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ILEOCAECAL TUBERCULOSIS ASSOCIATED
WITH DUODENAL INVOLVEMENT
A Upadhay*, P Rathi**, P Sawant***
*Resident; **Lecturer; ***Head, Department of Gastroenterology, LTM Medical College, LTM Gen. Hospital, Sion, Mumbai 22.
Endoscopically colonic tuberculosis presents as a deformed ileo-caecal valve, contracted caecum, ulcers, mucosal nodules, pseudopolypoid folds, and stricture. The following is an interesting case report of ileocaecal tuberculosis with associated duodenal involvement.CASE REPORT
A 45 year old male patient presented with complaints of post-prandial epigastric discomfort, more after solid food, retention vomiting, anorexia and weight loss of 12 kg over a 2 month period. He had been treated elsewhere with omeprazole for 6 weeks. For 6 weeks prior to presentation he could tolerate only liquids orally. He was non-alcoholic, non-smoker and had no major illness in the past. On clinical examination he was emaciated and had grade I clubbing.
Investigation showed haemoglobin 15.5 g/dl, total leucocyte count 7,600/dl (polymorphs 74%, lymphocytes 24%, eosinophils 1%, monocytes 1%, sedimentation rate 30 mm/1st hour, urine and stool examination normal, serum glutamate oxaloacetate transaminase 20 Units/1, alkaline phosphatase 6.7 KAU, blood urea nitrogen 11 mg/dl, serum creatinine 1.2 mg/dl, serum sodium 138 meq/l, serum potassium 3.6 meq/l, fasting blood sugar 70.6 mg/dl, post prandial blood sugar 106 mg/dl, chest X-ray normal.
The barium meal showed a deformed stricturous duodenum. An upper GI endoscopy oedematous duodenum and mucosal nodules in the 1st part with no erythema. Duodenal brush cytology showed normal columnar epithelial cells, regenerating basal type of epithelial cells, lymphocytes, germinal centre cells and plasmacytoid cells. The punch biopsy revealed glandular mucosa, lymphocytic infiltration with follicle formation probably lymphoid follicle, suggesting lymphoma (well differentiated). Since duodenal biopsy was suggestive of well differentiated lymphoma, barium enema was asked for to note the involvement of ileo-caecal region, which is a common site of involvement for lymphoma as well as tuberculosis, as well as the entire length of the colon.
Barium enema showed a pulled up caecum with multiple nodular areas with similar nodular areas in the terminal ileum, suggestive of ileo-caecal tuberculosis. Colonoscopy showed multiple nodules varying in size in I-C region suggestive of Ileo-caecal tuberculosis. Biopsies were taken which showed on cytology lymphocytes, histiocytes and superficial epithelial cells with a few bacterial clumps in a proteinaceous background. Punch biopsy showed the caecal mucosa with no lymphoid aggregate, no neoplasm, nor any granulation tissue. The lamina propria showed moderate inflammation with plasma cells and lymphocytes.
Since multiple biopsies from the colonic lesion failed to establish a diagnosis of either tuberculosis or lymphoma (or Crohn’s disease), the patient was referred for exploratory laparotomy and resection, for establishing diagnosis and also for relief of upper GI obstruction. The patient underwent pyloroplasty, exploratory laparotomy and right hemicolectomy. The frozen section ruled out lymphoma. Histopathology of the resected specimen showed non-caseating granulomas in the submucosa, muscularis propria and serosa. These granulomas were composed of Langhan’s giant cells, epitheloid cells and lymphocytes. The diagnosis was ileo-caecal tuberculosis. The patient was given AKT at discharge.
The patient was seen after 2 months on follow up, was asymptomatic and had gained 5 kg weight. Seven months later OGD scopy was performed which showed normal mucosa and regression of nodules in the duodenum. However retained sutures on the pyloric area along with duodenal narrowing were seen.
The patient has been examined every 6 months during follow-up visits over 2 years and been totally asymptomatic.
DISCUSSION
Tuberculosis of the GIT most commonly affects the caecum with 85% to 90% patients having disease at this site. Other common sites or involvement in order of frequency are ascending colon, jejunum, appendix, duodenum, oesophagus, sigmoid colon and rectum , [2] with at least one recent study showing a higher involvement of the small intestine.[3] [4]
Multiple sites in the same patient may be involved and our case is a good example of involvement of duodenum alongwith caecum. Such involvement of the GIT may occur in absence of any discernible tuberculous lesion in chest X-ray.
Various colonoscopic appearances in cases of GI tuberculosis have been described and include a deformed I-C valve, contracted caecum, ulcers, mucosal nodules, pseudopolypoid folds and stricture.
Our patient showed evidence of nodular, stricturous as well as pseudopolypoidal lesions: whereas the duodenum showed evidence of nodularity as well. The I-C region showed involvement in the form of stricture, pulling up of caecum, nodularity of mucosa and polyps in resected specimen obtained at surgery.
Colonoscopy with biopsy from the involved site in colon is an established mode of diagnosis of GI tuberculosis without the need for demonstrating AFB and/or culturing tubercle bacilli from biopsy specimen.[5]
Differential diagnosis from other conditions such as Crohn’s colitis and lymphoma may, at times, however be difficult even with experienced observers. In such cases, the clinical presentation of the patient and response to treatment as aids in final diagnosis assume greater importance .[5]In our case we considered a final diagnosis of tuberculosis in preference over Crohn’s disease because of several points. First of all Crohn’s disease is rare in this part of India. Secondly features such as fissures, fistulae and abscesses were never encountered throughout the illness and during follow up. The extra intestinal manifestations of Crohn’s disease such as skin lesions, uveitis, iritis, liver disease, arthralgia and arthritis (which occur in approximately 20% of patients with Crohn’s colitis) were never encountered. The presence of granulomas with Langhan’s giant cells and epitheloid cells and the dramatic response of the patient to antitubercular treatment is also suggestive. The mucosa of the duodenum which was oedematous with nodularity before treatment, completely regressed to normal. Lastly, he gained 5 kg weight within 2 months of starting therapy and was completely asymptomatic over a follow up of more than 2 years.
REFERENCES
1. Bhargava DK. The place of colonoscopy. Ind J Surg 1983; 45 : 150-64.
2. Grobach SL. Tuberculosis of the Gastrointestinal tract in Sleisenger MH Fordtran JS ED Gastrointestinal disease. Philadelphia : WB Saunders Company. 1993; 1158-61.
3. Vij JC, Malhotra VC, Choudhary V, et al. A clinicopathologic study of Abdominal tuberculosis. Ind J Tub 1992; 39 : 213-20.
4. Abraham P, Mistry FP. Tuberculosis of Gastrointestinal tract. Ind J Tub 1992; 39 : 251-56.
5. Shah S, Thomas V, Mathan M, et al. Colonoscopic study of 50 patients with colonic tuberculosis. Gut 1992; 33 : 347-51.
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