PRIMARY DUODENAL TUBERCULOSIS

PRIMARY DUODENAL TUBERCULOSIS: A Rare Cause of Duodenal Fistulae

BS ACHARYA, AIYER, RD BAPAT
Department of General Surgery, King Edward VII Memorial Hospital, Parel, Mumbai 400 012.

A 40 year old man had symptoms suggestive of gastric outlet obstruction (GOO) associated with weight loss. Endoscopy showed inflamed, ulcerated oedematous duodenal mucosa with obstruction beyond the first part of the duodenum and pus in the lumen. Biopsy revealed non-specific inflammation. Barium study revealed a fistula from the first part of the duodenum both into the abdominal cavity and also into the common bile duct (CBD). Contrast enhanced CT scan showed significantly thickened, oedematous duodenal wall with obstruction and no abdominal lymphadenopathy. On anti-tuberculous therapy, the symptoms disappeared, and repeat gastroscopy after four weeks revealed evidence of healing. Follow up barium study after 10 weeks showed almost complete healing of the fistulous tract. The patient is now still on anti - TB treatment and continues to be asymptomatic.

INTRODUCTION

Primary gastroduodenal tuberculosis is rare. The clinical presentation is similar to that of peptic ulcer disease. The reported complications include pyloric outlet obstruction,[1] acute ulcer perforation,[2] pyeloduodenal fistula[3] and obstructive jaundice.[4] We report a case of primary duodenal tuberculosis complicated by a choledochoduodenal fistula and an abdominal fistula.
CASE REPORT

A 40 year old man presented with history of weight loss, epigastric pain and repeated vomiting after meals for one month. Physical examination yielded a succession splash in the epigastrium. Plain radiograph of abdomen showed no free gas. Gastroscopy done after gastric decompression revealed inflamed oedematous, ulcerated proximal duodenal mucosa, with distal duodenal obstruction and pus in the lumen (Fig. 1). A strong suspicion of tuberculosis was entertained, and multiple duodenal biopsies obtained. Contrast enhanced CT scan showed thickened duodenal wall with obstruction and no periduodenal lymphadenopathy (Fig. 2). Barium study revealed gastric outlet obstruction, with a fistulous tract from the proximal duodenum into the common bile duct, and leak of contrast into the abdominal cavity (Fig. 3). Histopathology of the biopsy tissue showed non-specific inflammation. However, anti-tuberculous therapy was instituted empirically. Follow up gastroscopy after 4 weeks of treatment showed reduction in oedema and absence of pus (Fig. 4). Repeat barium study after 10 weeks showed almost complete healing of fistula. The patient is continuing on anti-tuberculous treatment and is completely asymptomatic.

Fig. 1: Ulcerated duodenal mucosa with intra-luminal pus.

Fig. 2: CT-abdomen: Thickened duodenal wall with obstruction; no lymphadenopathy.

Fig. 3: Ba study: gastric outlet obstruction with choledochoduodenal and abdominal fistulae.

Fig. 4: FU gastroscopy: e/o healing and absence of pus.

DISCUSSION

Although gastrointestinal tuberculosis is rampant in underdeveloped countries,[3] primary isolated duodenal TB is extremely uncommon.[5] Its clinical patterns vary, and diagnosis based on clinical features, endoscopy and imaging is difficult.[2]

Our case emphasizes the need for strong clinical suspicion and the limitation of endoscopic biopsy in diagnosis. To our knowledge, there is no previous report of a case of combined choledocho-duodenal and abdominal fistula due to primary duodenal tuberculosis.

REFERENCES

1.Tromba JL, Inglese R, Reiders B, Todaro R. Primary gastric tuberculosis presenting as pyloric outlet obstruction. Am J Gastroenterology 1991; 86 (12) : 1820-2.

2.Berney T, Badaoui E, Totsch M, Mentha G, Morel P. Duodenal tuberculosis presenting as acute ulcer perforation. Am J Gastroenterology 1998; 93 (10) : 1989-91.

3.Nair KV, Pal CG, Rajagopal KP, Bhat VN, Thomas M. Unusual presentations of duodenal tuberculosis. Am J Surg 1991; 86 (6) : 756-60.

4.Shah P, Ramakantan R, Deshmukh H. Obstructive jaundice - an unusual complication of duodenal tuberculosis : treatment with transhepatic balloon dilatation. Ind J Gastroenterology 1991; 10 (2) : 62-3.
5.Ray JD, Sriram PV, Kumar S, et al. Primary duodenal tuberculosis diagnosed by endoscopic biopsy. Trop Gatroenterology 1997; 18 (2) : 74-5.

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Fig. 1: Ulcerated duodenal mucosa with intra-luminal pus.	Fig. 2: CT-abdomen: Thickened duodenal wall with obstruction; no lymphadenopathy.

Fig. 3: Ba study: gastric outlet obstruction with choledochoduodenal and abdominal fistulae.	Fig. 4: FU gastroscopy: e/o healing and absence of pus.