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Primary duodenal and jejunal tuberculosis: Report of two cases
M Naga, H Okasha, H Goubran, et al.
Primary duodenal and jejunal tuberculosis: report of two cases Mazen Ibrahim Naga, MD, Hussein Hassan Okasha, MD, Hadi Alfons Goubran, MD, Samia Hassan Okasha, MD, Ehab Bahaa Monir, MD Current affiliation: Kasr El-Aini Hospitals, Cairo University, Cairo, Egypt. Reprint requests: Mazen Ibrahim Naga, MD, Professor of Internal Medicine and Gastroenterology, Cairo University, 15 El-Saha St. Bab El-Louk, Cairo, Egypt. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/54/122957 doi:10.1067/mge.2002.122957 752
GASTROINTESTINAL ENDOSCOPY
Brief Reports
Tuberculosis ranked among the leading causes of death in 1900. With the advent of chemotherapy, vaccination, and the eradication of animals carrying the bovine bacillus, the incidence of the disease and mortality have declined significantly.1 GI tuberculosis is unusual, but when it occurs it involves the ileocecal area in 85% to 90% of cases.2 Duodenal tuberculosis is an extremely rare malady,3 accounting for 0.2% to 0.6% of all sites of involvement in autopsy series.4 Primary duodenal tuberculosis occurs in underdeveloped areas of the world and can afflict immunosuppressed patients. This is a report of two cases of duodenal tuberculosis and a description of the clinical features and VOLUME 55, NO. 6, 2002
Brief Reports
M Naga, H Okasha, H Goubran, et al.
Figure 1. Endoscopic view of small (5 × 5 mm) sessile polyp in duodenal bulb.
management with emphasis on the roles of upper endoscopy, biopsy, and surgery. Presenting manifestations included intermittent fever, weight loss, vague abdominal pain, and vomiting. In neither case was there clinical or radiologic evidence of pulmonary tuberculosis. The diagnosis was confirmed in both cases by histopathologic evaluation of biopsy specimens. Although primary duodenal tuberculosis is rarely encountered, the development of newer diagnostic methods, such as the polymerase chain reaction for mycobacterial DNA with tissue specimens, will improve the diagnostic yield. CASE REPORTS Case 1 An 18-year-old Egyptian man presented with a 4month history of vague abdominal pain unrelated to meals. There was no history of vomiting but he had experienced fever, more marked at night, with occasional chills, and a weight loss of 4 kg. Examination revealed a mildly elevated temperature (37.8°C) and evidence of malnutrition. An erythrocyte sedimentation rate, white and red blood cell counts, and routine laboratory tests were all within normal limits and a chest radiograph revealed no abnormalities. Upper GI barium contrast radiography disclosed a small sessile polyp in the duodenal bulb together with ulceration in the descending duodenum. Upper endoscopy demonstrated a small (5 × 5 mm) sessile polyp in the bulb (Fig. 1) and multiple, transverse circular ulcers ranging from 2 to 3 cm in length with undermined edges and necrotic bases throughout the length of the descending duodenum (Fig. 2). Histopathologic evaluation of biopsy specimens revealed only nonspecific inflammatory changes without tubercle bacilli or evidence of caseation. Because a definite diagnosis could not be made, a 2week course of antisecretory agents was prescribed. However, there was no improvement in the patient’s symptoms. Two weeks later intestinal obstruction develVOLUME 55, NO. 6, 2002
Figure 2. Endoscopic view of transverse circular ulcer with undermined edges and necrotic base in second part of duodenum. oped, necessitating exploratory laparotomy. At surgery, there was involvement of the second part of the duodenum and jejunum, and a minimal amount of ascitic fluid was detected. The involved segments were resected with reanastomosis and drains were inserted in the hepatorenal and pelvic spaces. Moderate enlargement of the celiac group of lymph nodes with caseation was noted. Multiple biopsy specimens were taken, which demonstrated caseation with acid fast bacilli. During the second postoperative day the patient had a gradual rise of temperature, reaching up to 40.5°C, accompanied by rigors. There was output of large volumes of purulent fluid through the drains. Abdominal US revealed large volumes of turbid intraperitoneal fluid. The findings were presumed to be due to an anastomotic leak. On the third postoperative day hypotension developed along with severe chest pain and central cyanosis. The patient died 1 hour later; a massive pulmonary embolism was presumed to be the most likely diagnosis. Case 2 A 45-year-old man presented with a 2-year history of intermittent fever, malaise, and marked weight loss. He was admitted to his local hospital for evaluation. This included standard laboratory tests, serologic tests for various endemic infections, and tests for autoimmune diseases, all of which showed negative findings except for a hemoglobin of 10.5 gm/dL (normal: 13.5-17.5 gm/dL) and an erythrocyte sedimentation rate of 70 mm during the first hour (normal for males: 0-15 mm/hour). Chest radiograph and abdominal US were normal. No definite diagnosis was made and the patient was discharged. Over the next year he had occasional fever and malaise and then developed vague abdominal pain, mainly in the right upper quadrant and unrelated to meals, along with recurrent attacks of vomiting of clear fluid that occurred several hours after meals. Clinical examination was normal except for temperature (38.0°C) and evidence of malnutriGASTROINTESTINAL ENDOSCOPY
753
M Naga, H Okasha, H Goubran, et al.
Brief Reports
Figure 3. Endoscopic view of multiple circular ulcers in second part of duodenum.
Figure 4. Endoscopic view of circular ulcer in second part of duodenum.
tion. Upper GI barium contrast radiography was unremarkable apart from evidence of antral spasm and an irregular, circumferential narrowing of the second part of the duodenum. The mucosa, however, appeared intact. Upper endoscopy disclosed the presence of antral gastritis and multiple circular ulcers in the second part of the duodenum (Figs. 3 and 4). Multiple biopsy specimens were obtained and histopathologic evaluation of the specimens revealed caseating granuloma with acid fast bacilli. Colonoscopy showed normal findings to the terminal ileum. Antituberculous treatment was initiated with improvement in the clinical manifestations of the disease as well as the endoscopic findings.
only after a 1-year period of vague, nonspecific symptoms. Tuberculin skin testing was not performed in either of our patients because BCG vaccination is compulsory in Egypt. There was no evidence of concomitant pulmonary affection in either case, but this may occur in up to 50% of patients with intra-abdominal tuberculosis.8 Similar endoscopic findings were noted in both patients. In particular, there were multiple, transverse, circumferential ulcers in the second part of the duodenum with yellowish necrotic floor and undermined edges. The presence of such ulcers, especially in the presence of constitutional symptoms and vague abdominal pain, should raise the remote possibility of abdominal tuberculosis.
DISCUSSION Tuberculosis involving the ileocecal region is still relatively common in Egypt. Involvement of the stomach, duodenum, and jejunum, however, is extremely rare. This has been attributed in part to the rapid transit of gastric contents through the duodenum, the acid environment produced by the stomach, and the paucity of lymphoid tissue in these proximal segments of the upper GI tract.5 Even before the advent of chemotherapy, duodenal tuberculosis was rare.6 Symptoms are vague and nonspecific with no definite clinical pattern in most reports of primary duodenal tuberculosis.1 Pain appears to be the most common symptom.1 Weight loss, hematemesis, and/or melena have all been described.7 In our first patient, abdominal pain was the presenting symptom whereas in the second patient pain developed
754
GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Gleason T, Prinz R, Kirsch E, Jablokow V, Greenlee HB. Tuberculosis of the duodenum. Am J Gastroenterol 1979;72: 36-40. 2. Abrams JS, Holden WD. Tuberculosis of gastrointestinal tract. Arch Surg 1964;89:282-93. 3. Tishler JM. Duodenal tuberculosis. Radiology 1979;130:593-5. 4. Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum [clinical review]. Am J Gastroenterol 1993;88:989-99. 5. Tandon P, Pastakia B. Duodenal tuberculosis as seen by duodenoscopy Am J Gastroenterol 1976;66:483-6. 6. Mathews WB, Delaney PA, Dragsted LR. Duodenal tuberculosis. Arch Surg 1932;25:1055-66. 7. Mandal BK, Schofield PF. Abdominal tuberculosis in Britain. Practitioner 1976;216:683-9. 8. Bhansali SK. Abdominal tuberculosis: experience with 300 cases. Am J Gastroenterol 1977;67:324-37.
VOLUME 55, NO. 6, 2002
Primary duodenal and jejunal tuberculosis: report of two cases Mazen Ibrahim Naga, MD, Hussein Hassan Okasha, MD, Hadi Alfons Goubran, MD, Samia Hassan Okasha, MD, Ehab Bahaa Monir, MD Current affiliation: Kasr El-Aini Hospitals, Cairo University, Cairo, Egypt. Reprint requests: Mazen Ibrahim Naga, MD, Professor of Internal Medicine and Gastroenterology, Cairo University, 15 El-Saha St. Bab El-Louk, Cairo, Egypt. Copyright © 2002 by the American Society for Gastrointestinal Endoscopy 0016-5107/2002/$35.00 + 0 37/54/122957 doi:10.1067/mge.2002.122957 752
GASTROINTESTINAL ENDOSCOPY
Brief Reports
Tuberculosis ranked among the leading causes of death in 1900. With the advent of chemotherapy, vaccination, and the eradication of animals carrying the bovine bacillus, the incidence of the disease and mortality have declined significantly.1 GI tuberculosis is unusual, but when it occurs it involves the ileocecal area in 85% to 90% of cases.2 Duodenal tuberculosis is an extremely rare malady,3 accounting for 0.2% to 0.6% of all sites of involvement in autopsy series.4 Primary duodenal tuberculosis occurs in underdeveloped areas of the world and can afflict immunosuppressed patients. This is a report of two cases of duodenal tuberculosis and a description of the clinical features and VOLUME 55, NO. 6, 2002
Brief Reports
M Naga, H Okasha, H Goubran, et al.
Figure 1. Endoscopic view of small (5 × 5 mm) sessile polyp in duodenal bulb.
management with emphasis on the roles of upper endoscopy, biopsy, and surgery. Presenting manifestations included intermittent fever, weight loss, vague abdominal pain, and vomiting. In neither case was there clinical or radiologic evidence of pulmonary tuberculosis. The diagnosis was confirmed in both cases by histopathologic evaluation of biopsy specimens. Although primary duodenal tuberculosis is rarely encountered, the development of newer diagnostic methods, such as the polymerase chain reaction for mycobacterial DNA with tissue specimens, will improve the diagnostic yield. CASE REPORTS Case 1 An 18-year-old Egyptian man presented with a 4month history of vague abdominal pain unrelated to meals. There was no history of vomiting but he had experienced fever, more marked at night, with occasional chills, and a weight loss of 4 kg. Examination revealed a mildly elevated temperature (37.8°C) and evidence of malnutrition. An erythrocyte sedimentation rate, white and red blood cell counts, and routine laboratory tests were all within normal limits and a chest radiograph revealed no abnormalities. Upper GI barium contrast radiography disclosed a small sessile polyp in the duodenal bulb together with ulceration in the descending duodenum. Upper endoscopy demonstrated a small (5 × 5 mm) sessile polyp in the bulb (Fig. 1) and multiple, transverse circular ulcers ranging from 2 to 3 cm in length with undermined edges and necrotic bases throughout the length of the descending duodenum (Fig. 2). Histopathologic evaluation of biopsy specimens revealed only nonspecific inflammatory changes without tubercle bacilli or evidence of caseation. Because a definite diagnosis could not be made, a 2week course of antisecretory agents was prescribed. However, there was no improvement in the patient’s symptoms. Two weeks later intestinal obstruction develVOLUME 55, NO. 6, 2002
Figure 2. Endoscopic view of transverse circular ulcer with undermined edges and necrotic base in second part of duodenum. oped, necessitating exploratory laparotomy. At surgery, there was involvement of the second part of the duodenum and jejunum, and a minimal amount of ascitic fluid was detected. The involved segments were resected with reanastomosis and drains were inserted in the hepatorenal and pelvic spaces. Moderate enlargement of the celiac group of lymph nodes with caseation was noted. Multiple biopsy specimens were taken, which demonstrated caseation with acid fast bacilli. During the second postoperative day the patient had a gradual rise of temperature, reaching up to 40.5°C, accompanied by rigors. There was output of large volumes of purulent fluid through the drains. Abdominal US revealed large volumes of turbid intraperitoneal fluid. The findings were presumed to be due to an anastomotic leak. On the third postoperative day hypotension developed along with severe chest pain and central cyanosis. The patient died 1 hour later; a massive pulmonary embolism was presumed to be the most likely diagnosis. Case 2 A 45-year-old man presented with a 2-year history of intermittent fever, malaise, and marked weight loss. He was admitted to his local hospital for evaluation. This included standard laboratory tests, serologic tests for various endemic infections, and tests for autoimmune diseases, all of which showed negative findings except for a hemoglobin of 10.5 gm/dL (normal: 13.5-17.5 gm/dL) and an erythrocyte sedimentation rate of 70 mm during the first hour (normal for males: 0-15 mm/hour). Chest radiograph and abdominal US were normal. No definite diagnosis was made and the patient was discharged. Over the next year he had occasional fever and malaise and then developed vague abdominal pain, mainly in the right upper quadrant and unrelated to meals, along with recurrent attacks of vomiting of clear fluid that occurred several hours after meals. Clinical examination was normal except for temperature (38.0°C) and evidence of malnutriGASTROINTESTINAL ENDOSCOPY
753
M Naga, H Okasha, H Goubran, et al.
Brief Reports
Figure 3. Endoscopic view of multiple circular ulcers in second part of duodenum.
Figure 4. Endoscopic view of circular ulcer in second part of duodenum.
tion. Upper GI barium contrast radiography was unremarkable apart from evidence of antral spasm and an irregular, circumferential narrowing of the second part of the duodenum. The mucosa, however, appeared intact. Upper endoscopy disclosed the presence of antral gastritis and multiple circular ulcers in the second part of the duodenum (Figs. 3 and 4). Multiple biopsy specimens were obtained and histopathologic evaluation of the specimens revealed caseating granuloma with acid fast bacilli. Colonoscopy showed normal findings to the terminal ileum. Antituberculous treatment was initiated with improvement in the clinical manifestations of the disease as well as the endoscopic findings.
only after a 1-year period of vague, nonspecific symptoms. Tuberculin skin testing was not performed in either of our patients because BCG vaccination is compulsory in Egypt. There was no evidence of concomitant pulmonary affection in either case, but this may occur in up to 50% of patients with intra-abdominal tuberculosis.8 Similar endoscopic findings were noted in both patients. In particular, there were multiple, transverse, circumferential ulcers in the second part of the duodenum with yellowish necrotic floor and undermined edges. The presence of such ulcers, especially in the presence of constitutional symptoms and vague abdominal pain, should raise the remote possibility of abdominal tuberculosis.
DISCUSSION Tuberculosis involving the ileocecal region is still relatively common in Egypt. Involvement of the stomach, duodenum, and jejunum, however, is extremely rare. This has been attributed in part to the rapid transit of gastric contents through the duodenum, the acid environment produced by the stomach, and the paucity of lymphoid tissue in these proximal segments of the upper GI tract.5 Even before the advent of chemotherapy, duodenal tuberculosis was rare.6 Symptoms are vague and nonspecific with no definite clinical pattern in most reports of primary duodenal tuberculosis.1 Pain appears to be the most common symptom.1 Weight loss, hematemesis, and/or melena have all been described.7 In our first patient, abdominal pain was the presenting symptom whereas in the second patient pain developed
754
GASTROINTESTINAL ENDOSCOPY
REFERENCES 1. Gleason T, Prinz R, Kirsch E, Jablokow V, Greenlee HB. Tuberculosis of the duodenum. Am J Gastroenterol 1979;72: 36-40. 2. Abrams JS, Holden WD. Tuberculosis of gastrointestinal tract. Arch Surg 1964;89:282-93. 3. Tishler JM. Duodenal tuberculosis. Radiology 1979;130:593-5. 4. Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum [clinical review]. Am J Gastroenterol 1993;88:989-99. 5. Tandon P, Pastakia B. Duodenal tuberculosis as seen by duodenoscopy Am J Gastroenterol 1976;66:483-6. 6. Mathews WB, Delaney PA, Dragsted LR. Duodenal tuberculosis. Arch Surg 1932;25:1055-66. 7. Mandal BK, Schofield PF. Abdominal tuberculosis in Britain. Practitioner 1976;216:683-9. 8. Bhansali SK. Abdominal tuberculosis: experience with 300 cases. Am J Gastroenterol 1977;67:324-37.
VOLUME 55, NO. 6, 2002