerson, 1974).
References ABRAMS J. s. and HOLDEN w. D. (1964) Tuberculosis of the gastro-intestinal tract. Arch. Surg. 89, 282-293. (1 958) A Companion in Surgical Studies, 2nd ed. Edinburgh, Livingstone, p. 745. GAINES w., STEINBACH H. L. and LOWENHAUPT E. (1952) Tuberculosis of the stomach. Radiology 58, 808-81 8. GOOD R. w. (1931) Tuberculosis of stomach; analysis of cases recently reviewed. Arch. Surg. 22, 415425. GREENWOOD N. and FOX H. (1973) A comparison of methods for staining tubercle bacilli in histological sections. J. Clin. Pathol. 26, 253-257. HAMANDI w. J. and THAMER M. A. (1965) Tuberculosis of the bowel in Iraq: a study of 86 cases. Dis. Colon Rectum 8, 158-1 64. ILES P. B. and EMERSON P. A. (1974) Tuberculous lymphadenitis. Br. Med. J . 1, 143-145. KOSSICK P. (1969) Gastric tuberculosis. 5.Afr. Med. J. 43, 18-20. KUZIONOV P. V. and POLINKOVA G. A. (1973) Multiple perforations of T.B. stomach ulcers. Vestn Khir. 110, 134-135. NOVIS B. H., BANK S. and MARKS I. N. (1973) Gastrointestinal and peritoneal tuberculosis. S. Afr. Med. J. 47, 365-372. PALMER E. D. (1950) Tuberculosis of stomach and stomach in tuberculosis; review with particular reference to gross pathology and gastroscopic diagnosis. Am. Rev. Tuberc. Pulm. Dis. 61, I 16-1 30. AIRD I.
Fig. 2. Photomicrograph of stomach necrosis showing an inflammatory infiltrate with giant cells. ( x 90.)
Fig. 3. Photomicrograph of subserosal gastric lymph node showing giant cells, epithelioid cells and central caseation. ( x 90.)
was no histological evidence of neoplasia. The association is of interest, however, in that gastric neoplasia produces a state of debilitation, and in the presence of achlorhydria conditions would be theoretically ideal for t ubercu 1ous infection.
619
R. E. Page et al.
and TRAVIS R . C. (1934) Sarcoma and tuberculosis of the stomach. JAMA 102, 686-688. STIRK D. I. (1968) Primary tuberculosis of the stomach, caecum, and appendix treated with antituberculus drugs. Br. J. Surg. 55, 230-235. RENTSCHLER C. B.
620
and ISRAEL M. S. (1974) GeneralPathology, 4th ed. Edinburgh, Churchill Livingstone. p. 243. WIG K. L., CHITKAVA N. L., GUPTA P . S., KISHORE K. and MANCHANDA R. L. (1961) Ileocaecal tuberculosis with particular reference to isolation of Mycobacterium tuberculosis. Am. Rev. Resp. Dis. 24, 169-178. WALTER J. B.
