Diffuse Fistulizing Small Bowel Disease Small Bowel Tuberculosis: Challenging Case to Diagnose

Alqahtani IN, Masharfeh YH and Bazeed FM

Published on: 2020-02-18

Abstract

Diffuse small bowel disease is considered challenging case for physicians to diagnosed especially if they saw multiple fistulae between the bowel loops and colon and patient was labeled as query inflammatory bowel disease. In this report we describe the condition of a 27 years old Saudi male, with no history of chronic health problem was referred to our hospital with history of intermittent abdominal pain lasted for three months with gradual onset. The pain nature was colicky especially at para-umbilical area. This pain was associated with nausea and anorexia with history of weight loss. The patient also gave history of vomiting frequently with progressive abdominal distention for the last month. Gastroscopy was done showed multiple duodenal ulcers but colonoscopy was normal. MR Enterography show diffuse small bowel thickening. Push enteroscopy was done showed dilated small bowel with extensive erythematous mucosa and scattered ulcers with multiple small bowel fistula. Tissue PCR for TB was positive. Patient was finally diagnosed as small bowel TB case. Background: Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis (MTB) bacteria. (1) Tuberculosis generally affects the lungs, but can affect any part of the body. Most infections do not have symptoms, in which case it is known as latent tuberculosis. The classic symptoms of active TB are a chronic cough with blood- containing sputum, fever, night sweats, and weight loss. In 15–20% of active cases, the infection spreads outside the lungs, causing other kinds of TB. These are collectively denoted as "extrapulmonary tuberculosis". Approximately 15%-25% of cases with abdominal TB have concomitant pulmonary TB. Hence, it is quite important in identifying these lesions with high index of suspicion especially in endemic areas. The abdominal TB usually occurs in four forms: tuberculous lymphadenopathy, peritoneal tuberculosis, gastrointestinal (GI) tuberculosis and visceral tuberculosis involving the solid organs.

Keywords

Tuberculosis; Abdominal pain; Intestinal tuberculosis; Extra pulmonary tuberculosis; Intestinal fistula; Intestinal erosion

Case Presentation

A 27 years old Saudi male, with no history of chronic health problem was referred to our hospital with history of intermittent abdominal pain lasted for three months with gradual onset. The pain nature was colicky especially at para-umbilical area. The pain was not aggravated or relived by any factor. The pain intensity was increases in the last month before presentation which forced the patient to seek for medical advice. This pain was associated with nausea and anorexia with history of weight loss of more than 15 kg with history of intermittent low grade fever mainly at night with night sweating. The patient also gave history of vomiting frequently with progressive abdominal distention for the last month. The patient had negative history regarding PUD, NSAID use, contact with TB patient, skin rash, joint pain, and jaundice. Family and surgical history for the patient were also free. The patient was not a smoker or alcoholic. He works as a soldier and he is planning to get married. This patient was admitted in another hospital and he stayed for around one month as case of abdominal pain and ascites for investigation, CT abdomen was done and showed diffuse mural small bowel thickening, most pronounced in jujenal and distal ileum with moderate ascites. Ascetic fluid of about 8 ml was aspirated, and analysis showed ; LOW SAAG ascites with WBC 2100; 90% lymphocyte, 10 % neutrophil , protein 53.8 g /dl, and LDH 423 u/L. Gram stain showed no growth with negative AFB. Gastroscopy was done there and showed multiple duodenal ulcers but colonoscopy was normal. Patient then referred to our hospital for further investigation and management as query inflammatory bowel disease [1-8].

Clinical Examination

After patient admission, he looked ill, cachectic, BMI equals 11 (weight = 31 kg, height = 165 cm). No pallor was noticed with no jaundice or lymphadenopathy. Heart rate of 66 beats per minute was recorded and blood pressure of 100/66 mmHg with oxygen saturation of 99%. No fever was recorded on time of examination. Chest and CVS examination were normal. Abdominal examination showed distended abdomen with generalized tenderness allover abdomen mainly epigastrium with positive shifting dullness for ascites. PR examination showed no fistula but brownish stool was noticed.

Figure 1: MR Enterography show small bowel diffuse thickening.

Investigation

Laboratory investigations: WBC = 5.9, Hb = 12.8 g/dl, MCV 79.2, MCH 24, PLT 337, INR 1.0 CRP 31.9, ESR 13.

LFTs were normal, albumin of 18. Renal profile was normal. Stool analysis for was free.

PPD done: 10 mm after 72 hours. Hepatitis B and C, HIV were negative.

Imaging

Chest x-ray was free. Repeated gastroscopy in our hospital was normal. MR Enterography show small bowel diffuse thickening (Figure 1). Push enteroscopy was done and showed dilated small bowel with extensive erythematous mucosa and scattered ulcers, different in size, clean bases with multiple opening at jejunum 20 cm from pylorus (fistula), some fecal material was seen in the lumen coming from the opening (Figures 2 and 3). Small bowel follow through, was not conclusive due to diffuse thickness of small bowel. After that, small bowel biopsy of the push enteroscopy showed nonspecific inflammation, but Tissue PCR for TB was positive. Patient was finally diagnosed as small bowel TB.

Treatment

Patient started on anti-TB medication according to his weight and infectious disease team follow up. As patient couldn't tolerate the medication, TPN started for 3 weeks. After 3 weeks, patient tolerated oral therapy and his appetite improved.

Outcome and follow-up

After 3 weeks, patient gained weight around 10 kg (BMI 14). TPN weaned off. Patient was eating very well, no more complain. Abdomen was so soft and lax, and no tenderness. Patient discharged to home on anti-TB medication and follow up with ID after 2 weeks to check the laboratories. After 3 months, patient was seen in our clinic, asymptomatic and his BMI was 21, his Hg was normal, albumin 29, liver function tests were normal

Figure 2: Push enteroscopy showed dilated small bowel with extensive erythematous mucosa and scattered ulcers, different in size, clean bases with multiple opening at jejunum 20 cm from pylorus (fistula), some fecal material was seen in the lumen coming from the opening.

Figure 3: Multiple opening at jejunum (fistula), some fecal material was seen in the lumen coming from the opening.

Discussion

Tuberculosis (TB) is a life threatening disease which affects any organ or system [9]. World health organization reported that the global burden of TB is around 12 million with an annual estimated incidence of 8.6 million 1.3 million people died from disease in 2012 [10]. Incidence of TB in developed countries recorded increased trend in accordance with immune- compromised patients mainly due to many factors emerged in these countries including HIV infections, immigration, poverty, and cutbacks in public health services [11-13]. TB affect many organs other than lungs which is called extrapulmonary TB. The clinical presentation of these cases is usually non-typical, cases of extrapulmonary tuberculosis (EPTB) are often difficult to diagnose and manage [14]. The abdominal TB clinically can be presented in many forms including tuberculous lymphadenopathy, peritoneal tuberculosis, gastrointestinal (GI) tuberculosis and visceral tuberculosis [15]. Generally, computed tomography (CT) is the proved most specific diagnostic tool for abdominal TB. For intestinal mucosal lesions, barium with follow through remain superior for all other tools [16-18] The main symptoms of intestinal tuberculosis are abdominal pain (85%), weight loss (66%), diarrhea (20%), and other symptoms, including nausea, vomiting, and melena [19,20]. Abdominal pain, night sweats, and weight loss were the main symptoms in the current case most radiologic images were not diagnostic. Sub diaphragmatic free air has been reported as occurring in 25% to 71% in the literature [21-23]. But it was not recorded in case under study. Also, multiple air-fluid levels are seen with intestinal obstruction which also not recorded in our case [21]. Also the case understudy revealed intestinal erosions which was reported as 10% to 40% in previous articles [24-26]. Colonoscopy was considered to be the most specific diagnostic tool for intestinal TB [27,28]. Deformity of the ileocecal valve is often recorded with incompetence. The cecum also is usually deformed and contracted. Bhargava et al. described other typical colonoscopy findings such as segments of mucosal nodules and ulcerations with areas of stricture with nodules and ulceration [29]. Differentiating between intestinal tuberculosis and Crohn’s disease often not easy and constitutes a major diagnostic challenge for clinicians. The role of colonoscopy biopsy in differentiating between intestinal tuberculosis and Crohn’s disease is still unclear. Patients with intestinal tuberculosis and of those with Crohn’s disease will deficient discriminatory findings in endoscopic biopsy specimens. Management of these patients, as always, is based on clinical, endoscopic and radiologic findings [30-32].

Conclusion

In conclusion, diagnosis of intestinal tuberculosis is not easy as cases often confused with inflammatory bowel disease and intestinal neoplasms. Physicians should consider abdominal TB in their differential diagnosis with other clinical features. Treatment is mainly medical, and all patients should receive a full course of antituberculous therapy.

References

  1. Tuberculosis TB. Fact sheet N°104" WHO October 2015. 2016.
  2. Tuberculosis TB. World Health Organization. 2018.
  3. Global tuberculosis report. World Health Organization. 2017.
  4. Dolin, Gerald L, Mandell, John E, Bennett, Raphael, et al. Principles and practice of infectious diseases 7th 2010.
  5. Golden MP, Vikram HR. Extrapulmonary tuberculosis: an overview. American Family Physician. 2005; 72: 1761-1768.
  6. Ghosh, Thomas M. Habermann, Amit K. Mayo Clinic internal medicine: concise textbook. Rochester MN:Mayo Clinic Scientific Press.2008; 789.
  7. Horvath KD, Whelan RL. Intestinal tuberculosis: return of an old disease. Am J Gastroenterol. 1998; 93: 692-696.
  8. Akhan O, Pringot J. Imaging of abdominal tuberculosis. Eur Radiol. 2002; 12: 312-323.
  9. Rosado E, Penha D, Paixao P, Costa AMD, Amadora PT. Abdominal tuberculosis-Imaging findings. Educational Exhibit ECR. 2013.
  10. World Health Organization. Global tuberculosis report 2013.
  11. Pop M, Pop C, Homorodean D, Itu C, Man M, Goron M, et al. Abdominal miliary tuberculosis in a patient with AIDS: a case report. Rom J Gastroenterol. 2003; 12: 231-234.
  12. Albalak R, O’Brien RJ, Kammerer JS, O’Brien SM, Marks SM, Castro KG, et al. Trends in tuberculosis/human immunodeficiency virus comorbidity, United States, 1993-2004. Arch Intern Med. 2007; 167: 2443-2452.
  13. Burzynski J, Schluger NW. The epidemiology of tuberculosis in the United States. Semin Respir Crit Care Med. 2008; 29: 492-498.
  14. Welzel TM, Kawan T, Bohle W, Richter GM, Bosse A, Zoller WG. An unusual cause of dysphagia: esophageal tuberculosis. J Gastrointestin Liver Dis. 2010; 19: 321-324.
  15. Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum. Am J Gastroenterol. 1993; 88: 989-999.
  16. Hopewell PC. A clinical view of tuberculosis. Radiol Clin North Am. 1995; 33: 641-653.
  17. Sharma MP, Bhatia V. Abdominal tuberculosis. Indian J Med Res. 2004; 120: 305-315.
  18. Mukewar S, Mukewar S, Ravi R, Prasad A, Dua SK. Colon tuberculosis: endoscopic features and prospective endoscopic follow-up after anti-tuberculosis treatment. Clin Transl Gastroenterol. 2012; 3: 24.
  19. Bhansali SK. Abdominal tuberculosis. Experiences with 300 cases. Am J Gastroenterol. 1977; 67: 324-337.
  20. Gilinsky NH, Voigt MD, Bass DH, Marks IN. Tuberculous perforation of the bowel: A report of 8 cases. S Afr Med J. 1986; 70: 44-46.
  21. Talwar S, Talwar R, Prasad P. Tuberculous perforations of the small intestine. Int J Clin Pract. 1999; 53: 514-518.
  22. Kakar A, Aranya RC, Nair SK. Acute perforation of small intestine due to tuberculosis. Aust N Z J Surg. 1983; 53: 381-383.
  23. Wig JD, Malik AK, Chaudhary A, Gupta NM. Free perforation of tuberculous ulcers of the small bowel. Ind J Gastroenterol. 1985; 4: 259-261.
  24. Veeragandham RS, Lynch FP, Canty TG, Collins DL, Danker WM. Abdominal tuberculosis in children: Review of 26 cases. J Pediatr Surg. 1996; 31: 170-176.
  25. Mansoor J, Umair B. Primary pancreatic tuberculosis: a rare and elusive diagnosis. J Coll Phys Surg Pak. 2013; 23: 226-228.
  26. Tago S, Hirai Y, Ainoda Y, Fujita T, Takamori M, Kikuchi K. Perianal tuberculosis: a case report and review of the literature. World J Clin Cases. 2015; 3: 848-852.
  27. Chavhan GE, Ramakantan R. Duodenal tuberculosis: radiological features on barium studies and their clinical correlation in 28 cases. J Postgrad Med. 2003; 49: 214-217.
  28. Vinay K, Abbas, Abul K, Nelson F, Mitchell, Richard N. Robbins Basic Pathology 8th Saunders Elsevier. 2007; 516-522.
  29. Bhargava DK, Kushwaha AKS, Dasarathy S, Shriniwas DM, Chopra P. Endoscopic diagnosis ofsegmental colonic tuberculosis. Gastrointes Endosc. 1992; 38: 571-574.
  30. Pulimood AB, Ramakrishna BS, Kurian G, Peter S, Patra S, Mathan V, et al. Endoscopic mucosal biopsies are useful in distinguishing granulomatous colitis due to crohn’s disease from tuberculosis. 1999; 45: 537-541.
  31. Pulimood AB, Peter S, Ramakrishna BS, Chacko A, Jeyamani R, Jeyaseelan L, et al. Segmental colonoscopic biopsies in the differentiation of ileocolic tuberculosis from Crohn’s disease. J Gastroenterol Hepatol. 2005; 20: 688-696.
  32. Gan HT, Chen YQ, Ouyang Q, Hong Bu, Yang YX. Differentiation between intestinal tuberculosis and Crohns disease in endoscopic biopsy specimens by polymerase chain reaction. Am J Gastroenterol. 2002; 97: 1446-1451.