Gastrointestinal tuberculosis.
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Barium studies of a gastrointestinal tract and chest radiographs of 109 patients with gastrointestinal tuberculosis were investigated. The type and site of the tuberculous lesions in the bowel, as well as its association with pulmonary tuberculosis and surgical complications, were reviewed. The ileocecal region is the portion of the gastrointestinal tract most frequently involved. The ulcerohypertrophic type of tuberculous lesion was the most common. Thirty-two percent of the patients had a normal chest radiograph. Nineteen patients had a significant surgical complication. Fistulous tracts and intestinal perforation are rare. The radiographic differential diagnosis with regional enteritis and other forms of inflammatory bowel disease is discussed.
Tuberculous involvement of the gastrointestinal tract may be suspected in the presence of active pulmonary tuberculosis. This case demonstrates that tuberculous enteritis may develop in the absence of obvious pulmonary involvement. The diagnosis in such instances is established by a combination of roentgenographic studies and surgical exploration.
Tuberculosis continues to be a major health problem in India. Our experience of 102 cases of gastrointestinal tract tuberculosis is presented. Eighty-one of these patients experienced obstructive symptoms, 62 had radiographic evidence of intestinal obstruction, and four had bowel perforation. Lymphadenopathy was present in 16 patients and pulmonary tuberculosis in 28. The commonest sites of bowel involvement were ileo-caecal, ileum and ascending colon. Duodenal lesions were seen in three cases and in another three there was isolated appendicular involvement. Right hemicolectomy was necessary in 55 of the 74 patients who had surgical exploration. Histopathological reports were available in 88 subjects. The various radiographic manifestations of tuberculosis of the bowel are discussed. Radiologically and sometimes even on histopathology, differentiation of ileo-caecal tuberculosis from Crohn's ileo-colitis may prove impossible.
Gastrointestinal tuberculosis in children is an uncommon condition. Obstruction and hemorrhage are the known common complications of tuberculous enteritis. Perforation is an uncommon complication whereas tubercular enterocutaneous fistula is a still rarer complication. Five children with spontaneous tubercular enteroumbilical fistulas are being reported. All were below the age of 10 years, the youngest being 15 months old. Four children had conservative treatment with antitubercular drugs and one had exploration, resection of gut and excision of fistula. All the children who had conservative treatment survived whereas the child who underwent surgery died in the postoperative period. We feel that the conservative management is the treatment of choice in cases of established tubercular enterocutaneous fistulas.
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Material obtained from 35 cases of abdominal tuberculosis waps studied and an attempt was made to demonstrate tubercle bacilli by special staining of histological sections, culture and guinea-pig inoculation. Acid fast bacilli could be demonstrated in 80 per cent of cases. The remaining cases were also possibly due to tuberculous infection because granulomas with Langhans's type of giant cells and caseation or calcification of lymph nodes were present. The bacilli were demonstrated in bowel tissue showing non-specific histology in 1 case. In 2 other cases with non-specific lesions in the bowel the bacilli were demonstrated in lymph nodes. Guinea-pig inoculation studies showed that hypertrophic lesions of the bowel with a non-specific type of reaction could develop after intraperitoneal injection of tubercular material. Although it cannot be said on the basis of this study that Crohn's disease is caused by tuberculous infection, it can be concluded that tuberculous infection can give rise to a Crohn's type of lesion.
Twenty-seven cases of patients with intestinal tuberculosis were reported. Seventeen cases showed good response to antituberculosis chemotherapy. The numbers and size of ulceration, pseudopolyp and deformity of intestinal tract were checked by endoscopic and X-ray studies on comparative evaluation between prechemotherapeutic and postchemotherapeutic stage. In these cases, subjective symptoms were disappeared parallel with the marked improvement on X-ray and endoscopic findings. These data suggest that with current well planned antituberculosis chemotherapy program, tuberculous colitis is controlled fairly while tuberculous enteritis in controlled inadequately. Therefore, surgical procedures are commly indicated to the treatment of tuberculous enteritis.
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12 of the 24 cases of active tuberculosis which came to necropsy in Dundee hospitals from 1968 to 1975 were diagnosed after death. The overall distribution of anatomical types was similar to that in previous surveys, but in those diagnosed at necropsy there was an excess of psoas abscess and miliary, colonic, and adrenal lesions. Class-IV patients and a history of steroid therapy were also more common in cases diagnosed at necropsy. None of these differences is statistically significant.
Duodenal tuberculosis is a very rare disease and is usually associated with active pulmonary tuberculosis. These patients may present with symptoms and initial radiographic findings of pyloric canal obstruction. Hypotonic duodenography may reveal a submucosal mass with no other specific changes. The lesion is unpredictable. It may respond to medical therapy but it may also progress and require surgical intervention.
Tuberculosis associated with dialysis was studied at the Renal Unit of the Tokyo Medical and Dental University and Yokosuka Mutual Aid Hospital Kidney Center, in both of which the treatments of chronic renal failure are the same. There are 12 tuberculosis patients out of 367 patients on maintenance hemodialysis from January 1967 to December 1976, an incidence of 3.3%. This was 6-16 times greater than that in the general population of this country according to yearly statistics. The characteristics of dialysis-associated tuberculosis include a high incidence of miliary tuberculosis, especially in aged patients and difficulty in establishing the diagnosis before death. Clinical features which are helpful in the early diagnosis are intermittent high fever of unknown origin, weight loss, anorexia, abnormalities of the central nervous system, erythrocyte sedimentation rate over 100 mm/h, leukocytosis and high value of the C-reactive protein. With the increasing number of dialysis patients, an increase of dialysis-associated tuberculosis is expected and this will be one of the major problems of dialysis patients in future.
Segmental tuberculosis of the transverse colon is very rare and when present is usually associated with active pulmonary tuberculosis. These patients may have initial symptoms suggestive of neoplasm or of Crohn's disease. Radiographically the lesion manifests itself as a fairly long area of narrowing with nodular and ulcerated mucosa. Sinuses and fistulae may arise from the area of involvement. These changes are not specific for tuberculosis. The lesion is unpredictable. It may respond to medical therapy, but complications such as bleeding and sinus tract formation may require surgical intervention.
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Fibrosis of the intestinal lymphatic vessels, produced in one case by tuberculosis and, in the other, by appendicitis and peritonitis, caused blockage of the main lymphatic vessels causing, clinically, a protein-losing enteropathy similar to that noted in congenital lymphatic diseases of childhood. In the laboratory, there was noted a fall in serum protein, lipid and cholesterol. A fat absorption test was very abnormal showing a flat curve. During laparotomy, there was discovered on the small intestine, the same layout of lymph vessels, resembling a lace network, as that observed in congenital malformations. Intestinal lymphography showed considerable stasis of the opaque substance and absence of injection of the lymph vessels in the mesentery.
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