Figure 1
Non-enhanced CT
Tuberculosis, a possible cause of intestinal bleeding
SectionAbdominal imaging
Case TypeClinical Cases
Authors
Barral Juez I [1], Pérez-Batallón Miguez A [1], Noya Castro A [1] , San Luis González A [1], Ledo Rodriguez A [2]
[1]Radiology Department
[2]Department of Gastroenterology
Connected authors
54 years, female
Clinical History
54-year-old woman attended the emergency department complaining of rectal bleeding.
The blood test showed significant anaemia.
In the upper endoscopy a clot was visualized on the descending duodenal portion with an ulcerous injury and adjacent inflammatory changes.
The colonoscopy did not show relevant findings.
Urgent surgery was required because of hypovolemia.
The blood test showed significant anaemia.
In the upper endoscopy a clot was visualized on the descending duodenal portion with an ulcerous injury and adjacent inflammatory changes.
The colonoscopy did not show relevant findings.
Urgent surgery was required because of hypovolemia.
Imaging Findings
In the unenhanced CT several calcium density images on mesentery can be observed (calcified adenopathies).
In the contrast enhanced CT a hypodense lesion at the duodenum wall, contrast extravasation towards the intestinal lumen (compatible with active bleeding) and remarkable inflammatory changes in the mesentery fat can be shown. Extraluminal gas bubbles are also seen (pneumoperitoneum). Between the duodenum and right colon a tubular hypodense image can be observed, that could correspond to a fistulous tract.
On the surgery a 3cm lesion was found on the antimesenteric border of duodenum with intraluminal growth and border bleeding.
The hysthologic result showed: inflammatory granulomatous reaction in the duodenal lesion and extirpated adenopathies, necrotic areas in some adenopathies and flat ulcerations surrounded by granulomatous lesions at the duodenal mucosa. The findings were compatible with tuberculous etiology.
After surgery the patient was treated with antituberculous drugs and controlled at the Department of Infectious Disease.
In the contrast enhanced CT a hypodense lesion at the duodenum wall, contrast extravasation towards the intestinal lumen (compatible with active bleeding) and remarkable inflammatory changes in the mesentery fat can be shown. Extraluminal gas bubbles are also seen (pneumoperitoneum). Between the duodenum and right colon a tubular hypodense image can be observed, that could correspond to a fistulous tract.
On the surgery a 3cm lesion was found on the antimesenteric border of duodenum with intraluminal growth and border bleeding.
The hysthologic result showed: inflammatory granulomatous reaction in the duodenal lesion and extirpated adenopathies, necrotic areas in some adenopathies and flat ulcerations surrounded by granulomatous lesions at the duodenal mucosa. The findings were compatible with tuberculous etiology.
After surgery the patient was treated with antituberculous drugs and controlled at the Department of Infectious Disease.
Discussion
Intestinal TB may present as an inflammatory stricture, hypertrophic lesions resembling polyps or tumours, segmental ulcers and colitis.
After the bacillus enters the gastrointestinal tract, it traverses the mucosa and lodges in the submucosa where it induces inflammatory changes that can lead to lymphangitis, endarteritis and fibrosis which can progress to mucosal ulceration, caseating necrosis and narrowing of the intestinal lumen. Diagnosing abdominal TB is difficult because its presenting signs, symptoms and laboratory abnormalities are non-specific and non-diagnostic.
Symptoms of abdominal TB include abdominal pain, diarrhoea, fever, anorexia, weight loss, constipation and haemorrhage [2].
The most frequent symptom at presentation (in 90–100% patients) is abdominal colicky pain representing intermittent bowel obstruction. Massive haemorrhage necessitating blood transfusion is very uncommon in gastrointestinal tuberculosis. Indeed, few cases have been reported worldwide. Gastrointestinal tuberculosis is reported to be difficult to diagnose, because its symptoms are varied and sometimes overlap with a broad range of other abdominal ailments, such as colorectal cancer, Crohn’s disease, ulcerative colitis, colonic lymphoma, amoebic colitis, periappendicular abscess and diverticulitis and it can be located in any region of the gastrointestinal tract, complicating the location of infected areas [3].
Chest radiographs are positive in only 20–50% of patients with intestinal TB.
CT and abdominal ultrasound findings suggestive of abdominal TB include ascites, enlarged lymph nodes, omental thickening and bowel-wall thickening. Definitive diagnosis is based on histology, Ziehl-Neelsen staining for acid-fast bacilli and culture [1].
Colonoscopy with biopsy is the most useful non-operative diagnostic test for intestinal TB (identification of granulomatous lesions accompanied by necrosis and lymphangitis by biopsy) [2].
The management of abdominal TB relies on TB drugs; surgery is reserved for complications and uncertainty of diagnosis.
Intestinal TB may mimic other abdominal diseases, such as Crohn’s disease. Differentiating TB from Crohn’s disease is important, since treatment of these two disorders is very different. Both entities may present with mucosal ulcerations, nodularity, ulcers, pseudopolyps, luminal narrowing and strictures.
A timely diagnosis and initiation of therapy may prevent complications and improve outcomes [4].
It is imperative to consider gastrointestinal tuberculosis in the differential diagnosis of massive gastrointestinal bleeding.
After the bacillus enters the gastrointestinal tract, it traverses the mucosa and lodges in the submucosa where it induces inflammatory changes that can lead to lymphangitis, endarteritis and fibrosis which can progress to mucosal ulceration, caseating necrosis and narrowing of the intestinal lumen. Diagnosing abdominal TB is difficult because its presenting signs, symptoms and laboratory abnormalities are non-specific and non-diagnostic.
Symptoms of abdominal TB include abdominal pain, diarrhoea, fever, anorexia, weight loss, constipation and haemorrhage [2].
The most frequent symptom at presentation (in 90–100% patients) is abdominal colicky pain representing intermittent bowel obstruction. Massive haemorrhage necessitating blood transfusion is very uncommon in gastrointestinal tuberculosis. Indeed, few cases have been reported worldwide. Gastrointestinal tuberculosis is reported to be difficult to diagnose, because its symptoms are varied and sometimes overlap with a broad range of other abdominal ailments, such as colorectal cancer, Crohn’s disease, ulcerative colitis, colonic lymphoma, amoebic colitis, periappendicular abscess and diverticulitis and it can be located in any region of the gastrointestinal tract, complicating the location of infected areas [3].
Chest radiographs are positive in only 20–50% of patients with intestinal TB.
CT and abdominal ultrasound findings suggestive of abdominal TB include ascites, enlarged lymph nodes, omental thickening and bowel-wall thickening. Definitive diagnosis is based on histology, Ziehl-Neelsen staining for acid-fast bacilli and culture [1].
Colonoscopy with biopsy is the most useful non-operative diagnostic test for intestinal TB (identification of granulomatous lesions accompanied by necrosis and lymphangitis by biopsy) [2].
The management of abdominal TB relies on TB drugs; surgery is reserved for complications and uncertainty of diagnosis.
Intestinal TB may mimic other abdominal diseases, such as Crohn’s disease. Differentiating TB from Crohn’s disease is important, since treatment of these two disorders is very different. Both entities may present with mucosal ulcerations, nodularity, ulcers, pseudopolyps, luminal narrowing and strictures.
A timely diagnosis and initiation of therapy may prevent complications and improve outcomes [4].
It is imperative to consider gastrointestinal tuberculosis in the differential diagnosis of massive gastrointestinal bleeding.
Differential Diagnosis List
Intestinal TB
Crohn\'s disease
Duodenal abscess
Intestinal TB
Duodenal neoplasia
Final Diagnosis
Intestinal TB
References
[1] Hossein Jadvar, Robert E. Mindeizun, Eric W. Olcott, Diana B. Levitt (1997) Still the Great Mimicker: Abdominal Tuberculosis. AJR 168:1455-1460 (PMID: 9168707)
[2] Joanna M Tulczynska and Jean K Fleischman (2010) Abdominal Tuberculosis: An Unusual Cause of Abdominal Pain. Respiratory Care 55:3 (PMID: 20196886)
[3] Kazuko Beppu, Taro Osada, Kenshi Matsumoto, Tomoyoshi Shibuya,Naoto Sakamoto, Masato Kawabe, Akihito Nagahara, Michiro Otaka,Tatsuo Ogihara, Sumio Watanabe (2009) Gastrointestinal tuberculosis as a cause of massive bleeding. Med Sci Monit 15:CS151-154 (PMID: 19789515)
[4] Cher H. Tan, Dimitrios P. Kontoyiannis, Chitra Viswanathan, Revathy B. Iyer (2010) Tuberculosis: A Benign Impostor. AJR 194:555–561 (PMID: 20173128)
Case information
| URL: | https://www.eurorad.org/case/9246 |
| DOI: | 10.1594/EURORAD/CASE.9246 |
| ISSN: | 1563-4086 |
Figure 3
Contrast enhanced coronal CT
