ORIGINAL ARTICLE

Protean Manifestations of GastrointestinalTuberculosis

Y Ismail, FRCP, A Muhamad, M. Surg.

Kedah Medical Centre, Alor Setar

Introduction

The abdomen is a common site of extrapulmonarytuberculosis. It has a wide spectrum of non-specific symptoms and signs. From January 1998to December 2001, 193 cases of pulmonarytuberculosis (PTB) and 30 cases of confirmedextrapulmonary tuberculosis were diagnosed inKedah Medical Centre. The patients presentedwith appendicitis (3 cases), perianal fistula (2cases) and one case each with ascites, andabdominal mass. In addition, a number of cases ofhighly probable but unconfirmed cases(pulmonary and extrapulmonary) were alsorecorded. We present 11 cases (confirmed andsuggestive) of intestinal tuberculosis to highlighttheir protean manifestations.

This article was accepted: 26 January 2003Corresponding Author: Y Ismail, Kedah Medical Centre, Alor Setar

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Case Presentations1: Perianal FistulaCase 1: A 70-year old man had perianal abscess ofthree-week duration and developed fistula-in-anoafter drainage. Histopathology of the fistula tractshowed active on chronic granulomatousinflammation with Langhans giant cells consistentwith tuberculosis. Special stain for acid-fast bacilli(AFB) was negative. Preoperative chest x-rayshowed infiltrates in the right upper lobessuggestive of PTB. On questioning, he ad~itted tohave had 'chest infection' about 40 years ago andsince then had a chronic cough. Sputum direct-smear was positive for APB.

Case 2: A 21-year-old male student had recurrentperianal sinus. He first presented in June 1992 with

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perianal abscess. 'Since then he had undergonethree fistulectomies. Histopathology showedchronic inflammatory granulation withmicroabscess. There was no evidence of Crohn'sdisease or tuberculosis. He did not respond toantibiotics (including metronidazole). He also hadepisodes of cough with chest pain butinvestigations for tuberculosis including chest x-rays, Mantoux test, ESR, and sputum for AFB andTB culture were negative. In September 1994,three sputum specimen and the anal dischargewere all positive for Mycobacterium tuberculosisby polymerase chain reaction (PCR) method. Theperianal fistula and chest symptoms improvedafter treatment with anti-TB.

2: AppendicitisCase 3: A 25-year-old male lorry driver presentedwith a chronic discharging sinus from the woundof an appendicectomy done in another hospitaleleven months earlier. His grandmother hadpulmonary tuberculosis and his father hadundiagnosed haemoptysis. The chest x-ray wasnormal. Histopathology of the fistula tract showedtuberculous granuloma. Pus direct smear wasnegative for AFB but TB culture grewMycobacterium tuberculosis.

Case 4: A 29-year man had an appendicectomydone in another hospital. Hisotopathology of theappendix showed granuloma and the wound wasnon-healing. Chest x-ray was then done whichshowed bilateral upper lobe infiltrationssuggestive of PTB. Bronchial washing direct-smearwas positive for AFE. The wound healed after anti-TB treatment

3: AscitesCase 5: A 48-year-old lady was admitted withascites and weight loss. Laparoscopy foundnodular lesions on the surface of the bowel,omentum and peritoneum. Histology showednecrotising chronic granulomatous inflammatorylesions suggestive of tuberculosis. APB stain wasnegative. Patient responded well to anti-tuberculous therapy.

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4: "Ulcerative Colitis"Case 6: A 34-year-old lady presented to anotherhospital in June 1999 with a history of diarrheawith blood and mucus for about one year. It wasassociated with weight loss of about 10kg.Hemoglobin was 9.0 g/dl, TWBC: 10.0 x109/L andPlatelets: 550 x109/L. Colonoscopy revealedpancolitis and the histology was suggestive ofulcerative colitis. She was treated withsuphasalazine 1000 mg QID and metronidazole.After four months, she still had diarrhea and lost afurther lOkg in weight. Prednisolone was addedwithout effect and she was planned for surgery.

She then presented to our hospital in March 2000.She still had chronic diarrhea with mucus andblood. She also complained of bilateralsymmetrical joint pain of two weeks duration. Onexamination, she was thin (weight 43kg). Therewas a vague mass in the left iliac fossa. Bothankles were swollen and tender. Hemoglobin: 8.3g/dl; TWBC: 8.5 x109/L; Platelets: 548 x109/L;Erythrocyte sedimentation rate (ESR); 65 mm/hr.Barium enema showed a dilated colon with loss ofhaustrations suggestive of ulcerative colitis. Sherefused colonoscopy. Treatment was continuedwith metronidazole, prednisolone andsulphasalazine.

One month later (April 2000) she was admittedseverely unwell with severe diarrhea and skinlesions typical of erythema nodosum were notedover both legs. Hb: 9.5 g/dl; TWBC: 8.6 x109/L;

IPlatelets: 574 x109/L; ~SR: 92 mm/hr. She wasinitially treated with intravenous hydrocortisone,metronidazole, cefuroxime and anti-diarrhoeal butshe did not improve. On the third day, empiricalanti-TB therapy was started and the antibioticsstopped. She responded very well. After oneweek, the diarrhea stopped and erythemanodosum disappeared. Five months aftertreatment (September 2000), her weight rose to 47kg and the haemoglobin: 10.3 g/dl; TWBC: 7.5x109/L; Platelets: 499 x109/L ESR: 30 mm/hr. Sherefused barium studies. She remained well anddelivered a pair of healthy twins in November2001.

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Case 7: A 57-year old man presented with multipleperianal sinuses associated with anorexia andweight loss. He was diabetic and had a history ofrecurrent admissions for breathlessness andpyrexia of unknown origin for the past six years.He was treated with bronchodilators, steroids, andantibiotics. Chest x-ray showed cardiomegaly withconsolidation and a mild effusion in the rightlower zone. Colonoscopy showed oedematous,thickening of rectal mucosa and contact bleedingfrom anus up to 35cm, suggestive of ulcerativecolitis. Hisotopathology showed non-specificcolitis and proctitis. The chest and bowelsymptoms improved after anti-TB treatment.

5: Recurrent abdominal pain with intestinal'growth'Case 8: A 15-year old student was seen in June1999 with recurrent abdominal pain for 5 years. In1996, he was admitted to a hospital and told tohave 'gastric'. The pain was usually in theepigastrium but often radiated to the wholeabdomen. The patient often missed schoolbecause the pain occurred a few times a monthand lasted 1-2 days. There was associated fever,anorexia and weight loss. On examination, thepatient was thin (weight: 33kg). There was a'doughy feeling' on palpation of the abdomen.Barium meal follow through showed a segment ofdilatation in the lower small intestine suggestive ofgrowth or TB. The patient refused furtherinvestigations. He was put on empirical anti-TBand responded well. After two weeks there was nomore abdominal pain and his weight rose to 37kgafter two months.

Case 9: A 17-year-old male student presented withepigastric pain of seven years duration. He had anoesophagogastroduodenoscopy done in generalhospital seven years ago and told to be normal.He also had anorexia and weight loss but no feveror cough. On examination, the patient was paleand thin (weight: 48kg). There was a 'doughyfeeling' on palpation of the abdomen. Rectalexamination revealed a mass at the tip of thefinger, not seen on proctoscopy. On questioning,he admitted to have recurrent blood and mucus in

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Protean Manifestations of Gastrointestinal Tuberculosis

the stools. Barium enema showed irregularity ofthe lower rectum compatible with carcinoma orgranuloma. The patient refused colonoscopy. Hb:7.0 g/dl;TWBC: 4.7 xl09/L; Platelets: 462 xl09/LESR: 13 mm/hr. He was put on empirical anti-TBtreatment and responded well. After two monthshe had no further complaint, the mass disappearedand weight rose to 53kg.

6: Recurrent anemiaCase 10: A 19-year~01d female student was firstdiagnosed to have iron-deficiency anemia inMarch 1995 (Hb: 7.2 g/dl; TWBC: 7.9 xl09/L;Platelets: 565 xl09/L, Low serum iron, normalserum B12 and folate). She improved withhematinics. In June 1996, she presented withrecurrent anemia (Hb: 7.5g/dl TWBC: 6.0 xl0~/LPlatelets: 683 xl09/L ESR: 20 mm/hr). Onquestioning, she had a history of recurrent bloodand mucus in stools. Rectal examination revealeda mass. Colonoscopy revealed an ulcerativegrowth at 4cm from the anal verge.Histopathology showed inflammed, benignulcerated hyperplastic rectal polyps. She wascontinued on hematinics. She was referred againin August 2000 with similar problems. There was a'doughy feeling' on abdominal palpation andrectal examination showed similar findings.Barium enema showed persistent spasticnarrowing of the rectum. She was put on empiricalanti-TB and has been well since.

7: Gastric growthCase 11: An 81-year-old man had 'chronic gastriculcer' first diagnosed by gastroscopy/biopsy in1988. In 1997 he had a total gastrectomy (Biltroth I)for a 'large gastric ulcer'. Gross specimen show_uan ulcerativ,e growth in the greater curvatureencroaching the antrum and suspicious of a g:lf't,':::carcinoma. Histopathology revealed active antralulcer without malignancy. No family history wasrecorded and no chest x-ray was done.

In February 1999 he was admitted with left basalpneumonia. The TWBC was normal but no ESR orsputum studies were done. In August 1999 he was

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referred by a general practitioner on account ofchronic productive cough and prolonged feverassociated with anorexia and weight loss. Onquestioning, his wife died of PTB and onedaughter-in-law also had PTB. He was thin(weight: 43 kg). His weight was recorded to be 56kg in May 1998. Chest x-ray showed scattered softopacities in the right upper zone and both lowerzones suggestive of PTB. Sputum direct-smear wasnegative for APB. Bronchoscopy showed severeinflammation with mucoid secretions in allbronchi. Bronchial washing direct-smear waspositive for AFB confirming diagnosis of PTE.

DiscussionGastrointestinal tuberculosis is not uncommon andmay affect any part of the system. The signs andsymptoms are non-specific and may mimic otherdiagnoses. The eleven cases illustrates thatgastrointestinal TB may mimic appendicitis,perianal fistula, gastric ulcers, rectal ulcers andmay present as recurrent anemia.

The diagnosis of gastrointestinal tuberculosis canbe challenging and sometimes only made on post-mortem!. The chest x-ray may show associatedactive pulmonary tuberculosis in fewer than 50%of cases of intestinal tuberculosis2. Often, thediagnosis is made by endoscopy or at laparotomy.This is not possible in many of our patients who

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often refuse invasive procedures due to fear orfinancial reason. Furthermore, even histologicalappearances may be very non-specific3

Tuberculosis anal sepsis is common but is oftennot recognised and neglected4 . Not uncommonly,patients were diagnosed as Crohn's diseasebecause of negative staining on histology,mycobacterial culture and polymerase chainreaction5-7 Extensive colonic tuberculosis isknown to mimic ulcerative colitisS-9 Tuberculosispresenting as gastric ulcer or peri-rectal mass hasbeen reportedlO-ll but tuberculosis pesenting asgastric tumour is extremely rare!2.

Although ileocaecal tuberculosis is the commonestpresentation of abdominal tuberculosis, isolatedappendicular involvement is rare13 . However, inareas where tuberculosis is endemic, it ismandotary to send all appendicectomy specimensfor histopathology examination14

The recent upsurge in tuberculosis worldwide callsfor an increased vigilance by physicians especiallyfor extrapulmonary tuberculosis. Because thesigns and symptoms of intestinal TB are non-specific, and the histology and microbiology areoften negative, a high index of suspicion must bemaintained to ensure a timely diagnosis. Mostauthors recommend empirical therapy if intestinaltuberculosis is suspected, despite negativehistology, smear, and culture results!5-17,

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3. Taheni S, Crump J, Samarasinghe D, Weir W. TB orNot TB? Trans Royal Soc Trop Med Hygiene 1997;91: 241-4.

4. Kraemer M, Gill SS, Seow-Choen F. Tuberculousanal sepsis: report of clinical features in 20 cases.Dis Colon Rectum 2000; 43: 1589-91.

5. Arnold C, Moradpur D, Blum HE. Tuberculosiscolitis mimicking Crohn's disease. Am JGastroenterol 1988; 93: 2294-6.

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10. Chetri K, Prasad KK, Jain M, Choudhuri G. Gastrictuberculosis presenting as non-healing ulcer: a casereport. Trop Gastroentenrol 2000; 21: 180-1.

11. Koniaris LG, Seibel J1. Tuberculosis presenting as aperirectal mass; report of a case. Dis Colon rectum2000; 43: 1604-5.

12. Lin as, Wu SS, Yeh KT et al. Isolated gastrictuberculosis of the cardia. J astroenterol Hepatol1999; 14: 258-61.

13. Vaidya M, Sodhi J. Gastrointestinal tuberculosis: astudy of 102 cases including 55hemicolectomies. Clin Radiol 1978; 29: 189-95.

14. Gupta SC, Gupta AK, Keswani NK et al. Pathologyof tropical appendicitis. J Clin Pathol 1989; 42: 1169-72.

15. Horvath KD, Whelan RL. Intestinal tuberculosis:return of an old disease. AM J Gastroenterol 1998;93: 692-6.

16. Das HS, Rathi P, Sawant P et al. Colonictuberculosis: colonoscopic appearance and clinico-pathological analysis. J Assoc Physicians India 2000;48: 708-10.

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