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DUODENAL TUBERCULOSIS A CASE REPORT AND REVIEW OF LITERATURE
PP Agashe*, TM Dixit**
*Registrar, **Hon. Surgeon. Department of General Surgery, Dr. B Nanavati Hospital Mumbai.
This case emphasizes the lack of special clinical, radiological, endoscopic signs of duodenal tuberculosis and shows how this disease can mimic some other pathology.INTRODUCTION
Gastro-intestinal tuberculosis is still rampant in our country and can mimic other GI diseases. Isolated duodenal involvement is uncommon. Herein we report a case of isolated proximal duodenal tuberculosis the presentation of which resembled annular pancreas with obstruction of duodenum. The limitations of clinical evaluation, radiology and endoscopy are stressed and value of laparotomy is highlighted.
CASE REPORT
A 40 year old man presented with symptoms of fullness after meals since 1 year off and on. Symptoms increased in intensity subsequently. Patient used to vomit solid food about 2 hrs. After meals, liquids were well tolerated. Patient had immediate relief after vomiting. Appetite was poor. Patient's weight had come down from 56 Kg to 46 Kg. in 6 months. Motions were irregular. He was previously treated with antacids and H2 blockers without much relief. There was no past history of tuberculosis.
Physical examination was unremarkable. There was no lump in the abdomen. No jaundice. Routine blood investigations were normal. No anaemia, ESR was 15 mm. at I hour. Liver profile was normal.
OGD scopy showed marked narrowing of 2nd part of duodenum, Endoscopic biopsy showed nonspecific duodenitis.
Barium meal showed suspected extrinsic compression of duodenum. CT scan abdomen showed a rim of tissue encasing the 2nd part of duodenum suggestive of annular pancreas,
Patient was subjected to laparotomy for obstruction. On exploration there was evidence of diffuse fibrosis over the outer surface of duodenum with multiple whitish nodules, one of which was taken for biopsy. Biopsy showed typical tuberculous granuloma and not pancreatic tissue. The lymphnodes around the duodenum were not enlarged. Gastrojejunostomy was done to relieve obstruction. Other parts of gastrointestinal tract were normal. Postoperative period was uneventful and patient went home on the 7th day after the operation. He was put on antituberculosis drugs.
Subsequent follow-up showed complete recovery from symptoms and 5 kg - weight gain.
DISCUSSION
Tuberculosis of GI tract most often affects the ileocaecal region. Duodenal involvement accounts for only 2.5% of TB enteritis. [2] The disease may be either extrinsic or intrinsic or both. [2] In the extrinsic type there can either be primary duodenal involvement or compression due to enlarged periduodenal lymph nodes. In our case the radiological features had pointed to a suspected annular pancreas. Three types of lesions are recognized with intrinsic involvement -ulcerative, hypertrophic and ulcerohypertrophic. The third part is the most commonly affected site in the duodenum. [1]
The clinical manifestations of duodenal TB are varied and non-specific. Our patient had features of outlet obstruction. In a series of 30 patients two types of presentation were recognized. 22 had features of obstruction while 8 had mainly dyspeptic symptoms. [3] Pain and vomiting are common symptoms of duodenal TB, fever and weight loss may occur as in our case and some patients may present with upper GI bleeding. [4] An epigastric mass may be palpable in 33% of patients. [5] Active pulmonary tuberculosis can be seen in 10-50% of patients. Our patient did not have any evidence of pulmonary TB.
The radiological features of duodenal TB are non-specific. [3] Endoscopy may not be diagnostic as in our case and biopsies obtained show only nonspecific inflammatory changes. [7] In our case both barium studies as well as CT scan abdomen showed an extrinsic lesion suggestive of annular pancreas which in turn on exploration turned out to be tuberculosis with fibrosis.
Laparotomy with biopsy is often needed to diagnose the disease. [3],[6],[7] Gupta et al and Tishler et al have made similar observations. When resection of affected part is difficult, a bypass procedure followed by anti tuberculous treatment is enough. [3],[6]
The other complications of duodenal TB are GI bleed, perforation and fistula formation with other parts of GI tract and even the kidney and aorta [3],[8],[9],[10] and obstructive jaundice. [13]
The pathological appearance of duodenal tuberculosis [11] may either show an acute superficial ulcer with enlarged regional lymph nodes or in chronic infections a dense fibrotic reaction and hypertrophic appearance of the bowel as in our case.
Granulomas were seen on microscopic examination of the biopsy sample.
CONCLUSION
Duodenal tuberculosis being the rarest form of intestinal tuberculosis poses great difficulty in diagnosis. High index of suspicion supported by radiological investigation, exploratory laparotomy and histopathological examination of the tissue biopsy can only lead to a definitive diagnosis of this rare condition. Surgical treatment involves bypassing the lesion and antituberculosis therapy.
ACKNOWLEDGEMENT
We thank Dr. Ketan Vagholkar for his valuable suggestions in preparing this manuscript.
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