37poflee Etal

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Case report
DOI: 10.5958/2319-5886.2015.00180.0
Open Access
ISOLATED GASTRIC TUBERCULOSIS MASQUERADING AS CHRONIC PEPTIC

ULCER: A CASE REPORT
1
Poflee Sandhya V , Baste Balaji D , Umap Pradeep S , Shrivastava Alok C
ARTICLE INFO
th
Received: 12 May 2015

th
Revised: 15 June 2015
th
Accepted: 7 Aug 2015
1
Author details: Assistant Professor,

2
3
Resident,
Associate
Professor,
Department of Pathology, IGGMC,
Nagpur, Maharashtra, India
Corresponding author: Poflee
Sandhya V
1
Assistant Professor, Department of
Pathology, IGGMC, Nagpur,
Maharashtra, India
Email: [email protected]
Keywords:
Gastric
Chronic peptic ulcer
ABSTRACT
Abdominal Tuberculosis (TB) most commonly affects ileo-caecal region.
Isolated stomach involvement by TB, without pulmonary infection is rare.
Clinical presentation of Stomach TB may be non-specific, radiological
findings non-contributory and superficial endoscopic biopsies may not be
able to settle the diagnosis. Many cases are diagnosed only after
histopathological examination of surgical specimens. High degree of
suspicion is needed for early diagnosis of gastric tuberculosis, if
unnecessary surgical interventions are to be avoided. A young patient who
was being treated as a case of chronic peptic ulcer for one year was
referred for treatment of gastric outlet obstruction. Histopathological
examination of gastrectomy specimen of the patient showed multiple
caseating granulomas characteristic of tuberculosis and presence of acidfast bacilli on Fite-Faraco staining, with no evidence of tuberculosis at
pulmonary or other body sites. This case of isolated gastric TB is reported
for its rarity.
tuberculosis,
INTRODUCTION
Extrapulmonary tuberculosis (TB) accounts for 10-15%
of all cases of TB and the incidence reaches higher in
[1]
patients with AIDS. Gastro-intestinal tract (GIT) is the
sixth most frequent extra pulmonary site involved by
tuberculosis (TB) and ileo-caecal region is the most
[2,3]
common site of involvement in GIT TB.
Gastroduodenal or isolated gastric TB is uncommon even in
parts of the world where intestinal TB is endemic
including India and stomach and duodenal TB comprises
[4,5]
1% each of abdominal TB.
The presenting symptoms
of gastric TB are non-specific and misleading and often
[6]
mimic peptic ulcer disease or malignancy.
Primary
isolated gastric TB in absence of pulmonary TB in
[7]
immune competent host is rare.
This rare occurrence
of isolated gastric TB presenting as gastric outlet
obstruction in a patient without evidence of pulmonary
TB or immunodeficient state is presented.
any major illness. Her personal and family history was

not particular.
On general examination, the patient was a malnourished,
pale, afebrile female without
any other significant
clinical abnormality. Her abdominal examination revealed
epigastric fullness with suction splash and no
organomegaly. Complete hemogram showed low
hemoglobin level, dimorphic anemia and neutrophilic
leucocytosis. Her liver and kidney function tests were
within normal limits and her +HIV status was nonreactive.
Chest x-ray was normal and abdominal ultrasound
showed features suggestive of gastric outlet obstruction.
Barium studies revealed a distended stomach (Fig1A).
CASE REPORT
A 32 years old female was referred from a rural hospital
for abdominal distension and constipation since five
days. She gave history of abdominal pain since one year
associated with intermittent episodes of vomiting and low
grade fever off and on. Pain was localized to epigastrium
and umbilical region and was mild, intermittent in
character with no relation to food. The patient was being
treated as a case of chronic peptic ulcer without much
relief and has noticed significant loss of weight during
last six months. There was no history of cough,
hematemesis, diarrhea or malena and no past history of
Poflee et al.,
Fig 1(A): Barium study showing distended stomach. 1 (B):

Partial Gastrectomy specimen showing multiple ulcers with
undermined edges at the pyloric end of the stomach
Upper GI endoscopy revealed multiple pyloric ulcers

after sucking out fluid and debris from a grossly
896
Int J Med Res Health Sci., 2015;4(4):896-898
distended stomach with a non-negotiable pyloric

stenosis. No mass lesion was identified.
With diagnosis of gastric outlet obstruction secondary to
chronic peptic ulcer with pyloric stenosis, the patient
underwent exploratory laparotomy. Total truncal
vagotomy with distal partial gastrectomy and Billroth II
Roux-en-Y gastrojejunostomy with jejunojejunostomy
was undertaken. Rest of the abdomen was normal.
Partial gastrectomy specimen showed multiple ulcers
with undermined edges at the pyloric end of the stomach
(FIG1B).Necrotic material was expressed from the
ulcers. On histopathological examination sections
revealed ulcerated atrophic gastric mucosa and
presence of multiple granulomas in the wall of the
stomach (FIG2a).The granulomas comprised of central
area of caseous necrosis surrounded by groups of
epithelioid cells, Langhans giant cells and lymphocytes
(FIG 2a- inset).
Fig 2(a): Photomicrograph showing ulcerated and

atrophic gastric mucosa and presence of multiple
caseating granulomas in the wall of stomach (H & E,
400x). Inset: Photomicrograph showing granuloma
comprising of epithelioid cells, Langhans giant cell
and
lymphocytes
(H
&
E,
1000x).
2(b):
Photomicrograph showing acid fast TB bacillus on
special stain (Fite-Faraco, 1000x).
Diagnosis of TB was confirmed after visualizing acid-fast
Mycobacterium tuberculosis organisms on Fite-Faraco
stain (FIG2b). The patient was discharged after an
uneventful post-operative period and was enrolled under
Category-I of DOTS program. On monthly follow-up
visits, she showed remarkable improvement in her
general condition.
DISCUSSION
Gastric TB is commonly associated with TB at another
site, usually pulmonary or with an immunocompromised
state. Primary isolated gastric TB is rare in immune
[7]
competent host. First case of stomach TB was reported
[8].
by Barkhausen in 1824
The rarity of gastric tuberculosis is due to bactericidal
property of gastric acid, continuous motor activity of the
stomach and the scarcity of lymphatic follicles in the
[9].
gastric wall
The possible routes of infection include
direct infection of the mucosa by infected sputum,
hematogenous spread or extension from neighbouring
Poflee et al.,
[2]
tuberculous lymph nodes and fallopian tubes.

The
lesser curvature of antrum and prepyloric regions of
stomach are the most common sites involved.
Presenting symptoms of gastric TB are highly
nonspecific, vomiting and epigastric pain being the most
common and symptoms like weight loss, upper GI
bleeding, and fever with variable duration may be
[7]
present.
Clinical presentation of Gastric TB may
[10]
simulate gastritis, peptic ulcer or gastric carcinoma.
The patients usually land in surgery wards with
complications
such
as
gastric
outlet
obstruction,hematemesis,perforation or gastro-bronchial
[9]
fistula. Case reported here was referred to our centre
when the patient developed complication that needed
immediate surgical intervention.
There is lack of pathognomonic findings on imaging
studies in cases of gastric TB. Barium contrast study in
gastric TB,shows narrowing of gastric antrum and filling
defects. CT may show gastric wall thickening.
Upper Gastro-intestinal endoscopy in gastric TB reveals
single or multiple ulcers or hypertrophic nodular
[4]
lesions. In stomach TB a solitary ulcer may be seen in
fundus due to TB vasculitis with involvement of regional
lymph nodes. Four peculiarities of gastric TB described
on gastroscopy are- serpiginous nature of the ulcer with
undermined edges,multiple fistulous openings through
the mucosa and presence of superficial tubercles near
[7]
the lesion. However, Endoscopic biopsies are rarely
diagnostic as tubercular granulomas are mostly
submucosal, an area not included in endoscopic
[11]
biopsy
Granulomatous gastritis is a rare morphological
diagnosis and a variety of infectious and non-infectious
causes have to be considered in differential diagnosis.
Pathologic criteria established by Broders in 1917, for
diagnosis of gastric tuberculosis are similar to those
accepted today and require demonstration of caseating
epithelioid granuloma and presence of acid fast bacilli in
tissue. Histopathological examination of either a
gastroscopic biopsy or gastrectomy specimen for
characteristic morphological features and special stain
(Ziehl-Neelson or Fite Faraco) thus becomes most
important. But gastro duodenal TB is a pauci-bacillary
disease and demonstration of acid fast bacilli may not be
[1]
possible. PCR test of the biopsy specimen is essential
[8]
if culture study is not able to yield acid fast bacilli and
provides a faster alternative for the diagnosis. Antitubercular chemotherapy is the main modality for
management of gastric tuberculosis when the diagnosis
is established before surgery. Surgical intervention
becomes necessary when the patient presents with
complications such as gastric outlet obstruction,
[5,11,12]
perforation or fistula formation.
CONCLUSION
TB can involve any site in GIT and may present with
non-characteristic clinico-radiological features and
without
evidence
of
pulmonary
disease
or
immunodeficiency. High index of suspicion is needed for
diagnosis of gastric TB, especially in patients presenting
897
with endoscopic evidence of chronic inflammatory

activity and associated with non-specific fever.
Acknowledgements: Dr AV Shrikhande- Professor and
Head, Pathology and Dr. SM Lanjewar- Professor and
Head, Surgery IGGMC Nagpur for permission to publish
the case.
Conflict of interest: Nil
REFERENCES
1.
Gupta
P,Guleria
S,Mathur
SR,Ahuja
V.
Gastroduodenal Tuberculosis: A Rare cause of
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3. Dasgupta A, Singh N, Bhatia A. Abdominal
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Journal
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physician,Delhi.2010;1(2):56-61
4. Bandyopadhyay S, Bandyopadhyay R, Chatterjee U.
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8. Reddy DB, Krishnan M.K.R. Tuberculosis of the
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9. Amarapurkar DN, Patel ND, Amrapurkar AD.
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10. Kim SE, Shim KN, Moon II H. A Case of Gastric
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TK.Gastroduodenal
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management
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ISOLATED GASTRIC TUBERCULOSIS MASQUERADING AS CHRONIC PEPTIC

Poflee Sandhya V , Baste Balaji D , Umap Pradeep S , Shrivastava Alok C

Received: 12 May 2015

Author details: Assistant Professor,

any major illness. Her personal and family history was

Fig 1(A): Barium study showing distended stomach. 1 (B):

Upper GI endoscopy revealed multiple pyloric ulcers

distended stomach with a non-negotiable pyloric

Fig 2(a): Photomicrograph showing ulcerated and

tuberculous lymph nodes and fallopian tubes.

with endoscopic evidence of chronic inflammatory

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