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ISOLATED RECTAL TUBERCULOSIS MASQUERADING AS MALIGNANCY
T Patankar, J Babulkar, S Prasad, J Perumpilichira, Z Patankar*
Dept. of Radiology; *Dept. of Surgery; KEM Hospital, Mumbai 400 012, India.
Even though gastrointestinal tract is commonly affected by tuberculosis, isolated tuberculous involvement of the rectum is rare. We report a relatively uncommon case of isolated rectal tuberculosis in a 17 year old man, who presented with rectal bleeding and painful defaecation.
INTRODUCTION
Tuberculous involvement of the rectum may cause changes which are indistinguishable from malignancy on clinical examination and on imaging studies. Early recognition of rectal tuberculosis is of utmost importance, as anti-tuberculous chemotherapy is curative and obviates need for surgery.
CASE REPORT
A 17 year old non-addict, presented with massive haematochezia for two days. He had painful defaecation and significant weight loss over a period of 6 months. There was a positive family history of tuberculosis. Per rectal examination revealed a large. friable, ulcerated rectal mass, 8 cm from the anal verge causing circumferential luminal narrowing which was later confirmed on proctoscopy. Barium enema demonstrated mucosal irregularity with 60% circumferential narrowing and shouldering of a 5 cra long segment of the rectum. The presacral space measured 3 cm. Based on the clinical examination and barium enema findings, a provisional diagnosis of rectal carcinoma was considered. Sigmoidoscopic biopsy of the mass lesion yielded caseating granulomas with no evidence of malignancy. The biopsy from a supraclavicular lymph node showed features suggestive of tuberculous lymphadenitis. The remainder of the large bowel and the entire small bowel were found normal on barium follow through study. The patient showed remarkable clinical improvement, following 8 weeks of anti -tuberculous chemotherapy.
DISCUSSION
Puri et al [1] in series of eight patients with isolated rectal tuberculosis, showed that 88% of patients present with haematochezia, 75% with constitutional symptoms and 37% with constipation. Most of the patients had a tight stricture within 10 cm of the anal verge with absence of perianal disease.
A provisional diagnosis of carcinoma rectum was considered in our patient in view of the barium enema findings of circumferential rectal narrowing, widened presacral space and mucosal irregularity. However, biopsy revealed inflammatory cells with no evidence of malignant cells. Barium follow through studies were non-nal. In addition, biopsy of a supraclavicular lymph node revealed a tuberculous actiology. A repeat rectal biopsy was done which again showed inflammatory cells.
Lower gastrointestinal bleeding has been attributed to tuberculosis in 3%-4% of cases. [2], [3] Since tuberculosis causes obliterative endarteritis, massive bleeding per rectum associated with colonic TB is rare. [4], [5] However, massive haematochezia is associated with rectal T13 resulting from mucosal trauma caused by the scybalous stool traversing the stricturous segment.[1]
Puri, et at recommended tuberculosis as a possible aetiology in isolated rectal strictures and advised exclusion of malignancy on two separate biopsies. In view of the negative cultures and stains for mycobacterium tuberculosis, a polymerase chain reaction is recommended. [1]
In conclusion, tuberculosis which is an important cause of haematochezia in young patients can mimic malignancy and should be strongly considered in the differential diagnosis of an isolated stricture with mucosal ulceration.
REFERENCES
1. Puri AS, Vij JC, Kumar N, et al. Diagnosis and outcome of isolated rectal tuberculosis. Dis colon rectum 1996; 39 (10) :1126-9.
2. Bhargava DK, Rai RR, Dasarathy S, Chopra P. Colonoscopy for unexplained lower gastrointestinal bleeding in a tropical country. Trop Gastroenterol 1995; 16 (1) 59-63.
3. Goenka MK, Kochhar R, Mehta SK. Spectrum of lower gastrointestinal hemorrhage: an endoscopic study of 166 patients. Indian J Gastroenterol 1993; 12 (4) : 129-3 1.
4. Hiran S, Pande TK, Kumar S, ei al. Massive rectal bleeding due to ileocaecal tuberculosis (conservative approach). [letter]. Postgrad MedJ 1994; 70 (819) :55-6.
5. Monkemuller KE, Lewis JB Jr. Massive rectal bleeding from colonic tuberculosis. Am J Gastroenterol 1996; 91 (3) 1439-41.
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