Pitfalls in the diagnosis of intestinal tuberculosis: A case report

An 18-year-old long-term Norwegian resident of Somali origin was submitted to hospital with bloody diarrhoea, fever, weight loss and abdominal pain. On initial colonoscopy, colitis with segmental appearance was seen. Apart from a single polymerase chain reaction (PCR) from gastric aspirate staining, PCR and culture for acid-fast bacilli revealed negative results from the multiple samples taken including sputum, gastric fluid, stool, urine and intestinal mucosa. On physical examination and CT scan, there was no evidence of ascites, lymph node enlargement or pathologic pulmonary findings. Although the diagnosis was uncertain, tuberculostatic therapy was initiated. As the conformational testing of the PCR and the microbiological work-up remained negative and the patient's condition did not improve, tuberculostatic treatment was stopped and Crohn's disease was stated as the most likely diagnosis. Although the patient improved clinically under therapy with prednisolone, newly appearing fistulas deriving from the ascending colon were noted on follow-up. Thus tuberculostatic treatment was restarted. However, signs of an acute abdomen appeared and laparotomy was performed, thereby revealing a peritoneal spread of nodules. Resection of the ileum and ascending colon was performed. Diagnosis of intestinal tuberculosis with peritoneal spread was made by histology from resected bowel specimens showing caseating granulomas and a positive PCR result. The patient's condition improved after resection of the highly inflamed bowel segments and tuberculostatic therapy. Our case report shows the difficulty of proving intestinal tuberculosis by microbiological testing, macroscopic features on colonoscopy, histology, imaging such as CT scan and by empirical therapy. Therefore, in cases of colonic inflammation, where intestinal tuberculosis is an important differential diagnosis, a more aggressive diagnostic approach such as explorative laparoscopy should be considered.     

Tuberculous liver abscess in an immigrant patient with pulmonary tuberculosis

Liver abscess due to Mycobacterium tuberculosis associated with pulmonary tuberculosis is a rare diagnosis, particularly in patients without AIDS. We report the case of a male immigrant with no HIV infection who developed a tuberculous liver abscess and pulmonary tuberculosis simultaneously. Ziehl-Neelsen stain, PCR and L?wenstein-Jensen culture of material sampled from the abscess established the microbiological diagnosis. The patient's course was good, with disappearance of symptoms and the abscess after tuberculostatic treatment and drainage of the abscess with monitoring by computed tomography.     

Primary tuberculous peritonitis during infliximab therapy for Crohn's disease

A 64 year old male patient suffering from Crohn’s disease received infliximab therapy for a period of 5 months prior to presentation to our hospital. Due to the symptoms fever, ascites, and diffuse abdominal tenderness on palpation of unknown origin, a CT scan of the abdomen was performed and led to the suspected diagnosis of a peritoneal carcinomatosis. QuantiFERON™ test revealed a tuberculosis infection and molecular analyses of a peritoneal specimen obtained by laparoscopy clearly identified Mycobacterium tuberculosis DNA. Quadruple tuberculostatic therapy was initiated and the patient's condition continuously improved thereafter.     

A case of pneumatosis cystoides intestinalis: diagnosed by CT colonoscopy]

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by multiple gas filled cysts in the intestinal wall. The diagnosis of PCI is usually made by colonoscopy, histology, or radiologic findings. We report a case of PCI in a 35-year-old man. The patient initially complained of watery diarrhea and abdominal bloating for 2 weeks. Simple abdominal X-ray demonstrated numerous, small, round, air densities on the right upper abdomen along the ascending and proximal transverse colon. Colonoscopy revealed numerous, 5-20 mm sized, sessile polypoid, balloon-like distended, protruding subepithelial masses covered with normal colonic mucosa from cecum to proximal transverse colon. We performed a CT colonoscopy and confirmed PCI with multiple air-filled cystic masses along the colonic wall from cecum to proximal transverse colon. The patient was treated with antibiotics and oxygen inhalation for 2 weeks. Follow-up CT colonoscopy revealed marked regression in the number and size of the air-filled cystic masses. Herein, we report the first case of the PCI in Korea diagnosed by CT colonoscopy. Follow-up evaluation with CT colonoscopy was performed after the treatment of the PCI. CT colonoscopy is a useful non-invasive diagnostic tool for the diagnosis of pneumatosis cystoides intestinalis.     

Therapierefraktäre schwere Ileokolitis

The differential diagnosis of granulomatous intestinal diseases leads to recurrent false diagnoses. Our patient who was presenting with gastrointestinal complaints was first diagnosed as having Crohn's disease. Put on an immunosuppressive treatment, the symptoms deteriorated. Examination of sputum revealed acid-fast bacilli, later confirmed as M. tuberculosis in culture, and colonoscopy showed necrotizing granulomas, which lead us to the final diagnosis of abdominal tuberculosis. Our patient improved under an adequate tuberculostatic regime.     

无症状肠结核的结肠镜诊断

目的探讨无症状肠结核的结肠镜检诊断。方法回顾性分析本院1997年1月至2004年12月结肠镜检查诊断的无症状肠结核14例资料。结果结肠镜下表现:病变部位:11例位于回盲部或回肠末端,3例位于结肠;分型:炎症型3例,溃疡型4例,增殖型2例,混合型5例。病检:9例活检病理诊断肠结核,1次阳性5例,2次或以上阳性4例。结论结肠镜检重点观察肠结核好发部位及病变特征,结合活检是诊断无症状肠结核的重要手段。     

Does massive intraabdominal free gas require surgical intervention?

We describe a rare case of an 81-year-old man who presented with severe epigastralgia. A chest radiograph showed massive free gas bilaterally in the diaphragmatic spaces. Computed tomography(CT) scan also showed massive free gas in the peritoneal cavity with portal venous gas. We used a wait-andsee approach and carefully considered surgery again when the time was appropriate. The patient received conservative therapy with fasting, an intravenous infusion of antibiotics, and nasogastric intubation. The patient soon recovered and was able to start eating meals 4 d after treatment; thus, surgical intervention was avoided. Thereafter, colonoscopy examination showed pneumatosis cystoides intestinalis in the ascending colon. On retrospective review, CT scan demonstrated sporadic air-filled cysts in the ascending colon. The present case taught us a lesson: the presence of massive intraabdominal free gas with portal venous gas does not necessarily require surgical intervention. Pneumatosis cystoides intestinalis should be considered as a potential causative factor of free gas with portal venous gas when making the differential diagnosis.     

螺旋CT检查急性缺血性肠病所致门静脉和肠壁积气的表现特点及其临床诊断价值研究*

目的 探讨急性缺血性肠病所致门静脉和肠壁积气CT表现特点,总结CT诊断的价值。方法 回顾性分析2014年6月~2017年6月我院收治的20例缺血性肠病所致门静脉和肠壁积气患者CT检查资料,使用德国西门子 Emotion 64层螺旋CT进行扫描。行纤维结肠镜检查,并取组织行病理学检查。结果 在20例患者中,缺血性肠病的病变部位在小肠者9例（空肠5例、回肠4例）,回盲部3例（累及回肠末端和升结肠）,结肠8例（横结肠3例、结肠肝曲2例、结肠脾曲1例、降结肠1例、乙状结肠1例）;所有患者均显示有门静脉积气,其中13例门静脉和肝静脉呈现广泛的积气,表现为树枝状气体影,另7例CT显示肝缘下肝静脉远端有气体影;所有患者CT均显示肠壁有积气,病变部位可见气泡状低密度影,10例为单气泡影、7例为多气泡影、3例为带状泡影;14例CT显示肠壁增厚和水肿,6例肠管扩张、肠壁变薄,4例腹腔积液;行增强CT检查10例,显示病变肠段的肠壁和肠系膜强化程度减弱,分层强化后显示为环形靶征和晕征;所有患者入院治疗后1~2 d进行CT复查,显示门静脉和肠壁积气有不同程度的吸收,其中门静脉积气完全吸收4例、明显吸收9例、少量吸收4例、无显著变化3例。肠壁积气完全吸收5例、明显吸收7例、少量吸收6例、无显著变化2例。结论 门静脉和肠壁积气的CT表现有特征性,使用 CT检查对急性缺血性肠病患者的诊断有较好的临床应用价值。     

肠结核的影像学诊断

目的 探讨肠结核的CT与肠道X线造影的诊断价值及局限性,优化影像学组合检查。方法 收集经病理证实的肠结核22例,所有病例均经CT及肠道X线检查包括胃肠钡餐造影（GI）18例、十二指肠低张造影2例、小肠双对比造影3例、结肠双对比造影8例,分析两种检查的影像学表现。结果 CT对肠结核病灶检出的敏感性和定性论断如肠道X线检查,不易判断十二指肠水平段及空回肠病灶,但易于检出合并腹内肠外结核（特别是对诊断有帮助的特征性淋巴结结核）及侵犯肠道的肠外结核灶。肠道X线检查对肠结核的肠粘膜破坏和溃疡形成情况、肠道的累及范围、肠腔的狭窄程度及瘘管的显示有重要诊断价值。结论 各种影像学检查均有其优点及不足之处,根据肠结核不同部位行局部腹部CT扫描加相应的肠道X线检查中明显提高该病的诊断准确性。     

Diagnostic dilemma of abdominal tuberculosis in non-HIV patients： An ongoing challenge for physicians

INTRODUCTION In developing countries, tuberculosis is associated with poverty, deprivation, overcrowding, illiteracy, and limited access to health care facilities. While in developed worlds, tuberculosis is commonly accompanied with HIV infection, ageing …     

内镜活检对肠结核的诊断价值

目的探讨结肠镜检查及其活检标本对肠结核的诊断价值。方法对高度怀疑肠结核的患者34例进行结肠镜、胸腹部X线、病理组织学和结核菌PCR试验检查，并比较其阳性率。结果34例患者最终确诊为肠结核的有23例、克罗崽病3例、结肠癌3例，其他疾病5例。在各疾病中的阳性率均无明显差异。腹部X线阳性率47．8％，假阳性27．3％；内镜诊断阳性率为52．2％，假阳性27．3％；活检组织病理学阳性率82．6％，假阳性9．1％；PCR阳性率73．9％，假阳性18．2％；PPD阳性率52．2％，假阳性9．1％，结论结肠镜检查诊断肠结核的阳性率不高，结肠镜活柃标本进行组织学和结核菌PCR检测可显著提高肠结核的诊断率，但要注意假阳性结果。     

CT平扫及增强联合多模式重建技术用于结肠肿瘤病变的诊断价值

目的探讨CT平扫及增强扫描联合多模式重建技术用于结肠肿瘤病变的诊断价值。 方法回顾性分析广安市人民医院行肠镜检查怀疑为结肠病变的96例患者的临床资料,术后均经病理证实为结肠癌70例,结肠息肉26例,所有患者术前经CT平扫及增强扫描,并将扫描数据传入后处理工作站,获取多平面重建（MPR）、透明法（Raysum）及结肠仿真内镜（CTVC）图像,分析结肠癌CT表现,对结肠癌术前CT图像进行T、N分期,并与术后病理结果进行比较。 结果CT平扫及增强扫描联合多模式重建技术对结肠癌病变检出率、结肠息肉检出率均为100.00%。CT平扫及增强扫描联合多模式重建技术诊断累及浆膜层、累及邻近组织脏器、腹膜后淋巴结转移与病理结果比较差异均无统计学意义（P>0.05）。术前CT平扫及增强扫描联合多模式重建技术诊断T分期总准确度为84.29%,≤T₂期、T₃期、T₄期准确度分别为75.00%、73.33%、88.10%;诊断N分期总准确度为71.43%,N₀期、N₁期、N₂期准确度分别为72.73%、60.00%、77.27%。术前CT平扫及增强扫描联合多模式重建技术诊断T、N分期与病理诊断T、N分期一致性好（Kappa=0.725,0.547,均P<0.05）。 结论CT平扫及增强扫描联合多模式重建技术对结肠肿瘤病变诊断准确率高,可较好的显示结肠癌肠腔情况,明确肿瘤侵犯范围及腹膜后淋巴结转移情况,还可用于术前分期诊断,临床应用价值较高。     

螺旋CT诊断老年大肠癌162例

目的:探讨螺旋CT对老年大肠癌的诊断价值.方法:分析经外科手术加病理检查证实的162例老年大肠癌患者的螺旋CT扫描图像,比较螺旋CT检查与结肠镜检查对老年人结肠癌的诊断符合率.结果:CT检查受检率100%,电子肠镜受检率75.3%,40例患者未能完成结肠镜检查,其中包括冠心病、高血压病27例(16.67%),CT检查对老年大肠癌的诊断检出率为80.86%,与电子结肠镜(70.37%)比较有显著提高(P<0.05).结论:螺旋CT检查不仅能发现病变.还能确定病变侵犯范围及转移情况,且无痛苦,对老年患者更安全、方便易行,可作为老年大肠癌诊断的常规手段.     

56例结核性腹膜炎患者CT影像分析

目的 探讨结核性腹膜炎（TBP）特征性CT影像表现及治疗中影像动态变化的特点。方法 回顾性分析56例临床及病理确诊的TBP患者,观察分析CT影像特征,包括腹腔积液、腹膜（壁腹膜、肝包膜、大网膜及肠系膜）及腹腔淋巴结。56例均行CT平扫+增强扫描。治疗过程中收集动态复查CT影像。结果 腹腔积液45例,大量1例,中少量44例,限制性38例,CT值>20 HU者34例。壁腹膜增厚46例,肝脏边缘部腹膜均有受累,均匀增厚17例,扁丘状凸起或腹膜结核瘤29例,增强扫描结核瘤边缘强化,肝包膜或肝脏受累15例;网膜增厚35例,结节及斑片34例,网膜饼1例,增强扫描网膜饼呈轻度不均匀强化;肠系膜增厚41例,表现为斑片、结节及线状、星芒状条索状高密度影,与肠袢粘连,增强扫描肠系膜血管包埋其内,走形扭曲。腹腔及腹膜后淋巴结增大19例,伴钙化5例,簇集状排列,增强扫描环状或蜂窝状强化。17例完整的动态CT图像,腹腔积液吸收最快,网膜及肠系膜病变吸收稍慢,腹膜结核瘤缩小速度最慢。结论 TBP的CT诊断为多种征象的综合,中少量腹腔积液伴壁腹膜、网膜及肠系膜的增厚粘连是最为常见的影像表现;CT影像动态变化对临床评价疗效具有重要意义。     

Ileal chloride secretion as a cause of secretory diarrhea in a patient with primary intestinal tuberculosis.

Severe secretory diarrhea resulting in dehydration and hypokalemia was observed in a patient in whom primary cecal tuberculosis was diagnosed by colonoscopy. Although the ileum appeared normal at colonoscopy and by biopsy, intestinal perfusion studies showed that the ileum was secreting water and electrolytes. Chloride secretion against a high electrical gradient suggested active anion secretion. Absorption in the colon was unimpaired. The diarrhea resolved after 4 wk of antituberculous therapy. Repeat perfusion studies after 3 mo showed normal absorption in the ileum. This case report suggests that intestinal tuberculosis can cause secretory diarrhea. The mechanism by which secretion occurs is not clear, but probably involves active anion secretion.     

Haemoperitoneum post colonoscopy in a continuous ambulatory peritoneal dialysis patient

We present the case of a patient on peritoneal dialysis (PD) who had an uneventful oesophagogastroduodenoscopy and colonoscopy. His peritoneal dialysis after colonoscopy had bright red peritoneal dialysate. The patient was completely asymptomatic and a CT scan was performed which did not reveal any retroperitoneal haematoma and showed no signs of perforation or splenic tear. His PD dialysate cleared up with time. We do not find any such case in the literature in which a patient has had haemoperitoneum after a colonoscopy without any obvious cause to account for it. Our patient was unique due to his CAPD in combination with his immunosuppression for his kidney transplant which may have predisposed him to the intraperitoneal bleed after colonoscopy or it may just have been a normal phenomenon after colonoscopy. More studies need to be done as the realisation of its pathology can prevent unnecessary testing and avoid patient and healthcare worker’s anxiety.     

A case of lung tuberculosis which also incidentally found intestinal tuberculosis by 18F-fluorodeoxyglucose-positron emission tomography]

A 60-year-old women presenting with an abnormal shadow on a chest X-ray film was admitted to our hospital in June 2004. Her CT scan of the chest showed a cavitary mass shadow in the left upper lobe. FDG-PET was performed to examine whether this shadow was the lung cancer or not, and incidentally it showed an additional accumulation of FDG in the ileocecal resion. The colonoscopy was then carried out. Luminal narrowing with circumferential ulcer in the ileocecal resion could be observed, and pathological findings of the biopsy specimen revealed epithelioid cell granulomas. Partial lobectomy of the left upper lung was also performed, and the histological examination revealed typical pulmonary tuberculosis. Since the antituberculosis therapy was effective to the ileocecal lesion, we assert that the ileocecal lesion was intestinal tuberculosis.     

Fulminant amoebic colitis during chemotherapy for advanced gastric cancer

A 52-year-old man had bloody stools during chemotherapy for gastric cancer. A colonoscopy revealed necrotizing ulcer-like changes. A biopsy confirmed the presence of amoebic trophozoites. Subsequently, peritonitis with intestinal perforation developed, and emergency peritoneal lavage and colostomy were performed. After surgery, endotoxin adsorption therapy was performed and metronidazole was given. Symptoms of peritonitis and colonitis resolved. However, the patient＇s general condition worsened with the progression of gastric cancer. The patient died 50 d after surgery. Fulminant amoebic colitis is very rarely associated with chemotherapy. Amoebic colitis should be considered in the differential diagnosis of patients who have bloody stools during chemotherapy.     

Abdominal tuberculosis in children. Report of 10 cases

BACKGROUND: Abdominal tuberculosis is a rare location of this infection with a lot of diagnostic difficulties. The aim of this study was to review our experience of pediatric abdominal tuberculosis with that of the literature data. PATIENTS AND METHODS: A retrospective study was conducted over a 7-year period; 10 cases of abdominal tuberculosis in children were reviewed (6 girls and 4 boys, mean age: 11 years, extremes 4-14). Eight patients enrolled in this study satisfied the following criteria: a positive culture for mycobacterium tuberculosis on samples of ascites fluid, sputum, urine, abscess puncture and/or caseating granulomas on histologic examination of biopsies obtained by endoscopy, percutaneous aspiration or needle biopsy or exploratory laparotomy. Two other patients (patients No 1 & 5) had a favorable response within 10 weeks of antituberculous therapy. RESULTS: We observed 8 cases of peritoneal tuberculosis and 2 cases of intestinal tuberculosis. Extra-abdominal tuberculosis was found in 4 of those patients. Two patients had a contact with a tuberculosis positive individual. Nine children had BCG immunization. The main clinical features were abdominal distension (6 cases) and abdominal pain (6 cases). Abdominal ultrasonography visualized mesenteric lymphadenopathies (6 cases), an abdominal mass (5 cases), free (1 case) and localized ascites (1 case). Barium enema and small bowell series showed small bowel stenosis (1 case) and ileal ulcerations (1 case). Exploratory laparotomy, performed in 3 patients, showed whitish granulations and peritoneal abscesses with caseous necrosis on histology. Quadruple therapy with tuberculostatic agents was prescribed in all patients, associating isoniazid, rifampicin, pyrazinamide combined at the start of the treatment with streptomycin (7 cases) and ethambutol (3 cases). Short term outcome was favorable with no deaths. The long term outcome was complicated by persistent ascites (1 case) and the development of portal hypertension (1 case). CONCLUSION: Abdominal tuberculosis remains a rare localization with a lot of diagnostic difficulties.     

Ileoscopy in patients with ileocolonic tuberculosis

AIM: To study the role of retrograde terminal ileoscopy in patients suspected to have ileocolonic tuberculosis. METHODS: A retrospective analysis was performed for patients undergoing colonoscopy for suspected ileocolonic tuberculosis between January 2000 and June 2004, in whom retrograde ileoscopy had been performed. Only patients diagnosed with tuberculosis on the basis of histological findings of either a caseating granuloma or those having non-caseating granuloma or a collection of epithelioid cells at a minimum of one endoscopic lesion (either in the colon or the terminal ileum) on histology with good responses to conventional anti-tuberculous drugs were enrolled for the study. RESULTS: Fifty-three patients were included. The terminal ileum was involved in only 11 patients. Eight of these patients had involvement of the cecum too. Two patients had ileal lesions without cecal involvement; however, lesions were noted in the ascending colon. In one patient the whole colon was normal and only the terminal ileum showed nodularity and ulceration. Histological examination of the ileal biopsies obtained from the ileal lesions showed noncaseating granulomas in five, collection of epithelioid cells in four and nonspecific histology in two patients. Mucosal biopsies obtained from the lesion in the terminal ileum, in the patient in whom mucosal abnormality was observed to be confined to the ileum, showed noncaseating granulomas. In two other patients the ileal biopsies alone showed histological evidence of tuberculosis with biopsies from the colonic lesions showing non-specific inflammatory changes only. CONCLUSION: Retrograde ileoscopy should be performed in all patients undergoing colonoscopy for suspected ileocolonic tuberculosis. In some patients only the terminal ileum may be involved and histological examination may reveal evidence of tuberculosis only from the lesions in the terminal ileum. This approach would lead to additional lesions being picked up andincreasing the chances of well-timed diagnosis of tuberculosis.