Gastrointestinal Tuberculosis Research Articles

Intestinal tuberculosis revealed by stercoral peritonitis in a patient at D3 postpartum: A case report

Digestive tuberculosis is uncommon compared to pulmonary tuberculosis. Gastrointestinal tuberculosis accounts for 2.5% of cases of extra-pulmonary tuberculosis. Early diagnosis is not easy because of the non-specific clinical picture. We report a case of intestinal tuberculosis revealed by stercoral peritonitis in a 29- year-old patient whose CT scan showed a large pneumoperitoneum. The procedure consisted of a bowel resection, removing both perforations and performing a Bouilly volkman ileostomy. Anatomopathological examination of the operative specimen revealed ulcerated and perforated ileitis with epithelio-giganto-cellular and necrotizing granulomatous lesions suggestive of tuberculosis.

Direct peritoneal resuscitation in a patient with gastrointestinal tuberculosis with an open abdomen

Rationale/objectivesThis case report aims to illustrate the methodology involved in the management of a patient with gastrointestinal tuberculosis with an open abdomen with direct peritoneal resuscitation. We present a 49-year-old malnourished male, in septic shock, who presented with mechanical intestinal obstruction from gastrointestinal tuberculosis (GITB) and required delayed abdominal closure. Direct peritoneal resuscitation (DPR) was employed as an adjunct to shorten the interval to closure by reducing organ edema and inflammatory cytokine levels. MethodsThis is a case report describing the procedure of direct peritoneal resuscitation and its use in non-trauma related surgeries requiring delayed abdominal closure. ResultsThe patient recovered well from the surgery with the abdomen closed after nine days from the first procedure. ConclusionDirect peritoneal resuscitation is a viable adjunct in patients requiring delayed abdominal closure.

Right Colectomy for an Inflammatory Mass in the Cecum Later Found to Be Tuberculosis.

Gastrointestinal tuberculosis (TB) is a rare manifestation of extra-pulmonary TB that is known to mimic many different gastrointestinal diseases. We present a case of an 85-year-old male patient with delayed diagnosis of gastrointestinal TB who underwent colonic resection for a cecal mass that was initially suspected to be malignant. Acid-fast staining of the surgical specimen later revealed acid-fast bacilli and multiple lymph nodes with necrotizing granulomas. The purpose of this study is to stress the importance of including gastrointestinal TB as a differential diagnosis for patients with suspected colorectal malignancy, especially when initial biopsy results do not reveal malignant features.

Artificial intelligence for discrimination of Crohn's disease and gastrointestinal tuberculosis: A systematic review.

Discrimination of gastrointestinal tuberculosis (GITB) and Crohn's disease (CD) is difficult. Use of artificial intelligence (AI)-based technologies may help in discriminating these two entities. We conducted a systematic review on the use of AI for discrimination of GITB and CD. Electronic databases (PubMed and Embase) were searched on June 6, 2022, to identify relevant studies. We included any study reporting the use of clinical, endoscopic, and radiological information (textual or images) to discriminate GITB and CD using any AI technique. Quality of studies was assessed with MI-CLAIM checklist. Out of 27 identified results, a total of 9 studies were included. All studies used retrospective databases. There were five studies of only endoscopy-based AI, one of radiology-based AI, and three of multiparameter-based AI. The AI models performed fairly well with high accuracy ranging from 69.6-100%. Text-based convolutional neural network was used in three studies and Classification and regression tree analysis used in two studies. Interestingly, irrespective of the AI method used, the performance of discriminating GITB and CD did not match in discriminating from other diseases (in studies where a third disease was also considered). The use of AI in differentiating GITB and CD seem to have acceptable accuracy but there were no direct comparisons with traditional multiparameter models. The use of multiple parameter-based AI models have the potential for further exploration in search of an ideal tool and improve on the accuracy of traditional models.

S2712 Poor Consumption: A Case of Gastrointestinal Tuberculosis Mimicking Malignancy in an Immunocompromised Patient

S2712 Poor Consumption: A Case of Gastrointestinal Tuberculosis Mimicking Malignancy in an Immunocompromised Patient

Computed tomography versus ultrasonography in the evaluation of periumbilical abdominal pain

Background: The objective of this study was to study, assess, and make early diagnosis of periumbilical pain abdomen accurately. Aims and Objectives: To study, assess, and diagnose causes of periumbilical abdominal pain accurately so as to minimize the unnecessary exploratory laparotomy and operations and consequently improved patient care and to compare the role of ultrasonography (USG) and computed tomography (CT) in the evaluation of various causes of periumbilical abdominal pain. Materials and Methods: This prospective study (CTRI/2023/01/048809) was done on 315 patients with periumbilical pain at M.L.B. Medical College Jhansi, Uttar Pradesh on PHILIPS 16 Slice multi-detector CT SCAN machine and GE Vivid T8 ultrasound machine. These patients were blindly and randomly divided by chit system into two groups irrespective of their age and gender. The first group of patients which included 160 patients undergoes ultrasonographic evaluation and the other group of patients which includes 155 patients undergoes contrast-enhanced computed tomographic evaluation. Results: Among 315 patients, the most common cause of periumbilical pain was found to be appendicitis followed by bowel pathologies which include gastrointestinal tuberculosis. Conclusion: USG is the initial modality and modality of choice in female and young (3rd and 4thdecade) patients presenting with periumbilical pain as it is diagnostic in gynecological causes of periumbilical pain and also minimizes unnecessary radiation exposure to female and young patients. Contrast-enhanced CT is the modality of choice in male and old age patients (5th and 6th decade) as it is diagnostic in vascular causes. Overall plain CT has limited role.

The diagnostic challenge of gastrointestinal tuberculosis mimicking colon cancer: A case report

Gastrointestinal tuberculosis (TB) accounts for 3.5% of extrapulmonary TB cases and is associated with active or inactive pulmonary TB in 76% of cases. A 53-year-old lady with no prior history of morbidity visited our hospital's department with weakness, an inability to eat, a 39°C fever, no chills, and night sweats that had been present for about six months. Additionally, a colonoscopy revealed a mamelonated mass of a stenotic character in the ascending colon, along with minor mesenteric adenitis, on computed tomography scans of the abdomen and pelvis. The obtained specimen's histological analysis revealed histiocytes and a few large cells producing granulomas without neoplastic features. The colonic biopsy's Löwenstein-Jensen medium culture revealed development of the Mycobacterium TB complex. After receiving therapy for two months with rifampicin, isoniazid, pyrazinamide, and ethambutol, followed by four months with rifampicin and isoniazid, the patient had significantly improved. The current case serves as an example of the difficulty in diagnosing GI TB. The lack of symptoms and occasionally false-positive imaging results reinforce the necessity for increased clinical suspicion.

Intraspinal and Intracranial Neurotuberculosis, Clinical and Imaging Characteristics and Outcomes in Hospitalized Patients: A Cohort Study (2000-2022).

Neurotuberculosis (neuroTB) is a devastating disease, and is difficult to diagnose. The aim of this study was to analyze the clinical and imaging characteristics, and outcomes of a retrospective cohort (2000-2022) of hospitalized patients diagnosed with intraspinal and intracranial neuroTB. This work was designed through clinical, laboratory and imaging findings. Variables included: demographic data, history of tuberculosis, neurological complications, comorbidities and outcomes. Morbi-mortality risk factors were identified by univariate analysis. The cohort included: 103 patients with intraspinal and 82 with intracranial neuroTB. During the study period, in-hospital mortality of 3% for intraspinal and 29.6% for intracranial neuroTB was estimated. Motor deficit was found in all patients with intraspinal neuroTB. Risk factors for the unfavorable outcome of patients with intraspinal neuroTB were: age ≥ 40 years, diabetes mellitus (DM), diagnostic delay, kyphosis and spondylodiscitis ≥ 3 levels of involvement. Among the patients with intracranial neuroTB, 79/82 (96.3%) had meningitis and 22 patients had HIV infection (10 of them died). Risk factors for mortality from intracranial neuroTB were: HIV infection, hydrocephalus, stroke, lymphopenia and disseminated and gastrointestinal TB. Patients with intraspinal neuroTB had a significant number of destroyed vertebrae that determined their neurological deficit status. The mortality burden in intracranial neuroTB was conditioned by HIV infection and renal transplantation patients.

Physical Medicine and Rehabilitation Management in Patient with Loculated Empyema, Pleural Effusion et causa Chylothorax on WSD, Gastrointestinal Tuberculosis and History of Drop-Out Pulmonary Tuberculosis: A Case Report

Introduction: Tuberculosis (TB) is a lung disease caused by Mycobacterium tuberculosis (MTB), known for its high morbidity and mortality rate. When it infects organs outside the lungs, the condition is called extrapulmonary TB.
 Case report: A 52-year-old man who came to dr. Cipto Mangunkusumo hospital with worsening abdominal pain since a month ago. During the physical examination, tenderness in the right lower quadrant of the abdomen was felt. Furthermore, blood work showed leukocytosis and thrombocytosis. An X-ray examination revealed loculated pleural effusions. A WSD was placed, and pleural fluid analysis resulted in chylus. Sputum smears were negative. An abdominal CT scan revealed irregular thickening of the caecum wall extending to part of the large intestine and multiple surrounding lymphadenopathies. The patient was diagnosed with gastrointestinal TB and received category 1 anti-TB drugs.
 Conclusion: The patient also underwent pulmonary rehabilitation and had improvements at the end of the hospitalization period.
 Keywords: Extrapulmonary TB, Gastrointestinal TB, Loculated empyema, Pulmonary rehabilitation.

Tuberculosis revisted: classic imaging findings in childhood

Tuberculosis (TB) remains one of the major public health threats worldwide, despite improved diagnostic and therapeutic methods. Tuberculosis is one of the main causes of infectious disease in the chest and is associated with substantial morbidity and mortality in paediatric populations, particularly in low- and middle-income countries. Due to the difficulty in obtaining microbiological confirmation of pulmonary TB in children, diagnosis often relies on a combination of clinical and radiological findings. The early diagnosis of central nervous system TB is challenging with presumptive diagnosis heavily reliant on imaging. Brain infection can present as a diffuse exudative basal leptomeningitis or as localised disease (tuberculoma, abscess, cerebritis). Spinal TB may present as radiculomyelitis, spinal tuberculoma or abscess or epidural phlegmon. Musculoskeletal manifestation accounts for 10% of extrapulmonary presentations but is easily overlooked with its insidious clinical course and non-specific imaging findings. Common musculoskeletal manifestations of TB include spondylitis, arthritis and osteomyelitis, while tenosynovitis and bursitis are less common. Abdominal TB presents with a triad of pain, fever and weight loss. Abdominal TB may occur in various forms, as tuberculous lymphadenopathy or peritoneal, gastrointestinal or visceral TB. Chest radiographs should be performed, as approximately 15% to 25% of children with abdominal TB have concomitant pulmonary infection. Urogenital TB is rare in children. This article will review the classic radiological findings in childhood TB in each of the major systems in order of clinical prevalence, namely chest, central nervous system, spine, musculoskeletal, abdomen and genitourinary system.Graphical

Gastrointestinal tuberculosis: An autopsy-based study

BackgroundTuberculosis is a disease of great relevance since it is one of the leading causes of morbidity and mortality worldwide. Gastrointestinal tuberculosis is an unusual presentation. It is defined as the involvement of any segment of the digestive tract, associated viscera, and peritoneum. The study's main objective is to collect information from autopsies of patients diagnosed with gastrointestinal tuberculosis in a Pathology reference center in Colombia. MethodsThis is a retrospective and descriptive study of autopsy reports. A total of 4,500 autopsies were performed between January 2004 and December 2020. The inclusion criteria were authorization of a family member following local law regulations and a final autopsy diagnosis of gastrointestinal tuberculosis using microscopic visualization. ResultsForty-eight patients with gastrointestinal tuberculosis autopsies were included in our study. Most of the patients were male (n = 35, 72.9%) with a median age of 40.5 years old. Human immunodeficiency virus infection history was reported in 28 cases (58.33%). The most affected gastrointestinal tract site was the terminal ileum. Ulcers and thickened epithelium were common autopsies macroscopic findings. Tuberculosis multiorgan compromise was a relevant finding in patients with gastrointestinal tuberculosis. ConclusionsGastrointestinal tuberculosis is a disease of great importance, being its diagnosis a clinical challenge. Underdiagnosis can be reported in a high percentage of cases, so autopsy diagnosis can help reveal more accurate data about this condition.

Perfusion Computed Tomography May Help in Discriminating Gastrointestinal Tuberculosis and Crohn’s Disease

Gastrointestinal tuberculosis (GITB) and Crohn's disease (CD) are close mimics. This prospective study aimed to evaluate the diagnostic performance of perfusion computed tomography (CT) in differentiating GITB from CD. Consecutive patients with ileocaecal thickening underwent perfusion CT of the ileocaecal region between January 2019 and July 2020. Two radiologists (blinded to the final diagnosis) independently assessed blood flow (BF), blood volume (BV), mean transit time (MTT), and permeability at perfusion CT. These parameters were compared among the patients with GITB as well as active and inactive CD. Receiver operating characteristic curves were utilized for determining the diagnostic performance of perfusion CT. Interclass correlation coefficient and Bland-Altman analysis were performed to compare the observations of the two radiologists. During the study period, 34 patients underwent perfusion CT. Eight patients had diagnoses other than intestinal tuberculosis or CD. Thus, 26 patients (mean age 36 ± 14 years, 18 males) with GITB (n = 11), active CD (n = 6), and inactive CD (n = 9) were evaluated. BF, MTT, and permeability showed significant differences among the groups, while BV did not differ significantly among the groups. BF and permeability had 100% sensitivity and 100% specificity, while MTT had 61.5-100% sensitivity and 70-100% specificity for differentiating GITB from active CD and active from inactive CD. The interclass correlation coefficient for perfusion CT parameters was 0.88-1. Perfusion CT is a novel imaging technique that can improve the diagnostic performance of differentiating tuberculosis from CD.

Intestinal tuberculosis mimicking Crohn‘s disease: clinical case

Ieva Stainytė1, Martyna Vyčaitė1, Irma Kuliavienė2 1Lithuanian University of Health Sciences, Faculty of Medicine, Kaunas, Lithuania 2Hospital of the Lithuanian University of Health Sciences Kauno klinikos, Department of Gastroenterology, Kaunas, Lithuania Abstract Background. Gastrointestinal (GI) tuberculosis (TB) is a relatively rare form of tuberculosis that can affect the peritoneum, abdominal organs or the abdominal lymphatic system. As an extrapulmonary form, intestinal tuberculosis accounts for 2% of cases of this disease worldwide. Intestinal damage caused by Mycobacterium tuberculosis (M. tuberculosis) presents with nonspecific complaints such as constitutional symptoms, abdominal pain and changes in bowel movements. The most common site of damage is the ileocecal valve. People with immunosuppressive conditions are at greater risk of developing this disease. Clinical case. This article presents a clinical case of a patient in whom the initial diagnosis of Crohn’s disease (CD) and treatment with glucocorticoids were incorrect. Persistent symptoms led to consideration of ineffective treatment and alternative diagnoses, therefore, it was decided to perform a repeated fibrocolonoscopy (FCS). Ultimately, only a positive culture for M. tuberculosis confirmed the diagnosis of intestinal tuberculosis. Conclusions. This clinical case reflects the complicated diagnosis of intestinal tuberculosis and its differentiation from Crohn’s disease, which is determined by non-specific symptoms and insufficiently sensitive standard tests. A detailed examination, including fibrocolonoscopy with multiple biopsies for histological examination and microbiological identification of M. tuberculosis, is important for establishing the diagnosis. Multiplex polymerase chain reaction (PCR) testing is recommended when possible. Keywords: gastrointestinal tuberculosis, intestinal tuberculosis, M. tuberculosis. Full article https://doi.org/10.53453/ms.2023.2.16

Frequency, outcomes, and need for intervention in stricturing gastrointestinal tuberculosis: a systematic review and meta-analysis

BackgroundGastrointestinal strictures impact clinical presentation in abdominal tuberculosis and are associated with significant morbidity.AimTo conduct a systematic review of the prevalence of stricturing disease in abdominal and gastrointestinal tuberculosis and response to antitubercular therapy (ATT).MethodsWe searched Pubmed and Embase on 13th January 2022, for papers reporting on the frequency and outcomes of stricturing gastrointestinal tuberculosis. The data were extracted, and pooled prevalence of stricturing disease was estimated in abdominal tuberculosis and gastrointestinal (intestinal) tuberculosis. The pooled clinical response and stricture resolution (endoscopic or radiologic) rates were also estimated. Publication bias was assessed using the Funnel plot and Egger test. The risk of bias assessment was done using a modified Newcastle Ottawa Scale.ResultsThirty-three studies reporting about 1969 patients were included. The pooled prevalence of intestinal strictures in abdominal tuberculosis and gastrointestinal TB was 0.12 (95%CI 0.07–0.20, I2 = 89%) and 0.27 (95% CI 0.21–0.33, I2 = 85%), respectively. The pooled clinical response of stricturing gastrointestinal tuberculosis to antitubercular therapy was 0.77 (95%CI 0.65–0.86, I2 = 74%). The pooled stricture response rate (endoscopic or radiological) was 0.66 (95%CI 0.40–0.85, I2 = 91%). The pooled rate of need for surgical intervention was 0.21 (95%CI 0.13–0.32, I2 = 70%), while endoscopic dilatation was 0.14 (95%CI 0.09–0.21, I2 = 0%).ConclusionStricturing gastrointestinal tuberculosis occurs in around a quarter of patients with gastrointestinal tuberculosis, and around two-thirds of patients have a clinical response with antitubercular therapy. A subset of patients may need endoscopic or surgical intervention. The estimates for the pooled prevalence of stricturing disease and response to ATT had significant heterogeneity.

Evidence-based approach to diagnosis and management of abdominal tuberculosis.

Abdominal tuberculosis is an ancient problem with modern nuances in diagnosis and management. The two major forms are tuberculous peritonitis and gastrointestinal tuberculosis (GITB), while the less frequent forms are esophageal, gastroduodenal, pancreatic, hepatic, gallbladder and biliary tuberculosis. The clinicians need to discriminate the disease from the close mimics: peritoneal carcinomatosis closely mimics peritoneal tuberculosis, while Crohn's disease closely mimics intestinal tuberculosis. Imaging modalities (ultrasound, computed tomography, magnetic resonance imaging and occasionally positron emission tomography) guide the line of evaluation. Research in diagnostics (imaging and endoscopy) has helped in the better acquisition of tissue for histological and microbiological tests. Although point-of-care polymerase chain reaction-based tests (e.g. Xpert Mtb/Rif) may provide a quick diagnosis, these have low sensitivity. In such situations, ancillary investigations such as ascitic adenosine deaminase and histological clues (granulomas, caseating necrosis, ulcers lined by histiocytes) may provide some specificity to the diagnosis. A diagnostic trial of antitubercular therapy (ATT) may be considered if all diagnostic armamentaria fail to clinch the diagnosis, especially in TB-endemic regions. Objective evaluation with clear endpoints of response is mandatory in such situations. Early mucosal response (healing of ulcers at twomonths) and resolution of ascites are objective criteria for early response assessment and should be sought at twomonths. Biomarkers, especially fecal calprotectin for intestinal tuberculosis, have also shown promise. For most forms of abdominal tuberculosis, sixmonths of ATT is sufficient. Sequelae of GITB may require endoscopic balloon dilatation for intestinal strictures or surgical intervention for recurrent intestinal obstruction, perforation or massive bleeding.

MTBDRplus and MTBDRsl for simultaneous diagnosis of gastrointestinal tuberculosis and detection of first-line and second-line drug resistance.

Emergence of drug resistance, especially to second-line drugs, hampers tuberculosis elimination efforts. The present study aimed to evaluate MTBDRplus and MTBDRsl assays for detecting first-line and second-line drug resistance, respectively, in gastrointestinal tuberculosis (GITB). Thirty ileocecal biopsy specimens, processed in the Department of Microbiology between 2012 and 2022, that showed growth of Mycobacterium tuberculosis on culture were included in the study. DNA, extracted from culture, was subjected to MTBDRplus and MTBDRsl (Hain Lifescience GmbH, Nehren, Germany), following manufacturer's instructions. Their performance was compared against phenotypic drug susceptibility testing (pDST) and gene sequencing. Out of the 30 specimens, 4 (13.33%) were mono-isoniazid resistant, 4 (13.33%) were multidrug resistant (MDR), 2 (6.67%) were pre-extensively drug resistant (pre-XDR), and 2 (6.67%) were mono-fluoroquinolone resistant. The results were 100% concordant with pDST and gene sequencing. In the wake of growing drug resistance in all forms of extrapulmonary tuberculosis, including GITB, MTBDRplus and MTBDRsl are reliable tools for screening of resistance to both first-line and second-line drugs.

Diagnostic Efficacy of New Xpert Ultra for Extrapulmonary Tuberculosis Using Culture and Composite Reference Standard.

Xpert Ultra (Cepheid, USA) is recently introduced with an extra category of trace-positive results and higher sensitivity for tuberculosis (TB) diagnosis. The objective of the study was to assess the diagnostic accuracy of Xpert Ultra for extrapulmonary samples using culture and composite reference standard (CRS) as the gold standard. In a 1-year (March 2021-22) prospective observational study, samples of suspected extrapulmonary TB (EPTB) patients were subjected to Ziehl-Neelsen staining, culture, and Xpert Ultra (Cepheid, Sunnyvale, CA) tests. Relevant clinical and treatment information was noted. The diagnostic accuracy of Xpert Ultra compared with culture and CRS was calculated. Out of 1720 suspected patients of EPTB, 223 (13%), predominantly males 135 (60%), with a mean age of 41.46 ± 19.81 years, were diagnosed as TB positive following CRS criteria. The maximum cases were of pleural TB (35.4%), followed by central nervous system TB (17.9%), gastrointestinal TB (17.5%), and lymph node TB (12.1%). Of all samples, 150 (8.7%) were microbiologically confirmed, including 141 detected by Xpert ultra, 67 culture positive, and only 16 smear positive. Among the Xpert Ultra-positive samples, 35 showed trace results, including six false-positive results. Considering culture and CRS as the gold standard, the sensitivity (86.57%, 59.64%) and specificity (94.98%, 99.47%) of Xpert Ultra were calculated, respectively. Rifampicin resistance was detected in 1 (0.70%) sample. Diagnosis of EPTB is a challenge and Xpert Ultra may detect TB at a very early stage. However, it is essential to rule out false-positive results. Additional studies are needed on Xpert Ultra to interpret trace results better.

Comparative Evaluation of Multidetector Computed Tomography and Dual-Energy Computed Tomography Findings in Gastrointestinal Tuberculosis.

To compare multidetector computed tomography (MDCT) and dual-energy computed tomography (DECT) imaging findings in gastrointestinal (GI) tuberculosis. To study imaging findings of MDCT and DECT in GI tuberculosis. All the patients falling in the sampling frame and fulfilling the eligibility criteria were clinically examined and demographic details, presenting complaints, medical history, history of anti-tubercular treatment (ATT) intake, personal habits,and family history of tuberculosis were noted. All the patients underwent sputum acid-fast bacilli (AFB) assessment. Outcomes of investigations like bronchoscopy and fine-needle aspiration cytology (FNAC)/biopsy were also noted wherever available. Ascitic fluid AFB and culture assessments were also performed wherever feasible. All CT scans were performed on a 384-slice dual-energy CT scanner (Somaton Force, Siemens Healthcare) and all the images were post-processed on a workstation using syngo.via software that allows the analysis of images using three material decompositions. Features like peritonitis, lymph node involvement, GI wall thickening, and solid organ involvement were focused on. Subjective assessment of images of both MDCT and DECT were assessed by two experienced radiologists to prepare the CT diagnosis. The mutual agreement of the two observers was considered final. The findings of the study showed that both MDCT, as well as DECT, were useful in the diagnosis of GI tuberculosis. On the basis of these findings, DECT could be considered to have an edge over MDCT in the diagnosis of GI tuberculosis. Keeping in view the small sample size and high prevalence, further studies on a larger sample size with relaxed sampling criteria are recommended to validate the findings of the present study.

A RARE CASE REPORT ABDOMINAL TUBERCULOSIS PRESENTED WITH APPENDICULAR PERFORATION IN PATIENTS ON PPIs

Gastrointestinal tuberculosis (TB) accounts for 3% of extrapulmonary TB. Ileocecal region pf gastro intestinal tract being involved is about 75%. Primary Tuberculosis of appendix is a rare type of abdominal TB and is seen in only 0.1%–0.3% of cases. Diagnosis in most instances made after histopathologic examination of the appendectomy specimen. In development countries like India where the prevalence of TB is high patients on PPIs for longer periods have a chance of occurrence or activation of TB.17 Here we present a case of abdominal TB presented with perforated tubercular appendix , who is a known case of GERD on PPI s regularly

S3654 Primary Gastric Tuberculosis Without Pulmonary Involvement Presenting as Chronic Reflux With Anemia

Introduction: Gastrointestinal (GI) tuberculosis (TB) accounts for only 1-3% of TB cases worldwide. Of these GI cases, the ileocecal region is the most affected site. Gastric Tuberculosis (GTB) only accounts for 1-2% of GI TB. When present, GTB is typically seen in conjunction with pulmonary tuberculosis or associated with an immunodeficient state. Primary, isolated GTB in the immunocompetent is particularly rare. When present, GTB commonly presents as gastric outlet obstruction but can also have symptoms that mimic peptic ulcer disease or malignancy. The diagnosis requires biopsy showing caseating granulomas or the presence of acid-fast bacilli. We present a case of isolated GTB in routine workup of a patient with chronic anemia. Case Description/Methods: 60-year-old Honduran male with history of Parkinson’s disease presented for evaluation of constipation, reflux, and chronic anemia. He underwent endoscopy and colonoscopy revealing several gastric submucosal nodules as well as a duodenal ulceration (Figure 1). He subsequently had endoscopic ultrasound with biopsy for two of these nodules which was remarkable for chronic granulomatous inflammation with necrosis and inflamed fibrous tissue, and caseating granulomatous inflammation respectively (Figure 2). Acid-fast stain showed an indeterminant rod-shaped organism. He tested negative for TB polymerase chain reaction but positive for QuantiFERON-TB. There was concern for disseminated TB and CT scan chest/abdomen/pelvis was done which did not show any suspicious lesions. Gastric TB was diagnosed, and the patient received anti-tubercular treatment. Discussion: Although rare, clinicians should be suspicious of GTB in patients native to endemic areas presenting with symptoms reflecting gastric outlet obstruction, peptic ulcer disease, malignancy, or in the workup of chronic anemia. The lack of pulmonary involvement as seen in this case makes it particularly challenging to identify. The routes of infection of the gastric tissue include hematogenous spread, extension from neighboring TB lesion, or direct infection of the mucosa. The rarity of GTB can be attributed to the bactericidal properties of gastric acid and lack of significant lymphoid tissue in the gastric wall. The gastric mucosal barrier also plays a part in preventing migration into the tissue. Given the chronic reflux in this patient, it is possible he had gastritis and erosion of the barrier facilitating infection. Once diagnosed, patients respond well to anti-tubercular treatment.Figure 1.: Macroscopic gastric ulcerated nodular lesions found in EGD.Figure 2.: Microscopic pathology from biopsy of gastric ulcero nodular lesions showing caseating granulomas.