Gastrointestinal tuberculosis

Foregut tuberculosis: Too close but miles apart

The worldwide burden of tuberculosis (TB) has increased and it can involve virtually any organ of the body. Intestinal TB accounts for about 2% of the cases of TB worldwide. The ileocecal region is the most commonly affected site, and the foregut is rarely involved. The reported incidence is approximately 0.5%. Esophageal TB presents with dysphagia, weight loss, and hematemesis in rare cases. Gastroduodenal TB usually manifests with symptoms such as nausea, vomiting, weight loss, and sometimes with gastric outlet obstruction. Gastroscopy may reveal shallow ulcers in stomach and duodenal deformity when underlying TB is suspected, therefore histopathology plays pivotal role. On computed tomography, duodenal TB typically manifests as duodenal strictures predominantly, accompanied by extrinsic compression, and occasionally as intraluminal mass. But their diagnosis can easily be missed if proper biopsies are not taken and samples are not sent for GeneXpert testing, TB polymerase chain reaction investigation and histopathological analysis. Despite being in close proximity to the lungs, the esophagus and stomach are rare sites of TB. The reasons could be low gastric pH and acidity which does not let mycobacterium grow. But there are various case reports of TB involving the foregut. We have summarized the rare cases of foregut TB in different sections and highlighted the importance of esophagogastroduodenoscopy, histopathology and advanced techniques like endoscopic ultrasound in establishing the diagnosis.

Multimodality imaging of urinary tract tuberculosis

Imaging is a key component of diagnosis and treatment response evaluation of urinary tract tuberculosis (UT TB). Tuberculosis can have a long latency, but if found early, one may have the opportunity to prevent complications such as ureteral strictures, obstructive nephropathy, contracted (thimble) bladder, renal parenchymal destruction/calcification, and renal failure. Imaging can aid in diagnosis and differential diagnoses, evaluate the extent of disease and complications, and guide image-directed biopsy, surgical planning, and evaluation of treatment response. Imaging abnormalities in the renal parenchyma and urinary tract at different stages of the disease, lymphadenopathy, and extra-urinary tract organ involvement are suggestive of UT TB. Recent advances in imaging modalities aid in UT TB diagnosis, follow-up, and guiding treatment.

Primary extrapulmonary tuberculosis diagnosis warrants extra-precautious pulmonary tuberculosis exclusion workup

This editorial article takes an opportunity to apprehend the diagnostic challenges of primary gastrointestinal tuberculosis (an uncommon extrapulmonary tuberculosis condition) utilizing the recently published case report of a young male with prolonged gastrointestinal symptoms and weight loss who received intermittent anti-tubercular treatment and underwent operative interventions to relieve gastric outlet obstruction. The diagnosis chiefly relied on high-end examinations, like computed tomography scans and histopathological evaluation of post-operatively resected bowel tissue, which wasn't preceded by an all-inclusive stepwise primary pulmonary tuberculosis exclusion approach that usually begins with a detailed tuberculosis-pertinent history acquisition. Given the geographic locations where the patient had been (and/or treated), pivotal consideration of tuberculosis-associated endemicities in those regions, like human immunodeficiency virus (HIV) infection, might have improved the case description. The obtainment of HIV-relevant histories, like intravenous drug use and sexual practice, are good places to start. The sputum bacteriology also seems imperative to rule out atypical Mycobacterium species infection because of its clinico-radio-histopathological resemblance with pulmonary Mycobacterium tuberculosis. Altogether, this editorial aims to underscore that primary extrapulmonary tuberculosis diagnosis should comprise an elaborative, comprehensive, systematic, and stepwise primary pulmonary Mycobacterium tuberculosis exclusion workup.

Peritoneal Tuberculosis in Western Countries: A Rare Case With Concurrent Helminthic Infection

This case report presents a rare case of peritoneal tuberculosis (TB) coexisting with a helminthic infection in a 25-year-old female residing in Australia, highlighting the diagnostic challenges posed by abdominal TB. Despite the low incidence of TB in Western countries, abdominal TB remains a diagnostic dilemma due to its nonspecific symptoms and potential mimicry of other abdominal pathologies. The case highlights the importance of considering TB as a differential diagnosis of unexplained abdominal symptoms, particularly in individuals with a history of travel or previous residence in high-endemic regions. A multidisciplinary approach involving infectious disease specialists, radiologists, and surgeons is essential for comprehensive management. Prompt initiation of anti-TB therapy is recommended once diagnosis is confirmed.

Revisiting the Era of Intestinal Tuberculosis: A Case Presenting As Small Bowel Obstruction With Classical Imaging and Histopathological Appearances

The incidence of tuberculosis (TB) worldwide is still significantly high, with India contributing a high global TB burden. This case study features a 49-year-old male who had complaints of pain and abdominal distention for one and a half months. An erect abdominal radiograph showed features suggesting small bowel obstruction. Contrast-enhanced computed tomography (CT) of the abdomen was done. It showed multiple strictures involving the distal jejunum and ileum, causing small bowel obstruction. There was mesenteric and retroperitoneal lymphadenopathy with central necrosis and ascites. The patient was operated on for a small bowel obstruction. The resected intestine showed four strictures, tiny nodules on the serosal surface, and many enlarged lymph nodes. Representative tissue from these areas showed the typical picture of multiple caseating granulomas and fibrosis. Ziehl-Neelsen (ZN) staining highlighted the acid-fast bacilli (AFB). The suspicion index for intestinal tuberculosis (ITB) should be kept high while evaluating patients with intestinal obstruction presenting in endemic areas and high-risk populations, such as HIV-infected, undernourished, immunocompromised, and those with diabetes, smoking, and alcohol addiction.

Intestinal tuberculosis and inflammatory bowel disease; the usual challenging differential diagnoses: A case report

Intestinal Tuberculosis (TB) is a very rare presentation of TB, presenting with a nonspecific symptom that mimics Crohn's disease, making diagnosis challenging. We present a case of intestinal tuberculosis in a 37-year-old female who had long-term abdominal pain and diarrhea and showed all the signs of inflammatory bowel disease (IBD) during a thorough clinical, endoscopic, radiologic, and histologic examination. Seven months of right mid- and lower-abdominal discomfort brought a 37-year-old woman to our hospital with pain, diarrhea, bloating, and tiredness worsening after meals. A CT scan of the abdomen highly suggested inflammatory bowel disease. A colonoscopy revealed a patulous ileocecal valve with terminal ileum ulcerations, ileal stenosis, cecum, and valve ulcers, where biopsies findings suggesting also IBD. While planned to start mesalazine; PCR TB testing of biopsy material confirmed tuberculosis. She recovered well following conventional intestinal TB therapy. Intestinal TB is called the great mimicker because its symptoms resemble different illnesses. Misdiagnosis can lead to incorrect treatment, life-threatening complications, and mortality. This paper's radiology, macroscopy, and histopathology highly suggested Crohn's disease, however, intestinal TB was the diagnosis. TB quadrable treatment significantly benefited patients. Consider intestinal TB in this scenario, especially in patients coming from endemic TB areas is highly recommended. The importance of our case report is increasing the awareness that intestinal TB can mimic inflammatory bowel disease and other disorders such as chronic disease and malignancy, for which the treatment is completely different and could lead to fetal outcome; therefore, we should maintain a high level of suspicion when evaluating patients with nonspecific symptoms, particularly in endemic areas of the disease, to obtain a correct diagnosis and appropriate treatment.

Acute intestinal obstruction: What if it is instead colonic tuberculosis? What diagnostic and management dilemmas are there?

INTRODUCTION AND IMPORTANCE

Colonic tuberculosis is rare. Clinical, biologic endoscopic and radiological features are not unequivocal. A multitude of differential diagnoses interfere, including Crohn's disease and cancer.

CASE PRESENTATION

we present a case of a 48-year-old Tunisian female who complained from occlusive syndrome. For whom none of the various elements of the medical record, the clinical, endoscopic and radiological investigations had enabled a decision to be reached in favor of one diagnosis over the other. Several diagnoses were suggested, including Crohn's disease, neoplastic diseases and, ultimately, colonic tuberculosis, since our country was endemic for this pathology. The collegial decision of the medical staff involved in the management was to operate on the patient. Surgery was required with the intention to treat and mainly to provide histological proof of the disease. A right colectomy allowed histological examination and a diagnosis of colonic tuberculosis.

DISCUSSION

The diagnosis should be discussed in patient from endemic countries, who complain chronic abdominal pain, vesperal fever and weight loss for who endoscopy shows the presence of nodules or ulcers. The diagnosis is retained on the basis of pathological findings.

CONCLUSIONS

Because of a nonspecific clinical and endoscopic presentations, multiples biopsies even surgical resection are mandatory to rule out differential diagnosis and to confirm the diagnoses of colonic tuberculosis.

Abdominal visceral tuberculosis: a malignancy mimic

The purpose is to discuss abdominal tuberculosis mimicking malignancy involving the abdominal viscera. TB of the abdominal viscera is common, especially in countries where tuberculosis is endemic and in pockets of non-endemic countries. Diagnosis is challenging as clinical presentations are often non-specific. Tissue sampling may be necessary for definitive diagnosis. Awareness of the early and late disease imaging appearances of abdominal tuberculosis involving the viscera that can mimic malignancy can aid detecting TB, providing a differential diagnosis, assessing extent of spread, guiding biopsy, and evaluating response.

Intestinal tuberculosis can masquerade as Crohn's disease: A teachable moment

Intestinal tuberculosis and Crohn's disease are chronic granulomatous diseases with similar clinical presentations and can mimic one another. Their treatment modalities are completely different; however, sometimes it is challenging to differentiate them. We report a case of a 51-year-old female presenting with abdominal pain and on-and-off diarrhea for 4 years with weight loss. Clinical symptoms along with multiple aphthous ulcers in the terminal ileum and negative tuberculin test favored the diagnosis of Crohn's disease. The patient did not respond to steroids. A repeat colonoscopy with acid-fast bacilli stain showed Mycobacterium tuberculosis. This case highlights that acid-fast bacilli culture and tuberculosis polymerase chain reaction to confirm or rule out the diagnosis of intestinal tuberculosis in all patients suspected of Crohn's disease.

Gastrointestinal tuberculosis: An autopsy-based study

BACKGROUND

Tuberculosis 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.

METHODS

This 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.

RESULTS

Forty-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.

CONCLUSIONS

Gastrointestinal 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.

Abdominal Tuberculosis in Children: A Case Series of Five Patients

Tuberculosis remains (TB) to be one of the most common causes of child morbidity and mortality. Abdominal TB is not frequently diagnosed and, although its incidence is not definitively established, there are data that seem to indicate that it accounts for approximately 1–3% of all pediatric TB cases and for no more than 10% of those with extrapulmonary manifestations. It seems, however, that abdominal TB is significantly more common than usually thought as signs and symptoms are non-specific and may mimic other diseases. The delayed or wrong diagnosis of pediatric abdominal TB can have dramatic consequences as they can lead to untreated TB with miliary dissemination, unnecessary surgery, or dangerous drug therapies. This report describes five cases of abdominal TB diagnosed among 216 pediatric patients admitted for TB in Italy from 2011 to 2021. Our cases evidence that abdominal TB is a complex and potentially very severe disease that, when not appropriately diagnosed, may be associated with severe complications and prolonged anti-TB therapy. Discussion among specialists is crucial to achieve an early diagnosis and to promptly start the anti-TB treatment. Further studies are needed to clarify the appropriate duration of therapy as well as management of MDR abdominal TB cases.

The gut microbiome: A line of defense against tuberculosis development

The tuberculosis (TB) burden remains a significant global public health concern, especially in less developed countries. While pulmonary tuberculosis (PTB) is the most common form of the disease, extrapulmonary tuberculosis, particularly intestinal TB (ITB), which is mostly secondary to PTB, is also a significant issue. With the development of sequencing technologies, recent studies have investigated the potential role of the gut microbiome in TB development. In this review, we summarized studies investigating the gut microbiome in both PTB and ITB patients (secondary to PTB) compared with healthy controls. Both PTB and ITB patients show reduced gut microbiome diversity characterized by reduced Firmicutes and elevated opportunistic pathogens colonization; Bacteroides and Prevotella were reported with opposite alteration in PTB and ITB patients. The alteration reported in TB patients may lead to a disequilibrium in metabolites such as short-chain fatty acid (SCFA) production, which may recast the lung microbiome and immunity via the "gut-lung axis". These findings may also shed light on the colonization of Mycobacterium tuberculosis in the gastrointestinal tract and the development of ITB in PTB patients. The findings highlight the crucial role of the gut microbiome in TB, particularly in ITB development, and suggest that probiotics and postbiotics might be useful supplements in shaping a balanced gut microbiome during TB treatment.

Colonic tuberculosis: a case report

Aim

Colonic tuberculosis is rare. It accounts for 2-3% of abdominal tuberculosis. Clinical, radiological and endoscopic features are nonspecific. The diagnosis must be considered in front of chronic abdominal pain, vesperal fever and weight loss with on colonoscopy the presence of nodules or ulcers. The diagnosis is made on pathological findings.

Case report

We report a case of an 82-year-old female patient with the diagnosis of colonic tuberculosis. The diagnosis were suspected on clinical presentation: chronic abdominal pain, fever and weight loss. The colonoscopy showed a nodular aspect of the left and sigmoid colonic mucosa and the pathology examination of the multiple biopsy specimens showed an epithelioid and gigantocellular granulomas with caseous necrosis.

Conclusion

In front of a nonspecific clinical and endoscopic aspects, multiples colonic biopsies are mandatory to rule out differential diagnosis and confirm colonic tuberculosis.

S, Chawla H, Kaushik S, Khan Z, . R, Chitravanshi S, Kabir U, Ansari D. Comparative Evaluation of Multidetector Computed Tomography and Dual-Energy Computed Tomography Findings in Gastrointestinal Tuberculosis

AIM

To compare multidetector computed tomography (MDCT) and dual-energy computed tomography (DECT) imaging findings in gastrointestinal (GI) tuberculosis.

OBJECTIVE

To study imaging findings of MDCT and DECT in GI tuberculosis.

METHODOLOGY

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.

CONCLUSIONS

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.

Gall bladder tuberculosis: Review of literature

Gall bladder tuberculosis (GB TB) is a very rare disease and scarce data is available on exact incidence and clinicopathogenesis even in endemic areas. The aim is to provide an insight into epidemiology, pathophysiology and management for better understanding of gall bladder tuberculosis. We collected data available from the literature on all histologically proven gall bladder tuberculosis. Case reports with either no article or only abstracts were available excluded from the study. Fifty two case reports and series with total 73 patients were included in this study. Mean age of patients was 48 years (Range 8-86 years) with male: female ratio of 1:1.7. 53 (73%) patient had isolated disease and 18 (24%) had associated abdominal tuberculosis. 3 (4%) of patients had concomitant and 7 (9%) had past history of pulmonary tuberculosis. 39 patients presented as cholecystitis and 25 as gall bladder mass. 44 (60%) patients had gall stones and majority of them (56%) are multiple. Granuloma and caseous necrosis was found in 80% & 60% of patients respectively. In conclusion, Gall bladder tuberculosis is a very uncommon presentation of abdominal tuberculosis. Pre-operative diagnosis is not possible due to lack of specific diagnostic test so increase in awareness and a high index of suspicious is required.

Gastric tuberculosis presenting as a large gastric ulcer

While gastrointestinal (GI) tuberculosis (TB) accounts for 1%-3% of all TB cases worldwide, TB of the stomach is extremely rare and accounts for 1%-2% of all GI TB. Little is known about this entity, and most data are obtained from case reports. We report a case of a woman in her 60s who presented with a 2-week history of generalised weakness, fatigue and shivering, with severe loss of appetite on background history of dyspepsia and significant weight loss for the preceding 2 years. Upper endoscopy revealed a large gastric ulcer. Biopsy and histopathology revealed caseating granulomas with numerous acid-fast bacilli detected with Ziehl-Neelsen stain. She was diagnosed with gastric TB. Subsequently, she was also diagnosed with pulmonary, adrenal and colonic involvement.

Clinical, laboratory and evolutionary features of abdominal tuberculosis in comparison with other forms of extrapulmonary tuberculosis

BACKGROUND/OBJECTIVES

Tuberculosis is a multisystem disease that might affect any organ. Abdominal tuberculosis (ABT) represents 5-17% from all extrapulmonary tuberculosis (EPT) sites. We aimed to study the clinical, laboratory and evolutionary features of ABT cases and to identify predictive factors associated with ABT.

METHODS

We conducted a retrospective study including all patients hospitalized in the infectious diseases department for EPT between 1991 and 2019. We studied the characteristics of ABT cases, and we compared them with other EPT cases.

RESULTS

We identified 519 patients with EPT, among whom 86 (16.6%) patients had ABT. There were 58 females (67.4%). Peritoneal tuberculosis was the most common clinical form of ABT (68.6%), followed by intestinal tuberculosis (18.6%). Patients aged 60 years and above were significantly less affected with ABT (odds ratio (OR) = 0.2; p = 0.001). The revealing systemic symptoms including fever (OR = 2.04; p = 0.006), weight loss (OR = 2.5; p < 0.001) and anorexia (OR = 1.7; p = 0.021) were significantly more frequent among ABT patients. Inflammatory markers including C-reactive protein levels (37 [10-89] mg/l vs 10 [4-57] mg/l; p < 0.001) and erythrocyte sedimentation rates (43 [15-95] mm/h vs 27 [15-60] mm/h; p = 0.044) were significantly higher among ABT cases. Multivariate logistic regression analysis showed that anorexia (adjusted OR (AOR) = 1.9; p = 0.015) and pulmonary involvement (AOR = 3.3; p = 0.002) were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal (AOR = 0.18; p = 0.001) and osteo-articular (AOR = 0.2; p = 0.01) sites, 40-59 (AOR = 0.2; p < 0.001) and ≥60 (AOR = 0.2; p < 0.001) age groups as well as hemoglobin rate (AOR = 0.7; p < 0.001) were independently associated with lower rate of ABT.

CONCLUSIONS

Anorexia and pulmonary involvement were independent predictors of higher rate of ABT. Concomitant involvement of neuro-meningeal and osteo-articular sites, 40-59 and ≥60 age groups and hemoglobin rate were independently associated with lower rate of ABT.

A Rare Cause of Esophageal Dysphagia – Secondary Esophageal Tuberculosis

Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis. It continues to be one of the most common causes of death in adults across all countries. It is found to be relatively lower in North America. When aerosol droplets that contain Mycobacteriumtuberculosis are inhaled, it can deposit in the respiratory tract, particularly in the patient’s lungs. Following this deposition, one of the four outcomes can take place. These include clearance of the organism immediately, primary disease, latent infection, and reactivation disease. Unhindered bacterial growth after primary infection can lead to a hematogenous spread of bacilli to produce disseminated TB. Esophageal involvement causing esophageal TB can be primary or secondary esophageal TB.

We present a unique case of secondary esophageal TB with symptoms of dysphagia and odynophagia with primary TB focus on the lung. Computed tomography (CT) of the chest noted diffuse bilateral miliary lung disease. TB QuantiFERON gold and sputum culture were positive for TB. Mycobacterial culture for identification with high-performance liquid chromatography showed isoniazid-resistant TB. The patient was started on antitubercular therapy with rifampin, ethambutol, moxifloxacin, and pyrazinamide for a total of nine months. Esophagogastroduodenoscopy (EGD) reported severe ulcerations of the oropharynx and focal ulceration in the proximal to the mid esophagus. Histopathology revealed active ulcerative and granulomatous esophagitis with mycobacterial organisms. After EGD she was started on a full liquid diet and advanced as tolerated. After discharge, she followed with the Health Department and had three negative sputum cultures after the completion of therapy.

Primary Esophageal Tuberculosis With Dysphagia

Tuberculosis is a common infection caused by Mycobacterium tuberculosis. Tuberculosis can affect many organ systems of the human body including the gastrointestinal tract. Esophageal involvement of tuberculosis is however rare.

A 60 years old male from Nepal with an occupational history suggestive of exposure to tuberculosis presented with dysphagia. He did not have any other complaints and his physical examination was unremarkable. An upper gastrointestinal endoscopic examination revealed an esophageal ulcer at 25 cm from incisors. Biopsy from the edge of the ulcer revealed granulomas with central caseous necrosis. A computed tomography scan of the chest and abdomen did not reveal additional lesions. Considering the higher prevalence of tuberculosis in the geographical area, he was started on an empirical antitubercular regimen. His dysphagia subsided within two weeks of starting therapy. A repeat upper gastrointestinal examination at six months of therapy revealed complete healing of the esophageal lesion.

In this case report, we review the symptomatology, diagnosis, and treatment of esophageal tuberculosis.

The diagnostic challenge of abdominal tuberculosis in nonendemic countries: A case series from a tertiary hospital in Germany

Abdominal tuberculosis is a rare clinical condition in nonendemic countries and should be included as differential diagnosis by unspecific abdominal complaints, especially in patients with immigration background from high-prevalence regions.

Gastrointestinal tuberculosis: A systematic review of epidemiology, presentation, diagnosis and treatment

Tuberculosis (TB) once considered a disease of the developing world is infrequent in the developing world too. Its worldwide prevalence with a huge impact on the healthcare system both in economic and health terms has prompted the World Health Organization to make it a top priority infectious disease. Tuberculous infection of the pulmonary system is the most common form of this disease, however, extrapulmonary TB is being increasingly recognized and more often seen in immunocompromised situations. Gastrointestinal TB is a leading extrapulmonary TB manifestation that can defy diagnosis. Overlap of symptoms with other gastrointestinal diseases and limited accuracy of diagnostic tests demands more awareness of this disease. Untreated gastrointestinal TB can cause significant morbidity leading to prolonged hospitalization and surgery. Prompt diagnosis with early initiation of therapy can avoid this. This timely review discusses the epidemiology, risk factors, pathogenesis, clinical presentation, current diagnostic tools and therapy.

Gastrointestinal and Abdominal Tuberculosis

Gastrointestinal (GI) tuberculosis (TB) remains a significant problem worldwide, and may involve the luminal GI tract from oral cavity to perianal area in addition to associated viscera and peritoneum. Although GI TB more commonly affects immunocompromised hosts, it can also occur in immunocompetent people. Diagnosis is difficult because it usually mimics a malignancy or inflammatory bowel disease. A high index of clinical suspicion and appropriate use of combined investigative methods help in early diagnosis, and reduce morbidity and mortality. Anti-TB therapy is the same as for pulmonary disease, and invasive and specialized interventions are reserved for selected complications.

Tuberculous appendicitis: A review of reported cases over the past 10 years

BACKGROUND

Tuberculous appendicitis is a rare extrapulmonary manifestation of tuberculosis without clear summarization or consensus on its management.

DATA SOURCES

Case reports were gathered from several online literature databases by searching terms "tuberculosis", "tuberculous", and "appendicitis".Report eligibility criteria: Cases of appendicitis due to M. tuberculosis identified on operative histology. Exclusion criteria: appendicitis caused by a mycobacterium other than M. tuberculosis, and appendiceal tuberculosis identified incidentally during procedures for other reasons.

RESULTS

Thirty four patients were identified. Twenty five patients presented with acute right lower quadrant abdominal pain. Eleven patients described chronic symptoms of tuberculosis (cough, night sweats, or weakness/fatigue). Four patients had a known diagnosis of TB. Seven of 24 cases reported peri-operative chest imaging which demonstrated pulmonary lesions. AFB were present in tissue or fluid samples of 6 patients, and negative in 15 patients. All patients underwent pharmacotherapy on a WHO-recommended anti-tuberculous treatment (ATT) with RIPE or an alternative. The average duration of treatment was 7.2 ± 1.7 months.

LIMITATIONS

Data was gathered from case reports without complete uniformity in diagnostic work-up. The potential for larger scale study is limited due to disease rarity.

CONCLUSIONS

Tuberculous appendicitis cannot be diagnosed prior to histologic evaluation. Several data points may suggest the disease on a clinician's differential diagnosis if they present with a combination of the following: born in a country with endemic tuberculosis; chronic cough, weakness/fatigue, or nausea prior to onset of abdominal pain; pulmonary lesions on chest X-ray; white studding of the mesentery or peritoneum in a young patient; positive AFB stain of abdominal fluid or peritoneal tissue.

Enteric pathogenic bacteria and resistance gene carriage in the homeless population in Marseille, France

We aimed to assess the prevalence of pathogenic bacteria and resistance genes in rectal samples collected among homeless persons in Marseille, France. In February 2014 we enrolled 114 sheltered homeless adults who completed questionnaires and had rectal samples collected. Eight types of enteric bacteria and 15 antibiotic resistance genes (ARGs) were sought by real-time polymerase chain reaction (qPCR) performed directly on rectal samples. ARG-positive samples were further tested by conventional PCR and sequencing. We evidenced a 17.5% prevalence of gastrointestinal symptoms, a 9.6% prevalence of enteric pathogenic bacteria carriage, including Escherichia coli pathotypes (8.7%) and Tropheryma whipplei (0.9%). Only 2 persons carried blaCTX-M-15 resistance genes (1.8%), while other genes, including carbapenemase-encoding genes and colistin-resistance genes, (mcr-1 to mcr-6, mcr-8) were not detected. Our results suggest that sheltered homeless persons in Marseille do not have a high risk of harbouring gastrointestinal antibiotic resistant bacteria.

Surgical management of abdominal tuberculosis: A prospective single-center study

Objective

Tuberculosis (TB) can affect any part of the gastrointestinal tract. It is estimated that in 2018, 10 million people were affected with TB worldwide and there were 1.2 million TB deaths among human immunodeficiency virus-negative people. India has the highest TB burden in the world (27%), a significant proportion of which are of intestinal TB. The aims of this study were to assess clinical features and investigations for the diagnosis of abdominal TB and to analyze its various surgical manifestations and its management.

Materials and Methods

From October 1, 2014, to October 30, 2016, a total of 50 patients meeting the inclusion criteria for the study, age between 15 and 65 years and diagnosis of symptomatic intestinal TB requiring surgery, were enrolled in the study. We used descriptive statistics to analyze the data.

Results

Abdominal TB was most commonly seen in young adults. Intestinal obstruction was the most frequent presentation. The most common site of involvement in the present study was the ileum. Ultrasonography (USG) and X-ray were an integral part of the diagnosis, with computed tomography (CT) scan being rarely required. Although both anemia and erythrocyte sedimentation rate (ESR) are nonspecific, they may help in supporting the clinical and pathological findings. Most operations were elective, with intestinal obstruction being the most common indication and resection and end-to-end anastomosis performed most often. Histopathological examination was performed in all patients and showed caseating granuloma in 90% of cases, while 10% of cases had chronic noncaseating granulomas with ill-defined aggregates of epithelioid histiocytes.

Conclusion

Abdominal TB causes a significant problem in diagnosis due to nonspecific symptomatology and lack of specific laboratory tests. USG and X-ray were an integral part of the diagnosis. CT scan is rarely required. Although anemia and ESR are both nonspecific features, they may help in supporting the clinical and pathological findings. The most common site of involvement in the present study was the ileum. Intestinal obstruction was the most common indication for operation, with resection and end-to-end anastomosis being the most common operation. The mainstay of treatment is medical therapy and timely surgical intervention is required in a sizable number of patients.

Abdominal Involvement in Children With Bacteriologically Confirmed Tuberculosis: A Five-year Experience From Cape Town, South Africa

BACKGROUND

Abdominal tuberculosis (TB) in children is poorly described and often poses a diagnostic challenge. We evaluated abdominal involvement in children presenting with bacteriologically confirmed TB.

METHODS

We undertook a retrospective study at Tygerberg Hospital, Cape Town, from January 1, 2014, through December 31, 2018, of all children (<13 years) diagnosed with bacteriologically confirmed TB, in whom abdominal involvement was found. Demographic and clinical data were collected through folder review, laboratory records and imaging reports.

RESULTS

Of 966 children with bacteriologically confirmed TB, 111 (11.5%) had abdominal involvement; 16 (14.4%) were excluded from further analysis because of lack of clinical data. The median age of the remaining 95 children was 43 months (interquartile range 20-94); 26 (27%) were HIV positive. The main gastrointestinal symptoms/signs were weight loss (84.2%), abdominal distention (54.7%), hepatomegaly (60.0%) and abdominal pain (26.3%). The main pathologic types were intra-abdominal lymph nodes (68.4%), solid organ involvement (54.7%), peritoneal type (23.2%) and intestinal type (10.5%). Splenic abscesses and solid organ involvement on ultrasonography were more common in HIV-positive children (P < 0.001 and P = 0.008, respectively). Liver abscesses were associated with age less than 5 years (P = 0.03), while abdominal lymphadenopathy on ultrasonography was more common in children older than 5 years (P = 0.038). Abdominal specimens were collected in an attempt to identify Mycobacterium tuberculosis in 15 of 95 (15.8%) patients and were positive in 13 of 15 (86.7%).

CONCLUSIONS

Over 10% of children with confirmed TB had abdominal involvement. Abdominal TB should be considered in any pediatric TB case with abdominal symptoms, and ultrasonography should be the radiologic study of choice.

Abdominal Tuberculosis in Children: Challenges, Uncertainty, and Confusion

The diagnosis of abdominal tuberculosis (TB) is challenging, and the prevalence of abdominal TB in children is likely underestimated. It may present with nonspecific abdominal symptoms and signs, but children who present with pulmonary TB may have additional abdominal subclinical involvement. Diagnosis is specifically challenging because none of the available diagnostic tools provide adequate sensitivity and specificity. In this review, we summarize the best available evidence on abdominal TB in children, covering the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment. We propose a diagnostic approach that could be followed for symptomatic children. We believe that a combination of investigations could be useful to both aid diagnosis and define the extent of the disease, and we propose that abdominal ultrasound should be used more frequently in children with possible TB and any abdominal symptoms. This neglected disease has received little attention to date, and further research is warranted.

Gastrointestinal Bleeding in a Patient With Gastric Lymphoma, Tuberculosis Enteritis, and Cytomegalovirus Enteritis

Bleeding from the small bowel can be challenging to identify by endoscopic or radiographic evaluation. We present the case of a patient with incompletely treated latent tuberculosis and medical history of T-cell lymphoma who developed gastrointestinal bleeding because of concurrent Burkitt lymphoma, tuberculosis enteritis, and cytomegalovirus enteritis. The interplay of these 3 diagnoses is discussed.

Primary isolated asymptomatic gastric tuberculosis of the cardia mimicking gastric stromal tumor: a rare case report and literature review

Background

Primary isolated gastric TB of the cardia presenting as a submucosal tumor is extremely rare.

Case presentation

A 60-year-old female was admitted to our department; endoscopy revealed a smooth protruding lesion in the gastric cardia. The patient was diagnosed with a gastric cardia stromal tumor and the lesion was seen in muscularis propria by endoscopic ultrasonography (EUS). Endoscopic submucosal dissection (ESD) revealed that the lesion was filled with a milky, white liquid and white granulation tissue. Acid-fast specimen staining was negative. Hematoxylin and eosin staining showed patches of caseating necrosis and granulomatous inflammation. Gene sequencing subsequent to polymerase chain reaction (PCR) analysis of the ESD specimen identified Mycobacterium tuberculosis (M. TB) DNA fragments. The patient was put on ATT for 6 months.

Conclusion

Primary isolated gastric TB of the cardia should be suspected in patients without clinical symptoms whose manifestations are similar to those associated with submucosal tumors. TB-PCR may be helpful for further diagnosis.

How can gastro-intestinal tuberculosis diagnosis be improved? A prospective cohort study

Background

Gastrointestinal tuberculosis (TB) is diagnostically challenging; therefore, many cases are treated presumptively. We aimed to describe features and outcomes of gastrointestinal TB, determine whether a clinical algorithm could distinguish TB from non-TB diagnoses, and calculate accuracy of diagnostic tests.

Methods

We conducted a prospective cohort study of hospitalized patients in Kota Kinabalu, Malaysia, with suspected gastrointestinal TB. We recorded clinical and laboratory characteristics and outcomes. Tissue samples were submitted for histology, microscopy, culture and GeneXpert MTB/RIF®. Patients were followed for up to 2 years.

Results

Among 88 patients with suspected gastrointestinal TB, 69 were included in analyses; 52 (75%) had a final diagnosis of gastrointestinal TB; 17 had a non-TB diagnosis. People with TB were younger (42.7 versus 61.5 years, p = 0.01) and more likely to have weight loss (91% versus 64%, p = 0.03). An algorithm using age < 44, weight loss, cough, fever, no vomiting, albumin > 26 g/L, platelets > 340 × 10⁹/L and immunocompromise had good specificity (96.2%) in predicting TB, but very poor sensitivity (16.0%). GeneXpert® performed very well on gastrointestinal biopsies (sensitivity 95.7% versus 35.0% for culture against a gold standard composite case definition of confirmed TB). Most patients (79%) successfully completed treatment and no treatment failure occurred, however adverse events (21%) and mortality (13%) among TB cases were high. We found no evidence that 6 months of treatment was inferior to longer courses.

Conclusions

The prospective design provides important insights for clinicians managing gastrointestinal TB. We recommend wider implementation of high-performing diagnostic tests such as GeneXpert® on extra-pulmonary samples.

A case of gastrointestinal tuberculosis with unusual manifestations of carcinomatosis

Unusual manifestations of TB may include gastrointestinal symptoms such as abdominal pain, constipation, and IVC thrombosis. These symptoms may be misdiagnosed for carcinomatosis. According to our study even with medical advances, the diagnosis of GI TB is still enormously difficult.

Clinical features and outcomes of abdominal tuberculosis in southeastern Korea: 12 years of experience

Background

Abdominal tuberculosis (TB) is an uncommon form of infection with Mycobacterium tuberculosis in Korea. In this study, we aimed to highlight the clinical features, diagnostic methods, and outcomes of abdominal TB over 12 years in Southeastern Korea.

Methods

A total of 139 patients diagnosed as having abdominal TB who received anti-TB medication from January 2005 to June 2016 were reviewed. Among them, 69 patients (49.6%) had luminal TB, 28 (20.1%) had peritoneal TB, 7 (5.0%) had nodal TB, 23 (16.5%) had visceral TB, and 12 (8.6%) had mixed TB.

Results

The most frequent symptoms were abdominal pain (34.5%) and abdominal distension (21.0%). Diagnosis of abdominal TB was confirmed using microbiologic and/or histologic methods in 76 patients (confirmed diagnosis), while the remaining 63 patients were diagnosed based on clinical presentation and radiologic imaging (clinical diagnosis). According to diagnostic method, frequency of clinical diagnosis was highest in patients with luminal (50.7%) or peritoneal (64.3%) TB, while frequency of microscopic diagnosis was highest in patients with visceral TB (68.2%), and frequency of histologic diagnosis was highest in patients with nodal TB (85.2%). Interestingly, most patients, except those with nodal TB, showed a good response to anti-TB agents, with 84.2% showing a complete response. The mortality rate was only 1.4% in the present study.

Conclusions

Most patients responded very well to anti-TB therapy, and surgery was required in only a minority of cases of suspected abdominal TB.

Gastric tuberculosis

Tuberculosis of the stomach is an extremely rare manifestation of Mycobacterium tuberculosis infection and mimics gastric carcinoma in its presentation. Most of our knowledge about this rare disease comes from case reports and there are only a few case series published on this disease and thus the majority of the part remains uncovered. Diagnosis is made commonly only after a major surgery. Endoscopy and guided biopsy are the diagnostic modality of choice. Surgery is indicated in cases which present with complications. Patients respond well to antituberculous therapy. The authors encountered 4 cases of gastric tuberculosis over 5 years. This study summarises the available literature and gives comprehensive update on this rare disease.

Fitz-Hugh-Curtis syndrome associated with tuberculous salpingitis and peritonitis: a case presentation and review of literature

Background

Fitz-Hugh-Curtis syndrome or acute perihepatitis is considered a rare complication of pelvic inflammatory disease, mostly associated with chlamydial or gonococcal salpingitis.

Peritoneal tuberculosis is a rare site of extra-pulmonary infection caused by Mycobacterium tuberculosis. Infection usually occurs after reactivation of latent tuberculous foci in the peritoneum and more seldom after contiguous spread from tuberculous salpingitis.

Case presentation

We describe a case of a 21-year old female of Somalian origin diagnosed with Fitz-Hugh Curtis syndrome associated with tuberculous salpingitis and peritonitis, presenting with new onset ascites.

Acid fast stained smear and polymerase chain reaction for Mycobacterium tuberculosis on ascitic fluid, endocervical culture and tuberculin skin test were all negative. Eventually, the diagnosis was made laparoscopically, showing multiple peritoneal white nodules and perihepatic “violin string” fibrinous strands.

Conclusions

To our knowledge, this is the first case where Fitz-Hugh-Curtis syndrome is associated with both peritoneal and genital tuberculosis and where ascites was the primary clinical finding. Female genital tuberculosis has only rarely been associated with Fitz-Hugh-Curtis syndrome and all cases presented with chronic abdominal pain and/or infertility. Ascites and peritoneal involvement was not present in any case. Moreover, most patients with Fitz-Hugh-Curtis syndrome show no evidence of generalized intra-abdominal infection and only occasionally have concomitant ascites.

Acute presentation of koch's abdomen in children: Our experience

BACKGROUND

To analyse our experience with acute presentations of abdominal tuberculosis (TB) in children for early diagnosis and management.

MATERIALS AND METHODS

From December 2010 to April 2016, available electronic and operation theatre (OT) records of 17 patients with confirmed diagnosis of abdominal TB were analysed retrospectively. Parameters reviewed were age, sex, presentations, diagnostic investigations, surgery/intervention performed, final outcome and follow-up.

RESULTS

Out of 17 patients, 6 (35.3%) were already operated elsewhere. The duration of symptoms ranged from 4 to 58 weeks. Abdominal pain was present in all cases whereas 11 (64.7%) had abdominal distension, 16 (94.1%) fever, 14 (82.3%) ascites, 9 (52.9%) vomiting, 14 (82.3%) weight loss, 6 (35.3%) anorexia and 4 (23.5%) night sweat. All patients needed surgical intervention for definitive diagnosis. Thirteen (76.5%) out of 17 patients managed by staged surgery and primary anastomosis/repair/adhesiolysis were done in 4 (23.5%) patients. The main post-operative problems were wound infections (8; 47.1%), subacute bowel obstruction (6; 35.3%) and chest infections (12; 70.6%). Follow-up period ranged from 3 months to 5.5 years.

CONCLUSION

Abdominal TB should always be considered in differential diagnosis in children presenting with abdominal pain/distension, fever and ascites or with abdominopelvic mass. Recurrent bowel obstruction or anastomotic disruptions also give clues of its diagnosis. A careful history of illness, high index of suspicion, ascitic fluid adenosine deaminase or polymerase chain reaction for Mycobacterium needed for early diagnosis. Prompt minimal surgical interventions, preferred diversion over primary anastomosis, algorithmic vigilant post-operative care and early antitubercular treatment required for success in acute crisis.

Screening for genital tuberculosis in a limited resource country: case report

BACKGROUND

Screening for benign or malignant process of pelvis in young females is a challenge for a physician in a limited resource country. Tuberculosis should be always considered in the differential diagnosis of a pelvic mass in countries with high prevalence of tuberculosis. Negative results of analysis of peritoneal fluid for acid-fast staining, late cultures, and unavailability of new diagnostics methods such as polymerase chain reaction and adenosine deaminase of the aspirated fluid from peritoneal cavity can often result in invasive diagnostic procedures such as laparotomy.

CASE PRESENTATION

We report a case of a 24 year old Albanian unemployed female living in urban place in Kosovo who presented with abdominal pain, loss of appetite, fever, headache, a weight loss, nonproductive cough and menstrual irregularity for three weeks. In this example case, the patient with cystic mass in tubo-ovarial complex and elevated serum cancer antigen 125 levels was diagnosed for genital tuberculosis after performing laparotomy. Caseose mass found in left tubo-ovarial complex and histopathological examination of biopsied tissue were the fastest diagnostic tools for confirming pelvis TB. The Lowenstein-Jensen cultures were positive after six weeks and her family history was positive for tuberculosis.

CONCLUSION

Young females with abdominopelvic mass, ascites, a positive family history for tuberculosis and high serum cancer antigen 125, should always raise suspicion of tuberculosis especially in a limited resource country. A laparoscopy combined with peritoneal biopsy should be performed to confirm the diagnosis as this could lead to a prevention of unnecessary laparotomies.

Hematochezia: An Uncommon Presentation of Colonic Tuberculosis

Abdominal tuberculosis (TB) is an uncommon entity in the United States. Colonic TB is reported in 2-3% of patients with abdominal TB. It is frequently misdiagnosed as Crohn's disease or carcinoma of the colon due to their shared clinical, radiographic, and endoscopic presentations. We present a case of a 72-year-old male with colonic tuberculosis presenting as hematochezia. Our patient presented with shortness of breath and weight loss. Chest X-ray demonstrated ill-defined bilateral parenchymal opacities in the perihilar, mid, and lower lung zones. The patient was diagnosed and treated for community acquired pneumonia, with no improvement. Hematochezia complicated by symptomatic hypotension developed later in the course of admission. Colonoscopy revealed multiple ulcers at the anus and transverse and ascending colon as well as the cecum with stigmata of bleeding. Biopsy of a sigmoid ulcer was consistent with colonic tuberculosis. Antitubercular therapy was initiated, but the patient passed away secondary to multiorgan failure 29 days into admission.

Six-month therapy for abdominal tuberculosis

BACKGROUND

Tuberculosis (TB) of the gastrointestinal tract and any other organ within the abdominal cavity is abdominal TB, and most guidelines recommend the same six-month regimen used for pulmonary TB for people with this diagnosis. However, some physicians are concerned whether a six-month treatment regimen is long enough to prevent relapse of the disease, particularly in people with gastrointestinal TB, which may sometimes cause antituberculous drugs to be poorly absorbed. On the other hand, longer regimens are associated with poor adherence, which could increase relapse, contribute to drug resistance developing, and increase costs to patients and health providers.

OBJECTIVES

To compare six-month versus longer drug regimens to treat people that have abdominal TB.

SEARCH METHODS

We searched the following electronic databases up to 2 September 2016: the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase (accessed via OvidSP), LILACS, INDMED, and the South Asian Database of Controlled Clinical Trials. We searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov for ongoing trials. We also checked article reference lists.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared six-month regimens versus longer regimens that consisted of isoniazid, rifampicin, pyrazinamide, and ethambutol to treat adults and children that had abdominal TB. The primary outcomes were relapse, with a minimum of six-month follow-up after completion of antituberculous treatment (ATT), and clinical cure at the end of ATT.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed the risk of bias in the included trials. For analysis of dichotomous outcomes, we used risk ratios (RR) with 95% confidence intervals (CIs). Where appropriate, we pooled data from the included trials in meta-analyses. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

We included three RCTs, with 328 participants, that compared six-month regimens with nine-month regimens to treat adults with intestinal and peritoneal TB. All trials were conducted in Asia, and excluded people with HIV, those with co-morbidities and those who had received ATT in the previous five years. Antituberculous regimens were based on isoniazid, rifampicin, pyrazinamide, and ethambutol, and these drugs were administered daily or thrice weekly under a directly observed therapy programme. The median duration of follow-up after completion of treatment was between 12 and 39 months.Relapse was uncommon, with two cases among 140 participants treated for six months, and no events among 129 participants treated for nine months. The small number of participants means we do not know whether or not there is a difference in risk of relapse between the two regimens (very low quality evidence). At the end of therapy, there was probably no difference in the proportion of participants that achieved clinical cure between six-month and nine-month regimens (RR 1.02, 95% CI 0.97 to 1.08; 294 participants, 3 trials, moderate quality evidence). For death, there were 2/150 (1.3%) in the six-month group and 4/144 (2.8%) in the nine-month group. All deaths occurred in the first four months of treatment, so was not linked to the duration of treatment in the included trials. Similarly, the number of participants that defaulted from treatment was small in both groups, and there may be no difference between them (RR 0.50, 95% CI 0.10 to 2.59; 294 participants, 3 trials, low quality evidence). Only one trial reported on adherence to treatment, with only one participant allocated to the nine-month regimen presenting poor adherence to treatment. We do not know whether six-month regimens are associated with fewer people experiencing adverse events that lead to treatment interruption (RR 0.53, 95% CI 0.18 to 1.55; 318 participants, 3 trials, very low quality evidence).

AUTHORS' CONCLUSIONS

We found no evidence to suggest that six-month treatment regimens are inadequate for treating people that have intestinal and peritoneal TB, but numbers are small. We did not find any incremental benefits of nine-month regimens regarding relapse at the end of follow-up, or clinical cure at the end of therapy, but our confidence in the relapse estimate is very low because of size of the trials. Further research is required to make confident conclusions regarding the safety of six-month treatment for people with abdominal TB. Larger studies that include HIV-positive people, with long follow-up for detecting relapse with reliability, would help improve our knowledge around this therapeutic question.

Anti-tubercular therapy for intraocular tuberculosis: A systematic review and meta-analysis

Intraocular tuberculosis remains a diagnostic and management conundrum for both ophthalmologists and pulmonologists. We analyze the efficacy and safety of anti-tubercular therapy (ATT) in patients with intraocular tuberculosis and factors associated with favorable outcome. Twenty-eight studies are included in this review, with a total of 1,917 patients. Nonrecurrence of inflammation was observed in pooled estimate of 84% of ATT-treated patients (95% CI 79-89). There was minimal difference in the outcome between patients treated with ATT alone (85% successful outcome; 95% CI 25-100) and those with concomitant systemic corticosteroid (82%; 95% CI 73-90). The use of ATT may be of benefit to patients with suspected intraocular tuberculosis; however, this conclusion is limited by the lack of control group analysis and standardized recruitment and treatment protocols. We propose further prospective studies to better establish the efficacy of ATT and ascertain the factors associated with favorable treatment outcomes.

Clinical Features of Tuberculous Versus Crohn's Anal Fistulas, in Korea

BACKGROUND AND AIMS

In Western countries, tuberculous anal fistula may not be an issue because tuberculosis [TB] is not common, and this is a very rare form of extrapulmonary manifestation of TB. However in TB-endemic countries, careful diagnostic differentiation is required because the clinical features of TB anal fistula and Crohn's disease [CD] anal fistula are similar, with distinguishing features remaining unclear. We aimed to analyse the clinical features of TB versus CD anal fistulas.

METHOD

Among 13872 patients who underwent anal fistula surgery from 2003 to 2014, 87 patients with TB fistulas and 116 patients with CD fistulas were included. Data on the annual incidence of TB and CD, as well as the clinical, pathological, ultrasonographic, colonoscopic and surgical data were analysed.

RESULTS

Compared with CD, the TB group was older [median: 37 vs 22 years] and underlying chronic illness was more common [20.3% vs 2.6%]. In the TB group, 46 patients [59.7%] showed active or inactive pulmonary TB, and acid-fast bacilli and caseating granuloma were found in 56.3% and 62.1%, respectively. During colonoscopy, mucosal lesions were observed more frequently in CD [96.9% vs 16.9%].

CONCLUSIONS

TB anal fistula is clinically very similar to CD anal fistula. In Korea, the incidence of CD anal fistula has recently increased in prevalence, whereas the prevalence of TB anal fistula is decreasing but is still persistent. We recommend that clinicians should prepare for a possibility of TB as well as CD anal fistula in TB-endemic countries including Korea.

Primary gastric tuberculosis presenting as gastric outlet obstruction: a case report and review of the literature

Introduction

Tuberculosis is a major health problem worldwide. Sudan has high burden of tuberculosis (TB) with a prevalence of 209 cases per 100,000 of the population and it is commonly presented with pulmonary disease but involvement of the gastrointestinal tract is not uncommon. Abdominal tuberculosis comprises about 1–3 % of all cases of tuberculosis and about 12% of extrapulmonary tuberculosis. It involves the ileocecal region, but involvement of stomach and duodenum are rare sites. Here we present an unusual case of gastric outlet obstruction due to gastric tuberculosis.

Case presentation

A 54-year-old Sudanese man presented with a non-bile stain persistent projectile vomiting, and epigastric pain for two years associated with marked loss of weight. There is no fever or cough. He was on antacid, physical examination showed BMI 18 and stable vital signs. He was not pale or jaundiced, there was no cervical lymphadenopathy and chest was clear. Abdominal examination was normal apart of positive succussion splash. The results of haematological tests were normal, ESR was 30 mm/hr, hepatitis B, C and HIV were negative. Upper gastrointestinal endoscopy showed that the stomach was full of fluid and food particles and ulcerated mass in the pylorus extended to the proximal part of the duodenum with severe narrowing of the pylorus. The lesion biopsied and the result revealed active inflammatory cells, cryptitis and multiple lymphoid follicles, no malignancy seen. Sonographic test showed hypodense pyloric mass, enlarged para-aortic and mesenteric lymph nodes and mild pelvic ascites. A computed tomography scan of the abdomen and pelvis showed antral hypodense lesions multiple mesenteric lymphadenopathies peritoneal thickening and ascites. Chest X-ray was normal. Intra-operative findings were dilated stomach and pylorus mass with multiple mesenteric lymph nodes, peritoneal and omental seedlings all over with small nodules on the surface of the liver, gastro-jejunostomy was done. Histopathology confirmed the diagnosis of abdominal tuberculosis. Postoperative event was uneventful. Patient received anti-tuberculous.

Conclusions

Here we presented an unusual case of gastric outlet obstruction due to primary gastric tuberculosis, patient underwent surgery to relief his symptoms and received anti-tuberculous.

An Uncommon Case of Chronic Tubercular Appendicitis

Tuberculosis (TB) is a common disease that ranks as the second leading cause of death from an infectious disease worldwide, after the human immunodeficiency virus (HIV). However, primary TB of the appendix is rare and may or may not be associated with specific clinical features. Thus, diagnosis is made only after histopathological examination. It suggests that all surgically removed appendices should be subjected to histopathological examination. This reported case is an uncommon case of chronic tubercular appendicitis.

Perforated Intestinal Tuberculosis in a Non-AIDS Immunocompromised Patient

Patient: Male, 68

Final Diagnosis: Intestinal perforation

Symptoms: Abdominal pain

Medication: —

Clinical Procedure: Exploratory laparotomy and bowel resection

Specialty: Surgery

The features of intestinal tuberculosis by contrast-enhanced ultrasound

PURPOSE

To examine the imaging characteristics of intestinal tuberculosis by conventional ultrasound and contrast-enhanced ultrasound (CEUS).

MATERIALS AND METHODS

Characteristics of the conventional and contrast-enhanced ultrasound images of 31 patients with intestinal tuberculosis confirmed by surgery were retrospectively examined. CEUS was used to evaluate the pattern of the bowel wall enhancement.

RESULTS

Of the 31 patients with intestinal tuberculosis (IT), 27 had infections located at the ileocecum and 4 at the hepatic flexure of the colon. Conventional ultrasound showed that the mean thickening of bowel wall was 1.38 cm, ranging from 0.56 to 2.20 cm. Two types of bowel wall enhancement patterns on CEUS were observed. For 13 % of the patients (4/31), the serosa was quickly enhanced first, then the mucosa was enhanced gradually (type 1 enhancement). In the remaining 27 patients, the whole bowel wall was quickly diffusely enhanced (type 2 enhancement). In addition, the enhancement of the thickened bowel wall was homogeneous in 9 patients, while the others showed inhomogeneous enhancement.

CONCLUSION

CEUS found detailed patterns of bowel wall enhancement of intestinal tuberculosis and had the potential to provide useful information for the diagnosis of suspected patients.