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Severe chest pain from an indwelling Bravo pH probe
CASE REPORTS
Severe chest pain from an indwelling Bravo pH probe Stuart L. Triester, MD, Jonathan A. Leighton, MD, Adriane I. Budavari, MD, Michael D. Crowell, PhD, David E. Fleischer, MD
Continuous ambulatory esophageal pH monitoring can be helpful in the management of patients with refractory or atypical GERD. Until recently, the only available method for pH monitoring was placement of a transnasal catheter that contained a pH electrode 5 cm proximal to the manometrically identified lower esophageal sphincter. The catheter is left in place for 24 hours, and data are collected to quantify esophageal acid exposure. Although this method is reliable, it may be associated with significant patient discomfort and social embarrassment, leading many patients to modify their daily activity during the study. In turn, this may decrease the validity and reliability of the procedure.1 The Bravo ‘‘catheter-free’’ pH monitoring system (Medtronic, Minneapolis, Minn.) was approved in September 2000 by the U.S. Food and Drug Administration as an alternative to conventional pH monitoring. The Bravo system uses a pH-sensitive telemetry capsule that is attached to the esophageal mucosa 6 cm proximal to the squamocolumnar junction, either transorally, transnasally, or at the time of endoscopy. The telemetry system eliminates the need for an indwelling nasal catheter, thereby improving patient comfort and tolerance of pH monitoring. The capsule measures pH for up to 48 hours and transmits data to a small external receiver worn by the patient. The capsule spontaneously detaches from the mucosa 3 to 5 days after placement and is passed in the stool. Preliminary data suggest at least equivalent efficacy and improved tolerance with the Bravo system compared with traditional pH monitoring.2-7 However, review of published studies and abstracts of studies reveals that a limited number of patients may experience chest discomfort related to the Bravo capsule, but little detail are available that specifically concern this observation.2,3 This report presents what we believe to be the first full description of chest pain of esophageal origin severe enough to require hospitalization in a patient undergoing Bravo pH monitoring.
A 61-year-old woman with a history of GERD and a laparoscopic Nissen fundoplication presented with recurrent reflux symptoms. A Nissen fundoplication performed 5.5 years earlier had successfully controlled the GERD symptoms until 18 months before presentation,
when heartburn, regurgitation, and sore throat recurred along with intermittent dysphagia. The patient had experienced side effects when taking omeprazole, lansoprazole, and ranitidine, and, thus, was not taking any antisecretory medication when the symptoms returned. The initial evaluation included EGD with placement of a Bravo probe. Endoscopy revealed normal-appearing esophageal mucosa and changes consistent with the previous fundoplication. The probe was placed without difficulty 6 cm proximal to the gastroesophageal junction; placement was confirmed endoscopically. Immediately after the procedure, the patient noted a foreign-body sensation and mild dysphagia for both solid food and liquids. Within 24 hours, intermittent sharp substernal chest pain developed that radiated through to the back. The pain steadily increased in frequency and severity until it became constant, unbearable, and associated with mild dyspnea. The patient had noted infrequent episodes of similar discomfort over the preceding 10 years, which she attributed to reflux, but the discomfort had never been severe. She was referred to the emergency department for further evaluation. Examination was unremarkable, with no reproducible chest pain. Mild diffuse abdominal tenderness was noted, which the patient described as longstanding. CT of the chest demonstrated no evidence of pneumomediastinum or aortic dissection. The Bravo capsule was in place in the distal esophagus. An electrocardiogram was unremarkable, and a standard chest radiograph revealed no evidence of acute cardiopulmonary disease. Laboratory tests, including a complete blood count, biochemical tests of renal and hepatic function, and cardiac enzymes, were unremarkable. The patient was hospitalized for observation in the telemetry unit; myocardial infarction was ruled out. A dedicated CT for pulmonary embolism also was negative. The symptoms persisted and were poorly responsive to analgesic medications. EGD was performed for evaluation and possible removal of the Bravo probe. The latter was found to be in position, with no surrounding mucosal abnormality (Fig. 1A). The remainder of the examination was unchanged from that of 5 days earlier. The probe was removed from the esophageal mucosa by applying gentle pressure with the tip of the endoscope and then was pushed into the stomach. Initially, there was a small amount of bleeding from the attachment site, which gradually
www.mosby.com/gie
Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 317
CASE REPORT
Case Reports
Figure 1. A, Endoscopic view of Bravo probe attached to normalappearing esophageal mucosa. B, Endoscopic view after probe detachment, showing tissue nodularity and mild oozing of blood.
resolved during direct visualization. Closer inspection revealed nodularity that was presumed to be granulation tissue at the site of attachment (Fig. 1B). After removal of the Bravo device, the patient quickly noted resolution of dysphagia and a steady decline in the chest pain. She was discharged the following day. The chest pain was completely resolved by 72 hours and had not recurred at 16 days’ follow-up. The patient declined to undergo EGD to document healing.
study of its use, Pandolfino et al.2 used the Bravo system to monitor pH in 44 controls and 41 patients with GERD. They described two patients with ‘‘discomfort’’ significant enough to require endoscopic removal of the probe. In addition, 4 patients had moderate chest pain that resolved spontaneously. Patients in the study of Pandolfino et al.2 described significantly more esophageal discomfort than patients who underwent traditional transnasal pH monitoring. Our patient presented with chest pain severe enough to require a 2-day hospitalization that was temporally related to placement of the Bravo probe. She had rare episodes of similar discomfort during the preceding 10 years, but these lasted only a few minutes and were much less severe. A thorough evaluation for other causes of the chest pain was negative. The pain did not improve until the Bravo probe was removed endoscopically, whereupon all symptoms resolved within 3 days. The mechanism of chest pain was likely mucosal irritation caused by the capsule, perhaps similar to the pain that occurs after esophageal stent placement. The significance of the apparent granulation tissue at the site of capsule detachment is uncertain but may indicate deeper penetration than expected of the capsule into the esophageal wall. The capsule was removed by exerting gentle pressure with the tip of the endoscope, but we were prepared to use a snare or a net if initial attempts to dislodge it were unsuccessful. Pandolfino et al.2 grasped the Bravo capsules with a biopsy forceps and pushed them off the mucosa.2 The safest and most efficacious method of endoscopic removal of a Bravo capsule has not been determined. In conclusion, chest pain, at times severe, can be a side effect of the Bravo pH monitoring system. In most cases, the chest discomfort is mild and resolves once the Bravo probe detaches spontaneously from the esophageal mucosa. In a smaller number of patients, however, chest pain may be severe and may require urgent removal of the capsule. Endoscopic removal appears safe and well tolerated, but experience is limited. Physicians should be aware of this potential complication so that early capsule removal can be performed when necessary.
REFERENCES
Initial studies have demonstrated that patient tolerance of the Bravo pH monitoring system is significantly better compared with conventional transnasal pH monitoring.2-4 However, few data are available regarding significant side effects related to the Bravo system. In the only published
1. Fass R, Hell R, Sampliner RE, Pulliam G, Graver E, Hartz V, et al. Effect of ambulatory 24-hour esophageal pH monitoring on reflux-provoking activities. Dig Dis Sci 1999;44:2263-9. 2. Pandolfino JE, Richter JE, Ours T, Guardino JM, Chapman J, Kahrilas PJ. Ambulatory esophageal pH monitoring using a wireless system. Am J Gastroenterol 2003;98:740-9. 3. Ours T, Richter J. Bravo pH vs ambulatory 24 hour catheter pH monitoring: a prospective assessment of patient satisfaction, discomfort and impairment of daily activities [abstract]. Gastroenterology 2002;122(Suppl 1):W1174. 4. Antoniazzi L, Hua HT, Streets CG, Balaji NS, Gattolin A, Theodorou D, et al. Comparison of normal values obtained with the BRAVO
318 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 2 : 2005
www.mosby.com/gie
DISCUSSION
Case Reports catheter-free system, and conventional esophageal pH monitoring [abstract]. Gastroenterology 2002;122(Suppl 1):A338. 5. Guardino JM, Ours TM, Richter JE. Utilizing the BRAVO esophageal pH monitoring system to compare pH profiles in GERD patients and healthy adult volunteers [abstract]. Gastroenterology 2002;122(Suppl 1):A338. 6. Pandolfino JE, Kahrilas PJ, Cisler J, Chapman J, Ours T, Richter JE. Esophageal pH monitoring using a catheter-free pH-system (Bravo pH system) [abstract]. Gastroenterology 2002;122(Suppl 1):A19. 7. Streets CG, DeMeester TR, Peters JH, Bremner CG, Crookes PF, Mason RJ, et al. Clinical evaluation of the Bravo probe: a catheter-free ambulatory esophageal pH monitoring system [abstract]. Gastroenterology 2001;120:177.
Current affiliations: Division of Gastroenterology and Hepatology, Division of Hospital Internal Medicine, Mayo Clinic in Scottsdale, Scottsdale, Arizona. Reprint requests: Jonathan A. Leighton, MD, Division of Gastroenterology and Hepatology, Mayo Clinic in Scottsdale, 13400 East Shea Blvd., Scottsdale, AZ 85259. Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/2005/$30.00 + 0 PII: S0016-5107(04)02592-1
Gastric tuberculosis presenting as a submucosal tumor Se Hwan Kim, MD, Jee Hyun Park, MD, Kyung Hee Kang, MD, Jong Hyub Lee, MD, Chang Keun Park, MD, Chang Min Cho, MD, Won Young Tak, MD, Young Oh Kweon, MD, Sung Kook Kim, MD, Yong Hwan Choi, MD, Wan Sik Yoo, MD, Han I. K. Bae, MD
Gastric tuberculosis is a rare entity that usually occurs in association with pulmonary tuberculosis or tuberculosis elsewhere in the GI tract. Diagnosis is extremely difficult, because gastric tuberculosis usually is unsuspected. Most commonly, gastric tuberculosis presents as an ulcerating lesion on the lesser curvature of the antrum. Thus, the clinical picture is similar to that of peptic ulcer disease. Gastric tuberculosis was first described by Barhausen in 1824.1 Only a few cases have been reported in Korea since Suh et al.,2 in 1971, described a case of gastric tuberculosis presenting as a malignant gastric ulcer. Presentation of GI tuberculosis as a submucosal tumor is especially rare. This report describes a case of gastric tuberculosis in which the lesion was thought to be a submucosal tumor.
CASE REPORT A 21-year-old woman was referred for evaluation of abdominal discomfort of 1 month’s duration. She previously was healthy, and there was no history of pulmonary tuberculosis. The family history and social history were unremarkable. The patient was hemodynamically stable. On examination, auscultation of the lungs was normal. There were no palpable lymph nodes, and no tenderness was elicited of palpation of the abdomen. Laboratory test data included the following: Hb, 11.4 g/dL (14.0w17.5 g/dL); white blood cell count, 4730/mm3 (4,400w11,000/mm3) (segmented neutrophils 56.8%, lymphocytes 32.3%); erythrocyte sedimentation rate, 37 mm/h (0w30 mm/h); and CA125, 143 U/mL (0-30 U/mL). Biochemical tests of liver function and urinalysis were within normal ranges. A test for fecal occult blood, staining of sputum for acid fast bacilli, and a sputum culture were negative. www.mosby.com/gie
Chest radiography at admission demonstrated a right pleural adhesion and mild fibrosis in the right upper lobe, suggesting prior pulmonary tuberculosis. Transabdominal US and abdominal CT obtained at the referring medical center revealed a hypoechoic mass and a relatively welldefined soft-tissue mass, respectively, on the anterior wall of the antrum (Fig. 1). Endoscopy and EUS disclosed a submucosal mass arising from the muscularis propria on the anterior antrum (Fig. 2). A GI stromal tumor was suspected, and laparoscopic wedge resection was performed. At the operation, the mass was adherent to the greater omentum and the peritoneum had a fine granular appearance, resembling the appearance of a malignant neoplasm. Gross inspection of the surgical specimen revealed a well-defined submucosal mass filled with yellowish exudate and an intact overlying mucosa. Histopathologic examination revealed chronic granulomatous inflammation with caseation necrosis, findings consistent with tuberculosis (Fig. 3). Polymerase chain reaction for Mycobacterium tuberculosis with the resected tissue was positive. After surgery, the patient was treated with a standard 3-drug, orally administered antituberculous regimen (isoniazid, rifampin, ethambutol). She was discharged without complication, and no side effect or complication of the treatment was present at 3 months’ follow-up.
DISCUSSION The incidence of tuberculosis has continuously decreased until 1985 in western countries. More recently, there has been an upsurge of GI tuberculosis in the United State as a result of the influx of immigrants, the AIDS epidemic, and the use of immunosuppressant drugs. The Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 319
Severe chest pain from an indwelling Bravo pH probe Stuart L. Triester, MD, Jonathan A. Leighton, MD, Adriane I. Budavari, MD, Michael D. Crowell, PhD, David E. Fleischer, MD
Continuous ambulatory esophageal pH monitoring can be helpful in the management of patients with refractory or atypical GERD. Until recently, the only available method for pH monitoring was placement of a transnasal catheter that contained a pH electrode 5 cm proximal to the manometrically identified lower esophageal sphincter. The catheter is left in place for 24 hours, and data are collected to quantify esophageal acid exposure. Although this method is reliable, it may be associated with significant patient discomfort and social embarrassment, leading many patients to modify their daily activity during the study. In turn, this may decrease the validity and reliability of the procedure.1 The Bravo ‘‘catheter-free’’ pH monitoring system (Medtronic, Minneapolis, Minn.) was approved in September 2000 by the U.S. Food and Drug Administration as an alternative to conventional pH monitoring. The Bravo system uses a pH-sensitive telemetry capsule that is attached to the esophageal mucosa 6 cm proximal to the squamocolumnar junction, either transorally, transnasally, or at the time of endoscopy. The telemetry system eliminates the need for an indwelling nasal catheter, thereby improving patient comfort and tolerance of pH monitoring. The capsule measures pH for up to 48 hours and transmits data to a small external receiver worn by the patient. The capsule spontaneously detaches from the mucosa 3 to 5 days after placement and is passed in the stool. Preliminary data suggest at least equivalent efficacy and improved tolerance with the Bravo system compared with traditional pH monitoring.2-7 However, review of published studies and abstracts of studies reveals that a limited number of patients may experience chest discomfort related to the Bravo capsule, but little detail are available that specifically concern this observation.2,3 This report presents what we believe to be the first full description of chest pain of esophageal origin severe enough to require hospitalization in a patient undergoing Bravo pH monitoring.
A 61-year-old woman with a history of GERD and a laparoscopic Nissen fundoplication presented with recurrent reflux symptoms. A Nissen fundoplication performed 5.5 years earlier had successfully controlled the GERD symptoms until 18 months before presentation,
when heartburn, regurgitation, and sore throat recurred along with intermittent dysphagia. The patient had experienced side effects when taking omeprazole, lansoprazole, and ranitidine, and, thus, was not taking any antisecretory medication when the symptoms returned. The initial evaluation included EGD with placement of a Bravo probe. Endoscopy revealed normal-appearing esophageal mucosa and changes consistent with the previous fundoplication. The probe was placed without difficulty 6 cm proximal to the gastroesophageal junction; placement was confirmed endoscopically. Immediately after the procedure, the patient noted a foreign-body sensation and mild dysphagia for both solid food and liquids. Within 24 hours, intermittent sharp substernal chest pain developed that radiated through to the back. The pain steadily increased in frequency and severity until it became constant, unbearable, and associated with mild dyspnea. The patient had noted infrequent episodes of similar discomfort over the preceding 10 years, which she attributed to reflux, but the discomfort had never been severe. She was referred to the emergency department for further evaluation. Examination was unremarkable, with no reproducible chest pain. Mild diffuse abdominal tenderness was noted, which the patient described as longstanding. CT of the chest demonstrated no evidence of pneumomediastinum or aortic dissection. The Bravo capsule was in place in the distal esophagus. An electrocardiogram was unremarkable, and a standard chest radiograph revealed no evidence of acute cardiopulmonary disease. Laboratory tests, including a complete blood count, biochemical tests of renal and hepatic function, and cardiac enzymes, were unremarkable. The patient was hospitalized for observation in the telemetry unit; myocardial infarction was ruled out. A dedicated CT for pulmonary embolism also was negative. The symptoms persisted and were poorly responsive to analgesic medications. EGD was performed for evaluation and possible removal of the Bravo probe. The latter was found to be in position, with no surrounding mucosal abnormality (Fig. 1A). The remainder of the examination was unchanged from that of 5 days earlier. The probe was removed from the esophageal mucosa by applying gentle pressure with the tip of the endoscope and then was pushed into the stomach. Initially, there was a small amount of bleeding from the attachment site, which gradually
www.mosby.com/gie
Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 317
CASE REPORT
Case Reports
Figure 1. A, Endoscopic view of Bravo probe attached to normalappearing esophageal mucosa. B, Endoscopic view after probe detachment, showing tissue nodularity and mild oozing of blood.
resolved during direct visualization. Closer inspection revealed nodularity that was presumed to be granulation tissue at the site of attachment (Fig. 1B). After removal of the Bravo device, the patient quickly noted resolution of dysphagia and a steady decline in the chest pain. She was discharged the following day. The chest pain was completely resolved by 72 hours and had not recurred at 16 days’ follow-up. The patient declined to undergo EGD to document healing.
study of its use, Pandolfino et al.2 used the Bravo system to monitor pH in 44 controls and 41 patients with GERD. They described two patients with ‘‘discomfort’’ significant enough to require endoscopic removal of the probe. In addition, 4 patients had moderate chest pain that resolved spontaneously. Patients in the study of Pandolfino et al.2 described significantly more esophageal discomfort than patients who underwent traditional transnasal pH monitoring. Our patient presented with chest pain severe enough to require a 2-day hospitalization that was temporally related to placement of the Bravo probe. She had rare episodes of similar discomfort during the preceding 10 years, but these lasted only a few minutes and were much less severe. A thorough evaluation for other causes of the chest pain was negative. The pain did not improve until the Bravo probe was removed endoscopically, whereupon all symptoms resolved within 3 days. The mechanism of chest pain was likely mucosal irritation caused by the capsule, perhaps similar to the pain that occurs after esophageal stent placement. The significance of the apparent granulation tissue at the site of capsule detachment is uncertain but may indicate deeper penetration than expected of the capsule into the esophageal wall. The capsule was removed by exerting gentle pressure with the tip of the endoscope, but we were prepared to use a snare or a net if initial attempts to dislodge it were unsuccessful. Pandolfino et al.2 grasped the Bravo capsules with a biopsy forceps and pushed them off the mucosa.2 The safest and most efficacious method of endoscopic removal of a Bravo capsule has not been determined. In conclusion, chest pain, at times severe, can be a side effect of the Bravo pH monitoring system. In most cases, the chest discomfort is mild and resolves once the Bravo probe detaches spontaneously from the esophageal mucosa. In a smaller number of patients, however, chest pain may be severe and may require urgent removal of the capsule. Endoscopic removal appears safe and well tolerated, but experience is limited. Physicians should be aware of this potential complication so that early capsule removal can be performed when necessary.
REFERENCES
Initial studies have demonstrated that patient tolerance of the Bravo pH monitoring system is significantly better compared with conventional transnasal pH monitoring.2-4 However, few data are available regarding significant side effects related to the Bravo system. In the only published
1. Fass R, Hell R, Sampliner RE, Pulliam G, Graver E, Hartz V, et al. Effect of ambulatory 24-hour esophageal pH monitoring on reflux-provoking activities. Dig Dis Sci 1999;44:2263-9. 2. Pandolfino JE, Richter JE, Ours T, Guardino JM, Chapman J, Kahrilas PJ. Ambulatory esophageal pH monitoring using a wireless system. Am J Gastroenterol 2003;98:740-9. 3. Ours T, Richter J. Bravo pH vs ambulatory 24 hour catheter pH monitoring: a prospective assessment of patient satisfaction, discomfort and impairment of daily activities [abstract]. Gastroenterology 2002;122(Suppl 1):W1174. 4. Antoniazzi L, Hua HT, Streets CG, Balaji NS, Gattolin A, Theodorou D, et al. Comparison of normal values obtained with the BRAVO
318 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 2 : 2005
www.mosby.com/gie
DISCUSSION
Case Reports catheter-free system, and conventional esophageal pH monitoring [abstract]. Gastroenterology 2002;122(Suppl 1):A338. 5. Guardino JM, Ours TM, Richter JE. Utilizing the BRAVO esophageal pH monitoring system to compare pH profiles in GERD patients and healthy adult volunteers [abstract]. Gastroenterology 2002;122(Suppl 1):A338. 6. Pandolfino JE, Kahrilas PJ, Cisler J, Chapman J, Ours T, Richter JE. Esophageal pH monitoring using a catheter-free pH-system (Bravo pH system) [abstract]. Gastroenterology 2002;122(Suppl 1):A19. 7. Streets CG, DeMeester TR, Peters JH, Bremner CG, Crookes PF, Mason RJ, et al. Clinical evaluation of the Bravo probe: a catheter-free ambulatory esophageal pH monitoring system [abstract]. Gastroenterology 2001;120:177.
Current affiliations: Division of Gastroenterology and Hepatology, Division of Hospital Internal Medicine, Mayo Clinic in Scottsdale, Scottsdale, Arizona. Reprint requests: Jonathan A. Leighton, MD, Division of Gastroenterology and Hepatology, Mayo Clinic in Scottsdale, 13400 East Shea Blvd., Scottsdale, AZ 85259. Copyright ª 2005 by the American Society for Gastrointestinal Endoscopy 0016-5107/2005/$30.00 + 0 PII: S0016-5107(04)02592-1
Gastric tuberculosis presenting as a submucosal tumor Se Hwan Kim, MD, Jee Hyun Park, MD, Kyung Hee Kang, MD, Jong Hyub Lee, MD, Chang Keun Park, MD, Chang Min Cho, MD, Won Young Tak, MD, Young Oh Kweon, MD, Sung Kook Kim, MD, Yong Hwan Choi, MD, Wan Sik Yoo, MD, Han I. K. Bae, MD
Gastric tuberculosis is a rare entity that usually occurs in association with pulmonary tuberculosis or tuberculosis elsewhere in the GI tract. Diagnosis is extremely difficult, because gastric tuberculosis usually is unsuspected. Most commonly, gastric tuberculosis presents as an ulcerating lesion on the lesser curvature of the antrum. Thus, the clinical picture is similar to that of peptic ulcer disease. Gastric tuberculosis was first described by Barhausen in 1824.1 Only a few cases have been reported in Korea since Suh et al.,2 in 1971, described a case of gastric tuberculosis presenting as a malignant gastric ulcer. Presentation of GI tuberculosis as a submucosal tumor is especially rare. This report describes a case of gastric tuberculosis in which the lesion was thought to be a submucosal tumor.
CASE REPORT A 21-year-old woman was referred for evaluation of abdominal discomfort of 1 month’s duration. She previously was healthy, and there was no history of pulmonary tuberculosis. The family history and social history were unremarkable. The patient was hemodynamically stable. On examination, auscultation of the lungs was normal. There were no palpable lymph nodes, and no tenderness was elicited of palpation of the abdomen. Laboratory test data included the following: Hb, 11.4 g/dL (14.0w17.5 g/dL); white blood cell count, 4730/mm3 (4,400w11,000/mm3) (segmented neutrophils 56.8%, lymphocytes 32.3%); erythrocyte sedimentation rate, 37 mm/h (0w30 mm/h); and CA125, 143 U/mL (0-30 U/mL). Biochemical tests of liver function and urinalysis were within normal ranges. A test for fecal occult blood, staining of sputum for acid fast bacilli, and a sputum culture were negative. www.mosby.com/gie
Chest radiography at admission demonstrated a right pleural adhesion and mild fibrosis in the right upper lobe, suggesting prior pulmonary tuberculosis. Transabdominal US and abdominal CT obtained at the referring medical center revealed a hypoechoic mass and a relatively welldefined soft-tissue mass, respectively, on the anterior wall of the antrum (Fig. 1). Endoscopy and EUS disclosed a submucosal mass arising from the muscularis propria on the anterior antrum (Fig. 2). A GI stromal tumor was suspected, and laparoscopic wedge resection was performed. At the operation, the mass was adherent to the greater omentum and the peritoneum had a fine granular appearance, resembling the appearance of a malignant neoplasm. Gross inspection of the surgical specimen revealed a well-defined submucosal mass filled with yellowish exudate and an intact overlying mucosa. Histopathologic examination revealed chronic granulomatous inflammation with caseation necrosis, findings consistent with tuberculosis (Fig. 3). Polymerase chain reaction for Mycobacterium tuberculosis with the resected tissue was positive. After surgery, the patient was treated with a standard 3-drug, orally administered antituberculous regimen (isoniazid, rifampin, ethambutol). She was discharged without complication, and no side effect or complication of the treatment was present at 3 months’ follow-up.
DISCUSSION The incidence of tuberculosis has continuously decreased until 1985 in western countries. More recently, there has been an upsurge of GI tuberculosis in the United State as a result of the influx of immigrants, the AIDS epidemic, and the use of immunosuppressant drugs. The Volume 61, No. 2 : 2005 GASTROINTESTINAL ENDOSCOPY 319