Diagnosis of Intestinal Tuberculosis

Abstract

Intestinal tuberculosis occurs as an ulcerative lesion complicating pulmonary tuberculosis, as a hypertrophic mass, and as a miliary form associated with tuberculous peritonitis. The ulcerative lesion is the most common of the three varieties and its diagnosis can be made with a high degree of accuracy. The chief method of diagnosis is roentgenological and its development has been due chiefly to the work of Pirie, Stierlin, Brown and Sampson. The taking of a careful history is of next importance. The clinician must be familiar with the natural history of the various dyspepsias to evaluate properly the symptoms present. Laboratory findings are usually of little aid in diagnosis. Ulcerative intestinal tuberculosis is always a complication of pulmonary tuberculosis and often shows an activity parallel to that of the parent lesion. However, it frequently runs an independent course and may cause severe symptoms or death after the pulmonary lesions have become inactive. A study of over 300 cases shows a similar incidence in males and females. All ages are represented and the older patients have an incidence similar to younger patients, but the older the enteritis the less distressing are the symptoms. At Hopemont Sanitarium, the autopsy incidence of enteritis is 70 per cent. Clinically, however, it occurs in 15 to 20 per cent of the sanatorium population, where a great majority show faradvanced disease in the lungs. In a tuberculosis sanatorium the non-tuberculous dyspepsias are about four times more frequent than those due to tuberculous enteritis. In this series, only 1 per cent of the cases occurred in association with minimal pulmonary disease; 9 per cent occurred with moderately advanced disease; and 90 per cent with faradvanced disease. The exudative pulmonary lesion was associated with 25 per cent of the enteritis cases, and the chronic form with the remaining 75 per cent. Pulmonary cavitation was present in 94 per cent of the cases at the time of onset of bowel symptoms; cavitation had been present in 4 per cent prior to the onset of symptoms; no cavity was found in 2 per cent of the cases whose diagnosis was made by laparotomy or autopsy. The sputum was positive for tubercle bacilli in 97 per cent at the time of onset of the symptoms. Intestinal tuberculosis may be present without symptoms. Ten per cent of the enteritis found at autopsy showed no digestive disturbances during life. Enteritis may be present long before symptoms appear and may be started clinically by a pulmonary spread, pleural effusion or an operation. The reason for such variability, we believe, is due mainly to a local neuromuscular irritability plus an afferent-parasympathetic efferent reflex to the involved segment. We feel that this neurogenic view best explains the clinical onset of enteritis, its severity, symptomatology, duration and response to treatment. The onset of symptoms was sudden in 67 per cent and gradual in 33 per cent. The rapid onset often dates back to some food or laxative or surgical intervention. Although collapse therapy benefits greatly about 40 per cent of all cases of intestinal tuberculosis, yet some cases date their onset to some form of collapse therapy and other cases show an aggravation of symptoms by these procedures. The symptoms of enteritis may be many or few, mild or severe, local or general. Systemic symptoms may include nervousness, insomnia, chills, fever and failure to gain weight. The digestive symptoms occur in the following order: Anorexia, 85 per cent; crampy pain, 80 per cent; nausea, 70 per cent; diarrhea, 65 per cent; flatulence, 50 per cent; vomiting, 45 per cent; epigastric distress or pain, 30 per cent; constipation, 20 per cent; pyrosis, 20 per cent; tender right lower quadrant, 10 per cent; acid regurgitation, 10 per cent; constipation alternating with diarrhea, 10 per cent; gross blood in stool, 6 per cent; appendicitis, 4 per cent; allergic phenomena in 2 per cent. Diarrhea and pain occur in two-thirds of all cases and should one wait for these symptoms to appear many early cases will be missed. In this group we include also the cases