Int J Colorectal Dis DOI 10.1007/s00384-014-1894-y
LETTER TO THE EDITOR
Synchronous ileocecal and duodenal tuberculosis: case report and review of the literature Constanza Villalon & Felipe Quezada & Jonathan Hartmann & Juan Carlos Roa & Gonzalo Urrejola
Accepted: 27 April 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor:
Introduction Tuberculosis remains a health problem worldwide, especially in developing countries, and has gained importance with the rise of HIV prevalence. Pulmonary tuberculosis is the most common variety. Abdominal tuberculosis is a rare entity. It may present as peritoneal, nodal, or visceral disease. In the visceral variety, the ileocecal region is the most frequently affected segment. Gastric and duodenal locations are unusual. We describe a case of a patient who presented at our institution with both ileocecal and duodenal tuberculosis.
Case report A 35-year-old woman presented with a history of 8 months of diffuse abdominal pain and constipation, associated with 10kg weight loss, fever, and night sweats. Her previous medical history was unremarkable. The patient was admitted with a history of 3 days of right quadrant abdominal pain, abdominal distension, and constipation. Physical examination showed signs of malnutrition, and erythema nodosum on both lower extremities. Blood tests revealed anemia (29 % hematocrit), ESR 50, and an albumin of 2 mg/dl. Upper gastrointestinal endoscopy showed a duodenal ulcer. C. Villalon : F. Quezada : J. Hartmann : J. C. Roa : G. Urrejola (*) Colorectal Surgery Unit, Digestive Surgery Department, Faculty of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 350, Santiago, Chile e-mail: [email protected]
A CT scan revealed an enlargement of the right and transverse colon with retroperitoneal calcified necrotic adenopathies. Colonoscopy showed a stricture at the proximal transverse colon, with positive biopsy for a granulomatous disease and a real-time PCR for Mycobacterium tuberculosis. The patient evolved with an intestinal obstruction that required surgery on the 5th day of hospitalization. The surgical findings were a tumoral enlargement of the distal ileum and right colon with calcified mesocolonic adenopathies. A right hemicolectomy was performed with a diverting loop ileostomy because of the poor nutritional status. Postoperative course was uneventful with parenteral nutrition support and progressive oral intake. Biopsy confirmed ileocecal tuberculosis. Antituberculous therapy (pyrazinamide, ethambutol, rifampicin, and isoniazid) was initiated. On the 7th postoperative day, the patient experienced failure in progression of oral intake. A new CT scan and an upper GI study showed a stenosis of the third portion of the duodenum. A duodenoscopy was performed showing a circumferential scar with a biopsy compatible with granuloma, that was successfully treated with endoscopic balloon dilatations. Koch tissue cultures of colon and duodenum were positive for M. tuberculosis.
Discussion Extrapulmonary tuberculosis can be found in up to 20 % of immunocompetent patients and in up to 80 % of cases with HIV. Tuberculosis affecting the gastrointestinal tract is unusual; it is generally due to swallowing infected sputum from pulmonary tuberculosis, hematogenous spread from active miliary or pulmonary tuberculosis, or consumption of contaminated food. It can be seen in approximately 25 % of patients with active pulmonary tuberculosis.
Int J Colorectal Dis
The most frequently affected site is the ileocecal region. Duodenal involvement is extremely rare, and when affected, it is most frequent in the third portion [1]. Clinical manifestations can present years after time of exposure, making the diagnosis even more difficult and can be secondary to intrinsic or extrinsic lesions. Intrinsic lesions can present with gastrointestinal manifestations that can be divided into three categories: ulcerative (60 %), ulcerohypertrophic (30 %), and hypertrophic (10 %). Duodenal tuberculosis may present with dyspeptic symptoms, bleeding, perforation, gastric outlet obstruction, or duodenal obstruction associated to weight loss [1, 2]. General physical findings include generalized wasting and a palpable mass in the right lower quadrant. Symptoms of partial or complete bowel obstruction can be found, secondary to extrinsic compression from tuberculous pericolonic adenitis. More infrequently, it may present as a surgical emergency mimicking acute appendicitis or a perforated hollow viscous. Imaging studies (barium enema, ultrasound, and CT scan) may suggest the diagnosis but should not be made based on these alone. Endoscopic biopsy or fine needle aspiration allows detection of acid-fast bacilli or caseating granulomas while awaiting microbiologic confirmation. Stool cultures rarely demonstrate mycobacterium growth. Serology tests have sensitivity for intestinal tuberculosis of over 80 % but cannot reliably exclude Crohn’s disease [3]. Tuberculine skin test may result positive from remote disease or prior exposure, which does not make it very useful [4].
Treatment depends on clinical presentation and associated complications. In the presence of bowel perforation, intestinal ischemia, closed loop bowel obstruction, bleeding, or peritonitis, emergent surgical exploration is mandatory. Once the patient is stabilized, antituberculous therapy should be initiated. In the subacute setting, on the other hand, antituberculous therapy results in prompt healing, usually in less than 2 weeks. In cases that present with bowel obstruction that may require surgical intervention, it is still advised to attempt a medical trial first, since patients may resolve their symptoms, avoiding surgery. Endoscopic dilatation may be required in duodenal or rectal tuberculosis, and operative treatment should only be reserved for severely symptomatic cases.
References 1. Chavhan GE, Ramakantan R (2003) Duodenal tuberculosis: radiological features on barium studies and their clinical correlation in 28 cases. J Postgrad Med 49(3):214–217 2. Rao YG, Pande GK, Sahni P, Chattopadhyay TK (2004) Gastroduodenal tuberculosis management guidelines, based on a large experience and a review of the literature. Can J Surg Journal canadien de chirurgie 47(5):364–368 3. Alvares JF, Devarbhavi H, Makhija P, Rao S, Kottoor R (2005) Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital. Endoscopy 37(4):351–356. doi:10.1055/s-2005861116 4. Uygur-Bayramicli O, Dabak G, Dabak R (2003) A clinical dilemma: abdominal tuberculosis. World J Gastroenterol 9(5):1098–1101
LETTER TO THE EDITOR
Synchronous ileocecal and duodenal tuberculosis: case report and review of the literature Constanza Villalon & Felipe Quezada & Jonathan Hartmann & Juan Carlos Roa & Gonzalo Urrejola
Accepted: 27 April 2014 # Springer-Verlag Berlin Heidelberg 2014
Dear Editor:
Introduction Tuberculosis remains a health problem worldwide, especially in developing countries, and has gained importance with the rise of HIV prevalence. Pulmonary tuberculosis is the most common variety. Abdominal tuberculosis is a rare entity. It may present as peritoneal, nodal, or visceral disease. In the visceral variety, the ileocecal region is the most frequently affected segment. Gastric and duodenal locations are unusual. We describe a case of a patient who presented at our institution with both ileocecal and duodenal tuberculosis.
Case report A 35-year-old woman presented with a history of 8 months of diffuse abdominal pain and constipation, associated with 10kg weight loss, fever, and night sweats. Her previous medical history was unremarkable. The patient was admitted with a history of 3 days of right quadrant abdominal pain, abdominal distension, and constipation. Physical examination showed signs of malnutrition, and erythema nodosum on both lower extremities. Blood tests revealed anemia (29 % hematocrit), ESR 50, and an albumin of 2 mg/dl. Upper gastrointestinal endoscopy showed a duodenal ulcer. C. Villalon : F. Quezada : J. Hartmann : J. C. Roa : G. Urrejola (*) Colorectal Surgery Unit, Digestive Surgery Department, Faculty of Medicine, Pontificia Universidad Católica de Chile, Marcoleta 350, Santiago, Chile e-mail: [email protected]
A CT scan revealed an enlargement of the right and transverse colon with retroperitoneal calcified necrotic adenopathies. Colonoscopy showed a stricture at the proximal transverse colon, with positive biopsy for a granulomatous disease and a real-time PCR for Mycobacterium tuberculosis. The patient evolved with an intestinal obstruction that required surgery on the 5th day of hospitalization. The surgical findings were a tumoral enlargement of the distal ileum and right colon with calcified mesocolonic adenopathies. A right hemicolectomy was performed with a diverting loop ileostomy because of the poor nutritional status. Postoperative course was uneventful with parenteral nutrition support and progressive oral intake. Biopsy confirmed ileocecal tuberculosis. Antituberculous therapy (pyrazinamide, ethambutol, rifampicin, and isoniazid) was initiated. On the 7th postoperative day, the patient experienced failure in progression of oral intake. A new CT scan and an upper GI study showed a stenosis of the third portion of the duodenum. A duodenoscopy was performed showing a circumferential scar with a biopsy compatible with granuloma, that was successfully treated with endoscopic balloon dilatations. Koch tissue cultures of colon and duodenum were positive for M. tuberculosis.
Discussion Extrapulmonary tuberculosis can be found in up to 20 % of immunocompetent patients and in up to 80 % of cases with HIV. Tuberculosis affecting the gastrointestinal tract is unusual; it is generally due to swallowing infected sputum from pulmonary tuberculosis, hematogenous spread from active miliary or pulmonary tuberculosis, or consumption of contaminated food. It can be seen in approximately 25 % of patients with active pulmonary tuberculosis.
Int J Colorectal Dis
The most frequently affected site is the ileocecal region. Duodenal involvement is extremely rare, and when affected, it is most frequent in the third portion [1]. Clinical manifestations can present years after time of exposure, making the diagnosis even more difficult and can be secondary to intrinsic or extrinsic lesions. Intrinsic lesions can present with gastrointestinal manifestations that can be divided into three categories: ulcerative (60 %), ulcerohypertrophic (30 %), and hypertrophic (10 %). Duodenal tuberculosis may present with dyspeptic symptoms, bleeding, perforation, gastric outlet obstruction, or duodenal obstruction associated to weight loss [1, 2]. General physical findings include generalized wasting and a palpable mass in the right lower quadrant. Symptoms of partial or complete bowel obstruction can be found, secondary to extrinsic compression from tuberculous pericolonic adenitis. More infrequently, it may present as a surgical emergency mimicking acute appendicitis or a perforated hollow viscous. Imaging studies (barium enema, ultrasound, and CT scan) may suggest the diagnosis but should not be made based on these alone. Endoscopic biopsy or fine needle aspiration allows detection of acid-fast bacilli or caseating granulomas while awaiting microbiologic confirmation. Stool cultures rarely demonstrate mycobacterium growth. Serology tests have sensitivity for intestinal tuberculosis of over 80 % but cannot reliably exclude Crohn’s disease [3]. Tuberculine skin test may result positive from remote disease or prior exposure, which does not make it very useful [4].
Treatment depends on clinical presentation and associated complications. In the presence of bowel perforation, intestinal ischemia, closed loop bowel obstruction, bleeding, or peritonitis, emergent surgical exploration is mandatory. Once the patient is stabilized, antituberculous therapy should be initiated. In the subacute setting, on the other hand, antituberculous therapy results in prompt healing, usually in less than 2 weeks. In cases that present with bowel obstruction that may require surgical intervention, it is still advised to attempt a medical trial first, since patients may resolve their symptoms, avoiding surgery. Endoscopic dilatation may be required in duodenal or rectal tuberculosis, and operative treatment should only be reserved for severely symptomatic cases.
References 1. Chavhan GE, Ramakantan R (2003) Duodenal tuberculosis: radiological features on barium studies and their clinical correlation in 28 cases. J Postgrad Med 49(3):214–217 2. Rao YG, Pande GK, Sahni P, Chattopadhyay TK (2004) Gastroduodenal tuberculosis management guidelines, based on a large experience and a review of the literature. Can J Surg Journal canadien de chirurgie 47(5):364–368 3. Alvares JF, Devarbhavi H, Makhija P, Rao S, Kottoor R (2005) Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital. Endoscopy 37(4):351–356. doi:10.1055/s-2005861116 4. Uygur-Bayramicli O, Dabak G, Dabak R (2003) A clinical dilemma: abdominal tuberculosis. World J Gastroenterol 9(5):1098–1101
