A Case of Miliary TB Presenting with Massive Upper GI Bleeding

Abstract

Purpose: Less than 5% of patients with pulmonary tuberculosis in the U.S. have bowel involvement. In patients with luminal GI disease, the ileocecal region is most often affected. Tuberculous enteritis can lead to abdominal pain, a palpable mass, stricture, obstruction, ulceration, and GI bleeding. Case: A 59 year old Filipino woman presented to a tertiary care ICU with concerns for massive GI bleeding. She had presented to a local hospital one week prior with fevers, cough, hematochezia, and a 100 pound weight loss over the past year while on prednisone therapy for presumed lupus arthritis. She required intubation. Her abdomen was benign. A CXR revealed bilateral pulmonary infiltrates. She suffered a 6 mg/dL drop in Hgb in the first 24 hours, prompting a (normal) EGD, followed by a bleeding scan demonstrating bleeding at the proximal jejunum. Bronchoscopy revealed thick AFB+ secretions. She continued to have episodes of large volume hematochezia. She was transfused to maintain an Hgb > 8 mg/dL. Upon transfer the patient was intubated but alert, and denied abdominal pain. Upper endoscopy, push enteroscopy, and colonoscopy were performed without difficulty in the ICU. No identifiable bleeding source was found. A subcentimeter, nonbleeding, shallow, cratered erosion was found in the L colon and was biopsied. Capsule endoscopy was performed without identification of major pathology or any bleeding source. A CT scan of the C/A/P was performed revealing a large organized collection of fluid and air in the L abdomen, extensive ascites, collapsed vertebral bodies, extensive mesenteric lymphadenopathy, patchy airspace disease, and a large R cavitary lung lesion. Based on the presumed subacute nature of the abdominal collection and benign abdomen, IR placed a drainage catheter into the collection. The aspirate demonstrated AFB. Biopsies from the colonic lesion demonstrated granulomas. Arthrocentesis of a left knee effusion also revealed AFB. Her condition did not improve with supportive care and she was taken to the OR with resection of a 6 cm segment of friable, ulcerated, and perforated jejunum located 10 cm distal to the Ligament of Treitz. Her bowel specimen and accompanying liver biopsy revealed extensive tuberculosis. The patient succumbed to her disease weeks later after a prolonged ICU course. Conclusion: Tuberculous enteritis is a rare cause of bowel perforation and massive GI bleeding and it should be entertained in the appropriate clinical context.