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Original Article

Article original

Gastroduodenal tuberculosis management


guidelines, based on a large experience
and a review of the literature

Yannam Govardhana Rao, MCh;* Girish K. Pande, MS, PhD;† Peush Sahni, MS, PhD;* Tushar K.
Chattopadhyay, MS*

Background: To review our experience of gastroduodenal tuberculosis before formulating management


guidelines, we did a retrospective analysis at a large tertiary-care teaching institution in North India.
Method: We reviewed 23 consecutive cases of biopsy-proven gastroduodenal tuberculosis over a period
of 15 years. Results: The major presenting features were gastric outlet obstruction (61%) and upper
gastrointestinal (uGI) bleeding (26%). In 3 patients (13%), clinical, radiological and intraoperative fea-
tures suggested malignancy/pseudotumour: periampullary mass in 2 and gastric mass in 1 patient. Five
patients (23%) also had extragastrointestinal tuberculosis. Despite uGI endoscopy and biopsies, the pre-
operative diagnosis was correct for only 2 people. All patients except 1 required surgery for either diag-
nosis or therapy. Two patients with massive uGI hemorrhage requiring emergency surgery died in the
postoperative period. The other patients responded well to antitubercular treatment after surgery. Con-
clusions: Gastroduodenal tuberculosis has 3 forms of presentation: obstruction, uGI bleeding, and gas-
tric or periampullary mass suggestive of malignancy. Endoscopic biopsy has a poor yield. Surgery is usu-
ally required for diagnosis or therapy, after which patients respond well to antituberculous treatment. In
areas endemic for tuberculosis, a good biopsy from the site of gastroduodenal bleeding or mass lesion
and the surrounding lymph nodes should always be obtained.

Contexte : Pour revoir notre expérience de la tuberculose gastroduodénale avant de formuler des lignes
directrices sur le traitement, nous avons procédé à une analyse rétrospective à un important établisse-
ment d’enseignement de soins tertiaires dans le nord de l’Inde. Méthode : Nous avons étudié 23 cas
consécutifs de tuberculose gastroduodénale prouvée par biopsie sur une période de 15 ans. Résultats :
La sténose du défilé gastrique (61 %) et le saignement gastro-intestinal supérieur (GIs) (26 %) ont con-
stitué les principales caractéristiques au moment de la présentation. Chez trois patients (13 %), les carac-
téristiques cliniques, radiologiques et intraopératoires ont indiqué la présence d’une tumeur maligne-
pseudotumeur : masse périampullaire dans deux cas et masse gastrique chez un autre patient. Cinq
patients (23 %) avaient aussi une tuberculose extragastro-intestinale. En dépit d’une endoscopie GIs et
de biopsies, le diagnostic préopératoire était exact dans deux cas seulement. Tous les patients sauf un
ont eu besoin d’une intervention chirurgicale diagnostique ou thérapeutique. Deux patients qui avaient
une hémorragie GIs massive qui a obligé à pratiquer une intervention chirurgicale d’urgence sont morts
après l’intervention. Les autres patients ont bien répondu au traitement antituberculeux après l’interven-
tion chirurgicale. Conclusions : La tuberculose gastroduodénale se manifeste de trois façons : occlusion,
saignement GIs et présence d’une masse gastrique ou périampullaire indiquant la présence d’une tu-
meur maligne. La biopsie endoscopique produit des résultats médiocres. Il faut habituellement pratiquer
une intervention chirurgicale diagnostique ou thérapeutique après laquelle les patients répondent bien au
traitement antituberculeux. Dans les régions où la tuberculose est endémique, il faut toujours pratiquer
une bonne biopsie du point de saignement gastroduodénal ou de la tumeur ainsi que des ganglions lym-
phatiques voisins.

*Department of Gastrointestinal Surgery and Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India, and
†Department of Surgery, College of Medicine, Sultan Qaboos University, Muscat, Oman

Accepted for publication Nov. 10, 2003

Correspondence to: Dr. Girish K. Pande, Department of Surgery, College of Medicine, Sultan Qaboos University, PO Box 35, Al
Khod, Muscat 123, Sultanate of Oman; fax 968-513419

364 J can chir, Vol. 47, No 5, octobre 2004 ' 2004 Canadian Medical Association
Managing gastroduodenal tuberculosis

T uberculosis (TB) is endemic in


India. In the gastrointestinal
(GI) tract, the ileocecal region is the
requiring emergency surgery. Three
patients (13%) had clinical features
suggestive of malignancy. None pre-
doscopic biopsies failed to reveal any
malignancy.

predominant site of involvement.1 sented with perforation of the stom- Barium studies
Possibly because tubercular involve- ach or duodenum.
ment of the gastroduodenal (GD) Five patients (23%) also had extra- Upper-GI radiography with barium
region is rare,2,3 it is often misdiag- GI TB: 2 had an active pulmonary contrast was carried out in 11 pa-
nosed and treated as peptic ulcer dis- lesion with acid-fast bacilli on spu- tients. Findings included deformed
ease, even where it is endemic. tum smear; 1 had a healed fibrotic pylorus (in 2), duodenal stricture in-
Since GD TB exhibits no specific lesion in the lung suggestive of pul- volving the first (7) or third part (1),
symptoms or signs and no character- monary TB; and another 2 patients and the mass lesion in the stomach,
istic endoscopic or radiographic fea- had biopsy-proven tuberculous cervi- suggestive of malignancy, that has al-
tures, diagnosis requires a high index cal lymphadenitis. ready been mentioned (1 patient).
of suspicion. The paucity of informa- As for comorbid conditions, 4 pa-
tion about its presentation and man- tients were diagnosed with diabetes Ultrasound and
agement prompted us to review and mellitus, for which they were receiv- computed tomography
present our experience with 23 such ing oral hypoglycemic agents, and 18
cases along with a review of the liter- (78%) had received but not respon- Three patients, 1 with a mass in the
ature, and to suggest management ded to prior ulcer therapy with hista- stomach and 2 with periampullary le-
guidelines. mine-2 (H2) receptor antagonists. sions, underwent ultrasound scans
None of the patients studied were in- followed by CT imaging to evaluate
Method fected with HIV. the extent of disease. Findings inclu-
ded dilatation of the intrahepatic bili-
All 23 consecutive patients with his- Investigations ary ducts and bulky pancreas/retro-
tologically proven GD TB who were pancreatic mass with peripancreatic
treated at the Department of Gas- Upper gastrointestinal endoscopy lymph nodes. Duodenal dilatation
trointestinal Surgery, All India Insti- caused by periduodenal lymph nodes
tute of Medical Sciences, New Delhi All patients underwent endoscopy was also observed.
from January 1986 through July except 2. Of those who presented
2000 were reviewed retrospectively. with gastric-outlet obstruction, 12 Management
The diagnosis of TB was based on had duodenal stricture and 2 had py-
histopathology showing caseating loric stenosis. Additional findings Of the 23 patients, 1 with a duodenal
epithelioid-cell granulomas. (Acid- noted in this group were chronic ulcer bleed was managed, when the
fast bacilli as revealed by Ziehl–Neel- gastroduodenitis (2 cases), prepyloric biopsy of the ulcer showed features
sen stain were seen in only 6 cases.) ulcer (2), gastric ulcer (1) and duo- of TB, with antitubercular drugs
Data noted for analysis included age, denal ulcer (1). alone. The remaining 22 required
sex, presenting symptoms and their Of the 6 patients with upper-GI surgery either for diagnosis or for
duration, treatment(s) and outcome. hemorrhage, 2 had fundal varices, treating complications. Fourteen pa-
and another 2 had duodenal ulcers. tients (66%) had associated enlarged
Results Two patients who presented with hy-
potension after a massive hemorrhage
Table 1
The mean age of the 23 qualifying were taken directly for surgery with-
patients was 34.4 years (range 15– out endoscopy. Tuberculosis: presenting features
62 yr). The 17 men and 6 women Two patients with obstructive
Symptoms n %
yielded a gender ratio of 2.8:1. jaundice had periampullary ulcers. In
the patient with a gastric mass, a large Vomiting 14 60.8
Presenting symptoms and signs polypoidal lesion was present along Epigastric pain 13 56.5
the greater curvature. Loss of appetite, weight 7 30.4
Duration of symptoms varied from 2 All patients had multiple biopsies Upper GI bleeding 6 26.1
days to 15 years; the main presenting during endoscopy, but in only 2 cases Fever 2 8.7
symptoms are shown in Table 1. did preoperative endoscopic biopsies
Jaundice 2 8.7
Fourteen patients (61%) arrived with reveal TB (1 patient with gastric TB
Recurrent cholangitis 1 4.3
features of gastric-outlet obstruction. and another with a bleeding duoden-
Of the 23 patients, 17 presented with multiple
Six patients (26%) had upper-GI al ulcer). In the patient suspected to (2– 5) major symptoms. GI = gastrointestinal
hemorrhage, 3 with massive bleeding have gastric malignancy, multiple en-

Can J Surg, Vol. 47, No. 5, October 2004 365


Rao et al

mesenteric lymph nodes, and 1 with bleeding from duodenal ulcers (and suspected periampullary growths
gastric-outlet obstruction also had who were not correctly diagnosed underwent Whipple’s resection. An-
multiple ileal strictures. Preoperative from the endoscopic biopsy), 1 un- other had a large infiltrative lesion in-
diagnoses, the surgical procedures derwent truncal vagotomy and antrec- volving the entire stomach with mul-
performed and outcomes are sum- tomy. The other had multiple ulcers tiple nodules in the omentum. Biopsy
marized in Table 2. and required excision of the first and of an omental nodule revealed TB;
second parts of the duodenum. Persis- the patient’s condition improved with
Surgical treatment tent bleeding from the dissected area antitubercular drugs.
necessitated packing; despite these
Gastric-outlet obstruction ( n = 14) measures, the patient succumbed in Postoperative period and follow-up
the early postoperative period.
The 12 patients who presented with One patient presented with mas- After their surgical treatments, all pa-
obstruction (10 with pyloroduodenal sive hemorrhaging from a superior tients were given a standard 4-drug
stenosis and 2 with gastric TB) under- mesenteric artery–duodenal fistula. regime of antitubercular treatment
went truncal vagotomy and gastro- She underwent a total duodenecto- (isoniazid, rifampicin, pyrazinamide
jejunostomy, with or without feed- my with distal gastrectomy and clo- and ethambutol) for 4 months fol-
ing jejunostomy. Enlarged perigastric sure of a rent in the superior mesen- lowed by an additional 8 months on
lymph nodes were biopsied. teric artery. She nevertheless died 2 drugs (isoniazid and rifampicin).
Two additional patients underwent from persistent postoperative bleed- Two patients who had undergone
a Roux-en-Y duodenojejunostomy: 1 ing the day after her surgery. a gastrojejunostomy for gastric outlet
with a stricture of the third part of Two patients with segmental por- obstruction continued to produce
the duodenum, and another with an tal hypertension caused by enlarged immoderate nasogastric aspirates de-
obstruction of the common bile duct, splenic hilar lymph nodes underwent spite a stoma judged adequate via
who required a bilioenteric bypass in splenectomy and devascularization of endoscopy. When stomal adequacy
addition. the stomach. was confirmed in each patient by re-
exploration, only feeding jejunosto-
Gastrointestinal bleeding ( n = 5) Pseudotumour ( n = 3) my was done. One patient recovered,
but the other’s original gastrojejun-
Of 2 patients who arrived at the centre As shown in Table 2, 2 patients with ostomy did not become functional;
that patient had to undergo yet an-
other re-exploration, with an addi-
Table 2
tional gastrojejunostomy on the an-
Flow of events: predictive diagnosis, surgical treatment and outcome terior wall of the stomach. After this,
that patient at last had an uneventful
Preoperative Surgical Response
diagnosis (and no. of patients) treatment(s) to anti-TB recovery.
Gastric outlet obstruction (n = 14)
One of the remaining patients had
Gastric tuberculosis (2) 1 TV, GJ, gastric-wall biopsy Good
distal small-bowel obstruction at 5
1 GJ, gastric-wall biopsy Good months postoperatively, which res-
Duodenal TB (12) with stricture of ponded to conservative management.
1st part of duodenum (10) TV, GJ, lymph-node biopsy (2 with FJ) All good All patients tolerated the anti-
3rd part of duodenum (1) Roux-en-Y DJ, FJ Good tubercular regimen well except for 1
Common bile duct (1) Cholecystectomy, RY choledocho- Hepatitis who developed drug-induced hepati-
jejunostomy & DJ, lymph-node biopsy tis 20 days after starting treatment.
Upper gastrointestinal bleeding (n = 6) In this patient, the anti-TB treatment
Duodenal ulcer (3) 1 anti-TB postendoscopy (no surgery) Good regimen was modified to ethambu-
With severe bleeding (2) 1 TV, emergent antrectomy Good
tol, ciprofloxacin and streptomycin,
1 emergent partial duodenectomy Died PO
SMA– duodenal fistula (1) Emergent total duodenectomy Died PO
which were tolerated well.
Duodenal stricture with sPHT (1) TV, GJ, splenectomy, devasculariz’n Good
TB of stomach with sPHT (1) Splenectomy, devascularization Good Discussion
Pseudotumour (n = 3)
Periampullary growth (2) Whipple’s procedure Both good The most common site for GI in-
Stomach mass (1) Explor. laparotomy, omental biopsy Good volvement of TB is the ileocecal re-
anti-TB = antitubercular treatment; DJ = duodenojejunostomy; Explor. = exploratory; FJ = feeding gion, followed by the ascending co-
jejunostomy; GJ = gastrojejunostomy; PO = in postoperative period; RY = Roux-en-Y; SMA = superior lon, jejunum, appendix, duodenum,
mesenteric artery; sPHT = segmental portal hypertension; TB = tuberculosis; TV = truncal vagotomy
stomach, sigmoid colon and rectum.1

366 J can chir, Vol. 47, No 5, octobre 2004


Managing gastroduodenal tuberculosis

Involvement of the stomach and duo- also rare16 because of the surround- biopsies to include the submucosa. In
denum is rare; an autopsy series has ing inflammatory fibrosis induced by a review of 27 patients who under-
reported an incidence around 0.5%.2,3 the ulcer. went endoscopic biopsies of duode-
Possible causes for GD sparing in- Our series serves to highlight the nal TB,13 although 20 had images of
clude high acidity, a paucity of lym- rarity of gastric/pancreatic pseudo- nonspecific duodenitis, granulomas
phoid tissue and rapid transit of food tumour as a manifestation of GD were found in only 7. In our series,
in the stomach.2,4–6 Long-term thera- TB. We encountered only 3 such pa- only 2 of 20 patients had positive
py with H2 blockers increases the in- tients, in whom all preoperative at- endoscopic biopsies.
cidence of GD TB; 7 18 of our 23 pa- tempts to obtain a histopathological Acid-fast bacilli are rarely recov-
tients had previously had therapy diagnosis had failed. ered from the biopsy material, al-
with H2 blockers. Gastric involvement Another interesting aspect of this though fine-needle aspiration cytol-
most likely originates from adjacent study is the occurrence of segmental ogy may have a higher yield.20 In a
celiac lymph nodes.7,8 In western portal hypertension with bleeding minority of cases it is possible to iso-
countries, it is found either in immi- fundal varices caused by obstruction late mycobacteria in culture from
grants from countries where TB is en- of the splenic vein by perihilar lymph gastric lavage.13 Polymerase chain re-
demic or in patients with leukemia or nodes. Again, this has not been re- action amplification of mycobacterial
AIDS who are immunosuppressed.9 ported before. DNA may improve the rate of detec-
A chest x-ray may show evidence tion.22 However, false negatives are
Clinical features and sequelae of pulmonary TB in up to 20% of reported in 40%–65% of cases.23
cases.3 In our series, 14% did so. Bar-
Because the clinical features are often ium meal study is nonspecific and Management
vague and nonspecific, the disease is may show segmental narrowing of
seldom suspected in the absence of the pylorus or duodenum, some- When diagnoses of TB are estab-
pulmonary TB. In a collective review times associated with ulcers or sinus lished before surgery, most lesions
of 49 patients with duodenal TB,10 tracts. Thickening of the gastric or regress with appropriate antitubercu-
the most common presenting symp- duodenal wall, associated with en- lar treatment and do not require ex-
toms were pain (73%) and vomiting larged local lymph nodes, is often cision.24,25 Even in patients with stric-
(55%), whereas GI bleeding was rare visible via CT and may be the only tures, endoscopic balloon dilatation
(16%). In our series, however, epigas- clue to diagnosis. has been successful.26 Elective surgery
tric pain and vomiting occurred with Retroduodenal and pancreatic TB should be reserved for complications
similar frequency (60%), and bleeding can sometimes mimic pancreatic such as obstruction, fistula formation
occurred in 26% of cases. tumours.17,18 Extensive mesenteric or intractable ulceration.
Sequelae of GD TB that require lymph-node disease is reported in
surgery include obstruction of the 32%–65% of cases of intestinal TB, Obstruction
gastric outlet, upper-GI hemorrhage, but obstruction by enlarged pyloro-
fistulous communication and perfor- duodenal nodes occurs in only 4%.6 In patients with gastric-outlet ob-
ation. Obstruction, the most com- In our series, 63% of cases involved struction, gastrojejunostomy is pre-
mon cause of presentation, occurs in mesenteric lymph nodes, with an un- ferred over pyloroplasty, as intense fi-
the hypertrophic form or involves usually high incidence of periduode- brosis around the pyloroduodenal
perigastric or periduodenal lymph nal/perigastric lymph nodes (43%) junction precludes safe pyloroplasty.27
nodes with subsequent fibrosis.11 Al- causing gastric-outlet obstruction. Furthermore, subsequent stenosis as-
though hemorrhage is less common Two patients in our series had CT sociated with the healing of tubercu-
and is usually mild and intermittent, features suggestive of periampullary lar lesions may constrict the passage
in our series nearly a quarter of pa- mass or pancreatic tumour. after pyloroplasty, resulting in a re-
tients arrived with bleeding. Half of Upper-GI endoscopy may reveal currence of symptoms.28
these bled heavily, which caused 2 duodenal bulb deformity.19 In gastric Obstruction persisting despite an
deaths. TB, it may present as multiple shal- adequate gastrojejunostomy stoma
Fistulous communication can oc- low ulcers, especially on the lesser affected many of our patients, 2 of
cur between the duodenum and bile curvature of the stomach20 or as a whom required resurgery. This may
duct or renal pelvis.12–14 Massive hem- nondescript hypertrophic submucosal be related to prolonged gastric stasis
orrhage from aortoduodenal fistula mass.21 Even in ulcerated lesions, en- and atony, or to involvement of the
has been reported,15 but we found no doscopic biopsy rarely reveals granu- neural plexus. To overcome this
report of a superior mesenteric artery lomas because of the predominantly problem we always do a feeding je-
–duodenal fistula as seen in 1 of our submucosal location of these lesions junostomy along with the gastro-
patients. Perforation peritonitis is and the failure of routine endoscopic jejunostomy.

Can J Surg, Vol. 47, No. 5, October 2004 367


Rao et al

Bleeding Conclusion Duodenal tuberculosis presenting as bleed-


ing peptic ulcer. Am J Gastroenterol 1988;
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15. Kodaira Y, Shibuya T, Matsumoto K,
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TB, a tubercular etiology should be tion — and one should not err on the duodenal tuberculosis without an abdom-
considered.13 side of doing too little. A diagnosis of inal aortic aneurysm: report of a case. Surg
Today 1997;27:745-8.
During surgery, suspicious lymph tuberculosis in such cases, even in en-
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368 J can chir, Vol. 47, No 5, octobre 2004