CASE REPORT

Small Intestinal Tuberculosis Presenting as Massive Gastrointestinal Bleed: A Case Report

Sankar Venkatesan, Murali Jayaraman*, Y. Mohan Kumar, J. Prabhu

Department of Gastro Intestinal and HPB Surgery, Kauvery Hospital, Hosur, India

Abstract

Massive bleeding per rectum is an uncommon presentation of small intestinal tuberculosis. We report a patient who presented with hematochezia and hypotension. The patient had normal upper and lower GI endoscopy. However, contrast CT abdomen showed active extravasation of contrast in proximal ileum. Patient underwent laparotomy and resection of bleeding segment. Histopathological examination of resected intestine confirmed the diagnosis of tuberculosis. Intestinal tuberculosis should be considered as differential diagnosis for patients with pulmonary tuberculosis presenting with massive GI bleed.

Keywords: Intestinal tuberculosis, Bleeding, Small intestine

Background

The clinical presentations of gastrointestinal tuberculosis are usually non-specific and varied. The incidence of intestinal tuberculosis with pulmonary tuberculosis varies between 3-90%. Small intestinal tuberculosis is one of the commonest surgical emergencies due to obstruction (adhesion or stricture formation) and perforation. However, bleeding is usually rare [1]. Bleeding in intestinal tuberculosis most commonly occurs at ileocecal region because it is the most common site of involvement. Massive hematochezia is a rare symptom of small bowel tuberculosis [2-4]. Here we report a case of massive gastrointestinal bleed due to small intestine tuberculosis requiring surgical intervention.

Case Presentation

A 24-year male presented to ER with hematochezia of one day duration and low-grade intermittent fever associated with myalgia of 5 days duration. He also had abdominal pain associated with loss of appetite. No other significant history was elicited. On clinical examination, patient was conscious, oriented and severely pale. His vitals were as follows. Blood pressure, 90/50 mmHg; Pulse rate, 108/min; respiratory rate, 26/min; oxygen saturation, 96% in room air and temperature -98.6Â°F. Abdominal examination showed diffuse tenderness. His blood investigations showed haemoglobin, 4.4 gm/dl; haematocrit, 12.2%; total WBC count, 12,320 cells/cu mm; platelet, 157700 cells/cumm; albumin, 1.8 gm/dl; sodium, -123 mEq/L. Initial resuscitation was done in ER and shifted to ICU. In spite of continued resuscitation with blood products, patient continued to remain hemodynamically unstable. Emergency upper gastrointestinal endoscopy was normal up to second part of duodenum. Colonoscopy showed fresh blood clots in cecum and terminal ileum but no active bleeding lesions. Contrast CT abdomen, showed focal active contrast extravasation in small intestinal lumen (Fig. 1). Hence, emergency laparotomy done. Intraoperatively, jejunal and ileal loops had multiple stricturous lesions and were filled with blood (Fig. 2). Intraoperative enteroscopy showed active bleeding from proximal ileal ulcer (Fig. 3). Hence, that segment of proximal ileum with bleeding ulcer (Fig. 4) was resected and anastomosed. Postoperative period was uneventful and there was no further bleed. Histopathology confirmed the diagnosis of tuberculosis (Fig. 5). Patient was started on anti-tubercular treatment and discharged. After two months of follow up, there is no further bleeding episode.

Fig 1. CECT abdomen showing contrast extravasation in small bowel lumen.

Fig. 2. Small intestine with multiple strictures filled with blood.

Fig 3a. Fresh clot, (b) bleeding ulcer after clot evacuation.

Fig. 4. Cut open of resected bowel with bleeding ulcer.

Fig. 5. Langhans type and few foreign body type of giant cells with lymphoplasmacytic infiltrates.

Discussion

Abdominal tuberculosis is less common than pulmonary tuberculosis and it constitutes around 5% of all cases of tuberculosis. It commonly involves gastrointestinal tract, lymph nodes, peritoneum and solid organs. Gastrointestinal tuberculosis is difficult to diagnose and its symptoms overlap with other abdominal ailments such as carcinoma, lymphoma, inflammatory bowel disease, infective colitis, appendicitis and diverticulitis [5]. The most common abdominal symptoms include intestinal colic, diarrhoea, constipation, vomiting and bleeding. Gastrointestinal bleeding occurs in 5-15% of intestinal tuberculosis and it is usually lower GI bleed, but rarely massive [6].

In the review of literature, only few cases of intestinal tuberculosis presented with massive lower GI bleed and those were most commonly from ileocecal region [8,9]. Few cases had bleeding from transverse [7,10] and descending colon [11]. Bleeding from small bowel (except terminal ileum) is very rare. In our patient, there was massive lower GI bleed. Upper and Lower GI scopies were normal. CT showed active bleeding from small bowel. CT chest which showed evidence of pulmonary tuberculosis. Intra operatively, there were multiple stricturous lesions scattered throughout small intestine. Intra operative enteroscopy showed active bleeding from proximal ileal ulcer. Tuberculosis was confirmed with histo pathological examination which showed multiple epithelioid cell granulomas accompanied by Langhanâ€™s type and few foreign body type of giant cells with lymphoplasmocytic infiltrates. Major bleeding in gastrointestinal tuberculosis occur due to obliterative endarteritis of ulcer [6,7].

A study by Al Karawi et al [12], 130 patients with gastrointestinal tuberculosis, 44 patients (33.8%) had small intestinal tuberculosis and 29 patients (22.3%) had large intestine tuberculosis. Out of 44 patients with small intestine tuberculosis, only one patient had bleeding, but in 29 patients with large bowel tuberculosis three had bleeding. As per this study, though small intestinal tuberculosis is common, bleeding is rare.

As per the literature the preferred treatment of gastrointestinal tuberculosis is anti-tubercular treatment (ATT). For intestinal tuberculosis patients presenting with major bleeding the preferred treatment is resection of bleeding segment followed by ATT.

Conclusion

We report a rare case of massive gastrointestinal bleed from proximal ileal tuberculosis. In the presence of pulmonary tuberculosis, intestinal tuberculosis should be considered as differential diagnosis in patients presenting with massive gastrointestinal bleed.

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