- Email: [email protected]
Massive melaena: a rare indication for surgery in intestinal tuberculosis
lubezcle62 (1982) 133-135
004r-38"]9i81 00410133 $0200
( LongmanGroupLtd.
MASSIVEMELAENA: A RARE INDICATION FOR SURGERY IN INTESTINAL TUBERCULOSIS N. S. Vimla, S, K. Khanna', S. L. Broor, B. K. Sharma and S. R. Bhusnutmath Departments of Surgery, Gastroenterology, Internal Medtc/rle and Pathology, Po.stgradu~te Institute of Medice! Educ~tien and Research, Chandigarh. 160012. India.
Summary Two patients who had episodes of massive melaena caused by ulcerative tuberc,-lous lesions of the ileocaecum have been described. The rarity of this type of presentation is emphasised, R~sum~ L'article d6crit le cas de deux malades qui presentaient des 6pisodes de melaena tr~s important dO ) des I~sions tuberculeuses ulc6r~es de J'ileocaecum. La rarete de ce type d'aspect clinique est soulign6e. Resumen Se describe el caso de dos enfermos qua presentaron episodios de melena masiva causados por lesiones tuberculosas ulcerativas del segmento ileo-cecal. Se bace h incapi6 en la rata frecuencia de esta forma clinica. Introduction In India intestinal tuberculosis still remains a common abdominal condition requiring surgical intervention. Most often it presents as acute or chronic intestinal obstruction and rarely as perforation or peritonitis. Massive haemorrhage from intestinal tuberculosis is extremely rare, and in the last 16 years in this hospital only two such patients have required surgery. Their case histories form the basis of this report.
Case Reports Case 1
t- 1"7-year-old male was admitted to hospital in April, 1978 with sudden massive melaena associated with mild central abdominal pain. He had no other abdominal or constitutional symptoms, Similar episodes had occurred in August, 1976 and June, 1977 when all investigations including stool examination, sigmoidoscopy and barium studies had been n o n contributory. The bleeding on previous occasions had stopped spontaneously and the intervening periods were complete{y symptom free. Physical examination at the time of admission was essentially normal except for anaemia which required multiple blood transfusions to raise the haemoglobin level from 3 G/dl to 9 G/dl. The blood coagulation profile and chest X-ray were normal. A barium enema showed a filli.g defect in the review of tbe caecum and ascending colon and the possibility of a neoplasm ~Correspondenceto" Or S. K. Khann&AssociateProfesso~in Surgery,PoslgraduBle~nstituteo~Medica~EducBlionand Research,ChBndigarh,160012, India.
134
Vimla and u~hel,-,
CASEA~ING LY~4PH NODES
APPENDIX
7 THICKgNEO AND HYPERAEMIC AREAS
F:g,:,,:i
( ~5h,:1 ,'~I:[l(:dl
!; ,;rT~dtOr,~!Q'lV~-!:P~(iF-gS
lno~JrlJz~oJmvc,lv(~rl~4:nlandth~zexteqlolreseotJonareshOWZl.
Or or/ arteriovenous malformation was considered A superior mesenteric angiogram was (tone the following day and was noJ nlel. Cofonosco~y showed multiple ulcers in the caecum with angry grsnulations at the base aF~dparochial haenlonhages all around. Tile caecum distended well end no tumour was seen. It was concluded that an intramuraJ haematoma had given the appearance ol a Nling defect oil the bamml fi h~is A second barium enema was normal Without a definite diagnosis the patient was submitted to laparotomy and the operative findings were as shown in Fig I With a diagnosis of caecal tuberculosis e right hemieolectomy was performed Angiography of the resected sr~ecimen did not not show any abnormal vascular pattern to account for the bleeding. Examination of the resected specimen sho4,ed hypertrophic mucosal folds in tile ileocaecum end two ulcers in the caecum 2 2 mm in size; 10 out of 11 mesenteric nodes were caseous The appendix was congested. Histology showed classical features of caseation, epithelioid and Langerhans giant cell granulomas and fibrosis in the gut wall (ulcerated area), lymph nodes and appendix There was ne evidence of angiodysplasia. The patient was started on anti-tuberculosis treatment. He had an uneventful postoperative ~ecoveryand has been followed up fo.~more than 18 months. He remains asymptomatic. Case 2
A 16 year-old male was adnfilled to hospital in January, 1979 with massive rectal bleeding. Ne gave a history of similar episodes in Decernber and April, 1978. On bolt, occasions he was hospitalised elsewhere, required rnultipfe blood transfusions, routine investigation was un[emarkable and the bleeding stopped spontaneously, in tile intervening periods the patient had been symptom free Physical examination was unremarkab/e arid routine investigations, includ)ng coagulation profile and chest x-ray, were normal He continued to bleed and because of hie deteriorating general condition an emergency laparotorny was perforeleg
Metaena in intestinal tuberculosis
135
The terminal 5 cm. of ileum were congested and thickened. Two sllndar Jesior]s were present in [he ileum 7.5 cm. and 45 cm, from tile Jteo-ca~cal jullction. An enterotomy perfomled over tbu most proximal lesion revealed ulcerated and cungested mucosa. s mesentebe nodes were enlarged and caseous, A right hemicolectomy was pelf on ned Gross exan]ination of the reseated specimen revealed n}ucosal lMckenmg at the iieo-caecal Junction and there were two small areas in the ploximal part ot the ileurn showing oodulal thickening and ulceration of the mucosa. Casaation was seen in all 12 regionat nodes. Histology revealed ileal and iteo-caecal tuberculosis with tuberculous rnesenteric lynrpi)adenitis Anti-tuberculosis cher'notbelapy was stapled and the post-operative recovery was uneventfu! H e has been followed up for more than 1 0 months and rema ins asympto mat ic Discussien
Tuberculosis of various organs Js still e common problem m India and unusual modes of presentation can present a diagnostic challenge. Review of the literature shows that episodes of massive haemorrbage flora tuberculous ulcers of the intestines is extremely fare and in most large series reported from India this problem has not been encountered. Anand [1] (50 patients}, Anand and Pathak [2] (100 patients), Prakash [3] (300 patients), Bhansali [4] (310 patients) and Mukherjee [5] (557 patients) have not reported any cases of massive i]aemorrhage among patients with intestinal tuberculosis. According te Bhansali [4], gross haemorrhage from an intestinal lesion is rare because of associated endarterids There are a few references in the literature to massive bleeding from intestinal tuberculosis Massive haematemesis t~as been reported from one case each of oesophageal and pyloroduodenal tuberculosis [6, 7]. Three cases of rectal bleeding in intestinal tuberculosis have been reported [8] but the details regarding the site and type of lesion are not given. One instance of profuse haemorrhage from iejuna] tuberculosis has been recorded [9]. ]n this Institute, over the last 16 years, more than 300 patients with proven qestrointestinal tuberculosis have had surgical operations. These are the only two patients however, where surgery was undertaken for massive haemorrhage, The two cases had several common features Both were young adult males who presented with recurrent episodes of melaena with inter vening symptom-free periods; they had no constitutional symptoms and no demonstrable pulmonary lesions. In both patients the diagnosis was not clear before surgew. References
1 Anand. S, S. (1956). Hyperlrophicile~caecal tub~ in India Annals of tile Royal Co~logo of Surgeons .~/ England, 19, 205, 2 Anand,S. S. 8- Pathak,]. C. (1961I. Surgicaltreatmentof abdominaltuberculosiswith specialreference1oileocaecal tuberculosis. Joumaf of the lndian Medical Association, 37,423, 3 Prakash, A.(19"78).lntestinaltuberculosis, eiahteenyearreview, lndtanJouma/ofSurgezy, 40,55. 4 ~hansaI~S.K.(19~)~.Thecha~lenge~fabd~mim~tuber~ul~sin~1~ases.h7rEan~ume~Sdtgery~4~ 5 Mukherjee, PeRajor, R.(1979) AbdominalTuberculosis. lnflianJourn~tofTube~culosis, 26(2),52.
6 Roche,J. Y., Desfernmes,F., Coffin,J, C,, Ca~(ard,P, &' Pali,I, J C. (1977) Oesophaqealtuberculosis, revealedby massivehaem~rrt~a~e..Ch/tu~(l/e, 103.177 7 ~ar~ava~J~S~eSekh~n~GS~(197~)~PyI~r~du~dena~tubercul~sis~dianJ~uma~fSurgezy~5'5~4~ 8 SchuIze,K, Warner, H. A. E~Mulray. D (1977) }r/testinaltuberculosis,e• at a Canadianleachinginstitutiol~. Amen'/canJouma/ of Medtcme, 63, ?35 9 Clay/,F. 8" Pekka,P,(1975~,Intestinal and peritorlealtubercu[osls. Disea.~esof the Co~on andRectum, 18, 685.
004r-38"]9i81 00410133 $0200
( LongmanGroupLtd.
MASSIVEMELAENA: A RARE INDICATION FOR SURGERY IN INTESTINAL TUBERCULOSIS N. S. Vimla, S, K. Khanna', S. L. Broor, B. K. Sharma and S. R. Bhusnutmath Departments of Surgery, Gastroenterology, Internal Medtc/rle and Pathology, Po.stgradu~te Institute of Medice! Educ~tien and Research, Chandigarh. 160012. India.
Summary Two patients who had episodes of massive melaena caused by ulcerative tuberc,-lous lesions of the ileocaecum have been described. The rarity of this type of presentation is emphasised, R~sum~ L'article d6crit le cas de deux malades qui presentaient des 6pisodes de melaena tr~s important dO ) des I~sions tuberculeuses ulc6r~es de J'ileocaecum. La rarete de ce type d'aspect clinique est soulign6e. Resumen Se describe el caso de dos enfermos qua presentaron episodios de melena masiva causados por lesiones tuberculosas ulcerativas del segmento ileo-cecal. Se bace h incapi6 en la rata frecuencia de esta forma clinica. Introduction In India intestinal tuberculosis still remains a common abdominal condition requiring surgical intervention. Most often it presents as acute or chronic intestinal obstruction and rarely as perforation or peritonitis. Massive haemorrhage from intestinal tuberculosis is extremely rare, and in the last 16 years in this hospital only two such patients have required surgery. Their case histories form the basis of this report.
Case Reports Case 1
t- 1"7-year-old male was admitted to hospital in April, 1978 with sudden massive melaena associated with mild central abdominal pain. He had no other abdominal or constitutional symptoms, Similar episodes had occurred in August, 1976 and June, 1977 when all investigations including stool examination, sigmoidoscopy and barium studies had been n o n contributory. The bleeding on previous occasions had stopped spontaneously and the intervening periods were complete{y symptom free. Physical examination at the time of admission was essentially normal except for anaemia which required multiple blood transfusions to raise the haemoglobin level from 3 G/dl to 9 G/dl. The blood coagulation profile and chest X-ray were normal. A barium enema showed a filli.g defect in the review of tbe caecum and ascending colon and the possibility of a neoplasm ~Correspondenceto" Or S. K. Khann&AssociateProfesso~in Surgery,PoslgraduBle~nstituteo~Medica~EducBlionand Research,ChBndigarh,160012, India.
134
Vimla and u~hel,-,
CASEA~ING LY~4PH NODES
APPENDIX
7 THICKgNEO AND HYPERAEMIC AREAS
F:g,:,,:i
( ~5h,:1 ,'~I:[l(:dl
!; ,;rT~dtOr,~!Q'lV~-!:P~(iF-gS
lno~JrlJz~oJmvc,lv(~rl~4:nlandth~zexteqlolreseotJonareshOWZl.
Or or/ arteriovenous malformation was considered A superior mesenteric angiogram was (tone the following day and was noJ nlel. Cofonosco~y showed multiple ulcers in the caecum with angry grsnulations at the base aF~dparochial haenlonhages all around. Tile caecum distended well end no tumour was seen. It was concluded that an intramuraJ haematoma had given the appearance ol a Nling defect oil the bamml fi h~is A second barium enema was normal Without a definite diagnosis the patient was submitted to laparotomy and the operative findings were as shown in Fig I With a diagnosis of caecal tuberculosis e right hemieolectomy was performed Angiography of the resected sr~ecimen did not not show any abnormal vascular pattern to account for the bleeding. Examination of the resected specimen sho4,ed hypertrophic mucosal folds in tile ileocaecum end two ulcers in the caecum 2 2 mm in size; 10 out of 11 mesenteric nodes were caseous The appendix was congested. Histology showed classical features of caseation, epithelioid and Langerhans giant cell granulomas and fibrosis in the gut wall (ulcerated area), lymph nodes and appendix There was ne evidence of angiodysplasia. The patient was started on anti-tuberculosis treatment. He had an uneventful postoperative ~ecoveryand has been followed up fo.~more than 18 months. He remains asymptomatic. Case 2
A 16 year-old male was adnfilled to hospital in January, 1979 with massive rectal bleeding. Ne gave a history of similar episodes in Decernber and April, 1978. On bolt, occasions he was hospitalised elsewhere, required rnultipfe blood transfusions, routine investigation was un[emarkable and the bleeding stopped spontaneously, in tile intervening periods the patient had been symptom free Physical examination was unremarkab/e arid routine investigations, includ)ng coagulation profile and chest x-ray, were normal He continued to bleed and because of hie deteriorating general condition an emergency laparotorny was perforeleg
Metaena in intestinal tuberculosis
135
The terminal 5 cm. of ileum were congested and thickened. Two sllndar Jesior]s were present in [he ileum 7.5 cm. and 45 cm, from tile Jteo-ca~cal jullction. An enterotomy perfomled over tbu most proximal lesion revealed ulcerated and cungested mucosa. s mesentebe nodes were enlarged and caseous, A right hemicolectomy was pelf on ned Gross exan]ination of the reseated specimen revealed n}ucosal lMckenmg at the iieo-caecal Junction and there were two small areas in the ploximal part ot the ileurn showing oodulal thickening and ulceration of the mucosa. Casaation was seen in all 12 regionat nodes. Histology revealed ileal and iteo-caecal tuberculosis with tuberculous rnesenteric lynrpi)adenitis Anti-tuberculosis cher'notbelapy was stapled and the post-operative recovery was uneventfu! H e has been followed up for more than 1 0 months and rema ins asympto mat ic Discussien
Tuberculosis of various organs Js still e common problem m India and unusual modes of presentation can present a diagnostic challenge. Review of the literature shows that episodes of massive haemorrbage flora tuberculous ulcers of the intestines is extremely fare and in most large series reported from India this problem has not been encountered. Anand [1] (50 patients}, Anand and Pathak [2] (100 patients), Prakash [3] (300 patients), Bhansali [4] (310 patients) and Mukherjee [5] (557 patients) have not reported any cases of massive i]aemorrhage among patients with intestinal tuberculosis. According te Bhansali [4], gross haemorrhage from an intestinal lesion is rare because of associated endarterids There are a few references in the literature to massive bleeding from intestinal tuberculosis Massive haematemesis t~as been reported from one case each of oesophageal and pyloroduodenal tuberculosis [6, 7]. Three cases of rectal bleeding in intestinal tuberculosis have been reported [8] but the details regarding the site and type of lesion are not given. One instance of profuse haemorrhage from iejuna] tuberculosis has been recorded [9]. ]n this Institute, over the last 16 years, more than 300 patients with proven qestrointestinal tuberculosis have had surgical operations. These are the only two patients however, where surgery was undertaken for massive haemorrhage, The two cases had several common features Both were young adult males who presented with recurrent episodes of melaena with inter vening symptom-free periods; they had no constitutional symptoms and no demonstrable pulmonary lesions. In both patients the diagnosis was not clear before surgew. References
1 Anand. S, S. (1956). Hyperlrophicile~caecal tub~ in India Annals of tile Royal Co~logo of Surgeons .~/ England, 19, 205, 2 Anand,S. S. 8- Pathak,]. C. (1961I. Surgicaltreatmentof abdominaltuberculosiswith specialreference1oileocaecal tuberculosis. Joumaf of the lndian Medical Association, 37,423, 3 Prakash, A.(19"78).lntestinaltuberculosis, eiahteenyearreview, lndtanJouma/ofSurgezy, 40,55. 4 ~hansaI~S.K.(19~)~.Thecha~lenge~fabd~mim~tuber~ul~sin~1~ases.h7rEan~ume~Sdtgery~4~ 5 Mukherjee, PeRajor, R.(1979) AbdominalTuberculosis. lnflianJourn~tofTube~culosis, 26(2),52.
6 Roche,J. Y., Desfernmes,F., Coffin,J, C,, Ca~(ard,P, &' Pali,I, J C. (1977) Oesophaqealtuberculosis, revealedby massivehaem~rrt~a~e..Ch/tu~(l/e, 103.177 7 ~ar~ava~J~S~eSekh~n~GS~(197~)~PyI~r~du~dena~tubercul~sis~dianJ~uma~fSurgezy~5'5~4~ 8 SchuIze,K, Warner, H. A. E~Mulray. D (1977) }r/testinaltuberculosis,e• at a Canadianleachinginstitutiol~. Amen'/canJouma/ of Medtcme, 63, ?35 9 Clay/,F. 8" Pekka,P,(1975~,Intestinal and peritorlealtubercu[osls. Disea.~esof the Co~on andRectum, 18, 685.