Diagnostic and Therapeutic Approach in Intestinal Tuberculosis

CASE REPORT

  

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Tri Hapsoro Guno*, Barry A Putra*, Telly Kamelia**, Dadang Makmun***

• Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General National Hospital Jakarta **Division of Pulmonology, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta ***Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine Universitas Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta

  Corresponding author:

Dadang Makmun. Division of Gastroenterology, Department of Internal Medicine, Dr. Cipto Mangunkusumo

General National Hospital. Jl. Diponegoro No.71 Jakarta Indonesia. Phone: +62-21-3153957;

Facsimile: +62-21-3142454. E-mail: hdmakmun@yahoo.com $%675$&7

  

Tuberculosis was still a global health problem. Beside lung, tuberculosis also manifest in other organs, one

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symptoms so that its diagnostic procedure was not rarely inconclusive. We reported a 24 years old woman with

chief complain of worsening abdominal pain in all region, accompanied by nausea, vomiting, bloating, and absent

bowel movement. She also had a fresh bloody stool. She had an active pulmonary tuberculosis on initiation phase

treatment. Physical examination suggest a bowel obstruction sign with distended abdomen and increase bowel

  

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for malignancy similar to computerized tomography (CT) scan result, but pathlogic result showed an active

colitis without any sign of malignancy. Because of its contradiction, the second colonoscopy was performed and

concluded as intestinal tuberculosis, matched with second pathologic examination. Although polymerase chain

reaction (PCR) tuberculosis (TB) showed a negative result, a further clinical judgement concluded this as an

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drugs and planned to have colonoscopy evaluation. After general condition was good and obstructive ileus sign

was relieved, patient planned for outpatient care.

  Keywords: intestinal tuberculosis, colonoscopy, abdominal pain, diagnosis, therapy $%675$.

  

Tuberkulosis (TB) masih merupakan masalah kesehatan global. Selain pada paru, TB juga bermanifestasi

pada organ lain, salah satunya organ abdomen. Tuberkulosis abdomen merupakan penyakit kompleks dengan

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inkonklusif. Pada laporan kasus ini, dilaporkan seorang perempuan berusia 24 tahun dengan keluhan nyeri

perut yang memberat di semua bagian, disertai mual, muntah, kembung, dan tidak bisa buang air besar.

Pasien juga mengeluarkan tinja bercampur darah segar. Dia menderita TB paru aktif pada pengobatan fase

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Pada temuan prosedur kolonoskopi, terdapat massa yang menghambat lumen usus di daerah ileosekal, diduga

adanya keganasan, mirip dengan hasil computerized tomography (CT) scan, namun hasil pemeriksaan patologi

  Diagnostic and Therapeutic Approach in Intestinal Tuberculosis

menunjukkan kolitis aktif tanpa tanda-tanda keganasan. Karena kontradiksi ini, maka dilakukan kolonoskopi

kedua dan disimpulkan sebagai tuberkulosis usus, sesuai dengan pemeriksaan patologi yang kedua. Walaupun

reaksi berantai polymerase TB menunjukkan hasil negatif, penilaian klinis lebih lanjut menyimpulkannya

sebagai kasus tuberkulosis usus. Pasien akhirnya diterapi sebagai pasien tuberkulosis usus dengan obat anti

tuberkulosis kategori satu dan direncanakan untuk menjalani evaluasi kolonscopi. Setelah kondisi umum baik

dan gejala ileus obstruktif tidak ada, pasien direncanakan untuk rawat jalan.

  Kata kunci: TB usus, kolonoskopi, nyeri perut, diagnosis, terapi ,1752'8&7,21

  Tuberculosis (TB) was a worldwide emergency with high mortality and morbidity. TB remained one RI WKH WRS FDXVH RI GHDWK ZLWK PRUWDOLW\ ZDV DV KLJK DV PLOOLRQ 7% GHDWKV FDVH LQ ,QGRQHVLD ZLWK RWKHU ¿YH FRXQWULHV &KLQD 1LJHULD 3DNLVWDQ ,QGLD DQG

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  Extrapulmonary TB was a Mycobaterium tuberculosis LQIHFWLRQ LQ RUJDQV RWKHU WKDQ OXQJ VXFK DV SOHXUD O\PSK QRGHV XULQDU\ WUDFW VNLQ MRLQW ERQH PHQLQJHQV DQG DOVR DEGRPLQDO RUJDQV LQGHHG LQWHVWLQDO 7% 7KH GLVHDVH site of the largest proportion of extrapulmonary TB ZDV SOHXUDO O\PSKDWLF JHQLWRXULQDU\ ERQH MRLQW FXWDQHRXV PHQLQJHDO SHULWRQHDO JDVWURLQWHVWLQDO DQG RWKHUV

  Diagnostic approach for extrapulmonary TB consist of clinical examination with other examination such DV EDFWHULRORJLFDO DQG SDWKRORJLFDO H[DPLQDWLRQ DQG also bacteriological examination to make sure wether pulmonary TB was also present or not. ¹ Abdominal

  WXEHUFXORVLV ZDV D FRPSOH[ GLVHDVH ZLWK XQVSHFL¿F sign and symptoms. Most of its diagnostic procedure ZDV LQYDVLYH H[SHQVLYH DQG QRW UDUHO\ LQFRQFOXVLYH ⁴ This report will present an intestinal tuberculosis case with partial obstruction ileus as its main symptoms. As

  LQWHVWLQDO 7% GLDJQRVWLF ZDV GLI¿FXOW ZLWK PDQ\ SRVVLEOH GLIIHUHQWLDO GLDJQRVLV HVSHFLDOO\ FRORQ WXPRU WKLV FDVH was an interesting case to learn about diagnostic and therapeutic approach in patietns with intestinal TB problems.

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  $ IHPDOH SDWLHQW DJHG \HDUV ROG FRPH ZLWK worsening abdominal pain since three days before admission as a chief complaint. The abdominal pain felt DV FUDPS LQ DOO DEGRPLQDO UHJLRQ IROORZHG E\ QDXVHD and vomiting. The pain actually was present since three months ago but was reliefed without any medical drugs. She also feels her stomach bloating and full with frequent vomits per day. She could not defecate since three days EXW WKH ÀDWXV ZDV VWLOO SUHVHQW 6KH KDV DQ RUDO LQWDNH GLI¿FXOW\ EHFDXVH RI WKH QDXVHD DQG YRPLW VLQFH WKUHH days. No fever reported. Sometimes fresh bloody stool was also complained starting about four months before admission. From the previous examination patient was diagnosed as a new pulmonary tuberculosis case on ¿UVW ZHHN WKHUDS\ ZLWK FKLHI FRPSODLQW RI IRXU ZHHNV SURGXFWLYH FRXJK DFFRPSDQLHG ZLWK QLJKW VZHDW ZHLJKW ORVV DQG LQWHUPLWWHQW IHYHU 3UHYLRXV EDFWHULRORJLFDO examination from sputum showed a negative result. It LV NQRZQ WKDW KHU PRWKHU KDV MXVW ¿QLVKHG VL[ PRQWK tuberculosis therapy. There were no history of Diabetes PHOOLWXV K\SHUWHQVLRQ KHDUW GLVHDVH OXQJ GLVHDVH OLYHU GLVHDVH DQG DQ\ GUXJV FRQVXPSWLRQ 7KHUH ZHUH QR family history of Diabetes mellitus and malignancy. Patient was an administration staff in a private company.

  6KH GLG QRW FRQVXPH DOFRKRO DQG FLJDUHWWH QR KLVWRU\ of intravenous drug use and promiscousity.

  Physical examination shows a moderately ill ZLWK QRUPDO EORRG SUHVVXUH UHVSLUDWRU\ UDWH DQG WHPSHUDWXUH EXW WDFKLFDUGLD ZLWK KHDUW UDWH ESP Body mass index showed normal weight. Examination RI KHDG QHFN DQG WKRUD[ ZDV ZLWKLQ QRUPDO OLPLW Abdominal examination reveals a bloating abdomen ZLWK SHULVWDOWLF PRYHPHQW WKDW FOHDUO\ VHHQ LQFUHDVLQJ frequency of bowel sound. On percussion tymphanic

  VRXQG IRXQG RQ DOO DEGRPLQDO UHJLRQ WKHUH ZHUH QR pain and organomegaly. Extremity was warm with JRRG FDSLOODU\ UH¿OO WLPH PRWRULF DQG VHQVRULF DELOLW\ was normal in all limb. Digital rectal examination showed a small hemorrhoid mass with normal tonus

  VSKLQFWHU UHFWXP DQG QR PDVV ZDV IRXQG Laboratory examination showed hemoglobin

  OHYHO J G/ OHXNRF\WH FRXQW FHOO ǐ/ DQG WKURPERF\WH FHOO ǐ/ 5HQDO DQG OLYHU IXQFWLRQ test was normal. Electrolyte level and ECG result was QRUPDO &KHVW ; UD\ VKRZHG DQ LQ¿OWUDWH SURFHVV RQ right lung parenchyme with pleural effusion on the right Tri Hapsoro Guno, Barry A Putra, Telly Kamelia, Dadang Makmun

  OXQJ 7KUHH ZD\ DEGRPLQDO ; UD\ VKRZHG D PXOWLSOH DLU ÀXLG OHYHO GLODWDWLRQ DQG WKLFNHQLQJ RI LQWHVWLQDO wall with bowel air that found in distal part suspiction of partial obstructive ileus. Abdominal ultrasonography

  7KH SRVVLEOH ULVN IDFWRU ZDV PDOQXWULWLRQ KHDOWKFDUH DFFHVVLELOLW\ DQG VSUHDG RI VDOSKLQJLWLV WXEHUFXORVLV into abdominal organs. Its has a wide clinical spectrum

  ,Q WKLV SDWLHQW a hyperthrophic lesion of polypoid mass was found in LOHRFDHFDO UHJLRQ 7KLV ZDV PDWFK IRU FRORQ FDUFLQRPD but its pathological examination showed an tuberculosis infection with dathia langhans cell found on the tissue.

  ,Q KLVWRSDWKRORJLF H[DPLQDWLRQ JUDQXORPDWRXV WXEHUFOH ZLWK FRQÀXHQW VKDSH LQ YDULRXV VL]H ZDV WKH PDLQ FKDUDFWHULVWLF RI LQWHVWLQDO WXEHUFXORVLV DWKRXJK sometimes it was also found in submucosal layer below WKH XOFHU 7XEHUFXORXV XOFHU ZDV VXSHU¿FLDO DQG UDUHO\ LQ¿OWUDWH PXVFXODULV OD\HU 7KLV LV D WUDQVYHUVDO XOFHU that if affect all intestinal mucosa will result in stricture formation. A deeper lesion would show a different stages RI ¿EURVLV 0RVW RI LW VKRZLQJ D QRQVSHFL¿F FKURQLF LQÀDPDWLRQ ZLWKRXW DQ\ JUDQXORPD 0HVHQWHULF O\PSK nodes could also infected so that it enlarged followed by caseous formation. Granuloma was only found in patients consuming tuberculosis drugs.

  VWDWLV DUHD ZKHUH ÀXLG DQG HOHFWURO\WH DEVRUSWLRQ ZDV KLJK PLQLPDO GLJHVWLRQ DFWLYLW\ DQG ORW RI O\PSKRLG WLVVXH WKDW FDQ EH IRXQG WKHUH 0 FHOO LQ 3H\HU¶V SODTXH will fagositized M. Tuberculosis bacteria and would be the entry point for M. Tuberculosis to spread to the adjacent organs. Our patient has several risk factors for LQWHVWLQDO 7% LQIHFWLRQ WKDW LV ZRPHQ LQ \RXQJ DJH years old) with abnormalities on ileum and ileocaecal region was the part of intestine that having similar to intestinal tuberculosis in general.

  Ileocaecal was the preferred location of tuberculosis mycobacterium infection because of it was a physiologic

  IUHTXHQF\ IROORZHG E\ SHULWRQLWLV WXEHUFXORVLV LQWUDDEGRPLQDO YLVFHUDO WXEHUFXORVLV DQG O\PSKDGHQLWLV WXEHUFXORVLV %KDQVDOL HW DO 3UDNDVK HW DO DQG +RUYDWK HW DO UHSRUWHG WKDW WKH SUHGLOHFWLRQ of intestinal tuberculosis was in ileum and caecum.

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  IURP DV\PSWRPDWLF WR DFXWH FKURQLF DQG HYHQ DFXWH exacerbated manifestation.

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  VKRZHG DQ DVFLWHV LQ OHIW IRVVD VSOHQRUHQDO OHIW SUDFROLF and perivesical region. Thoracic ultrasound reveal bilateral pleural effusion then continued by diagnostic WKRUDFRFHQWHVLV ZLWK UHVXOW RI H[XGDWH SOHXUDO HIIXVLRQ ZLWK $'$ OHYHO RI 8 / VXJJHVWHG WXEHUFXORVLV LQIHFWLRQ $W WKLV SRLQW LW FDQ EH FRQFOXGHG WKDW WKH patient has a tuberculosis infection of lung and pleural cavity with partial obstructive ileus suspected caused by carcinoma of colon with intestinal tuberculosis was the differential diagnosis.

  IRU DFLG IDVW VWDLQLQJ DQG P\FREDFWHULDO FXOWXUH Intestinal tuberculosis was found mostly in young

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  Gastrointestinal tuberculosis was the most commonly forms of abdominal tuberculosis with LQFLGHQFH UDWH RI ZLWK LOHRFDHFDO FRORQ and jejenum as the most location found. Abdominal tuberculosis diagnosis was hard because of its

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  IRU WKH HYDOXDWLRQ SDWLHQW SODQQHG WR KDYH FRORQVFRS\ evaluation.

  As the possibility of intestinal tuberculosis was still SUHVHQW ZH GHFLGHG WR XQGHUJR VHFRQG FRORQRVFRS\ ,Q VHFRQG FRORQRVFRS\ WKH VFRSH FDQ HQWHU IXUWKHU WKHQ D SRO\SRLG JUDQXODU PDVV LQ DSSHQGL[ RUL¿FH LOHRFDHFDO YDOYH GLVWDO WHUPLQDO LOHXP DQG VWHQRVLV RI ileocaecal llumen was found. An intestinal tuberculosis was suggested and the second biopsy was done. The pathological examination result showed a suggestive tuberculosis infection with granuloma tissue consist RI HSLWKHRLG FHOO GDWLD /DQJKDQV FHOO DQG O\PSKRF\WH LQ¿OWUDWLRQ $ 3&5 7% ZDV DOVR GRQH EXW WKH UHVXOW ZDV QHJDWLYH 3DWLHQW ZDV ¿QDOO\ WUHDWHG IRU LQWHVWLQDO WXEHUFXORVLV ZLWK ¿UVW OLQH DQWLWXEHUFXORVLV GUXJV DQG

  VKRZHG D KLVWRORJLFDOO\ DFWLYH FKURQLF FROLWLV PLOG cript destruction with no sign of malignancy. CT scan ZLWK FRQWUDVW WKHQ SHUIRUPHG VKRZHG D WKLFNHQLQJ DQG FRQWUDVW HQOLJKWPHQW LQ FDHFXP LQWUDOXPLQDO ZDOO sugest a malignancy that involved terminal ileum with SHULFROLF DQG PHVHQWULDO O\PSKDQGHQRSDWK\ SOXV DQ obstructive ileus with dilatation of small intestine wall DQG PXOWLSOH DLU ÀXLG OHYHO GDQ IRUP D VWHS ODGGHU From analysis that pathological result of biopsy was not match to the CT scan result.

  Colonoscopy examination initially showed an H[WHUQDO KHPRUUKRLG QR PXFRVDO DEQRUPDOLW\ LQ UHFWRVLJPRLG GHVFHQGHQ DQG WUDQVYHUVDO FRORQ There was a bloody frail mass occluding the lumen 60 cm from anus and scope cannot move further for HYDOXDWLRQ UHYHDOHG D SRVVLELOLW\ RI FRORQ FDUFLQRPD A biopsy was done and pathology examination

  Symptoms of intestinal tuberculosis have two main FRXUVH FRQVWLWXWLRQDO VXFK DV IHYHU OHWKDUJ\ DQHPLD QLJKW VZHDW DQG ZHLJKW ORVV DQG ORFDO VXFK DV LQ 7DEOH below.

  Diagnostic and Therapeutic Approach in Intestinal Tuberculosis

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  DFWLYH GLVHDVH $EGRPLQDO ; UD\ PD\ VKRZHG DQ

  7\SH RI /HVVLRQ &OLQLFDO PDQLIHVWDWLRQ Ulcerative Chronic diarhea, malabsorption, bowel

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  perforation, rectal bleeding (Colonic TB)

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  Hypertrophic Bowel obstruction or ileocecal lump Stricture/constriction Subacute bowel obstruction (vomiting,

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  constipation, colic and abdominal

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  distention). Bowel dilatation and movement on inspection to acute instestinal

  x-ray during hospital admission. This patient also obstruction. having an active pulmonary tuberculosis with intestinal

  Anorectal

  6WULFWXUH RU ¿VWXOD DQL Gastroduodenal Ulcus peptikum with or without gastric

  tuberculosis.

  outlet obstruction or perforation Hepatosplenic Hepatosplenomegaly and granuomaotus hepatitis on microscopic examination (part of disseminated TB) Peritoneum Abdominal distention and ascites

  Lymph nodes Lump or mass on central abdomenmay be felt as dulll pain on abdomen.

  A specific symptoms of ileocaecal tuberculosis is bomborygmi bowel sound and frequent vomiting. Several findings on physical examination was LQWUDDEGRPLQDO PDVV ZLWK FOHDU ERUGHU PRELOH LQ ULJKW lower quadrant. Ascites and bowel dilatation with A B SHULVWDOWLF PRYHPHQW VHHQ FRXOG EH WKH SK\VLFDO ¿QGLQJ RQ LQWHVWLQDO WXEHUFXORVLV DWKRXJK LQ VRPH FDVHV WKHUH ZHUH QRVSHFLLF ¿QGLQJV 6HYHUDO GLVHDVH ZLWK VLPLODU

  VLJQ LV O\PSKRPD RU FDUFLQRPD LQÀDPPDWRU\ ERZHO GLVHDVH OLYHU FLUUKRVLV ZLWK DVFLWHV LOHRFDHFDO PDVV RU chronic appendicitis. The main symptoms reported in this patient was abdominal pain with some constitutional tuberculosis symptoms and bowel obstruction symptoms

  VXFK DV QDXVHD YRPLWLQJ ZLWK SUREOHPV LQ GHIHFDWLRQ RQ C D physical examination a distended and dilated abdomen

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  with more frequent bowel sound. For younger patient

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  with symptoms mention above should be suspected

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  for intestinal tuberculosis with sugestive a stricture or

  H[WUDOXPLQDO IUHH DLU VXJJHVWLYH IRU SDUWLDO ERZHO REVWUXFWLRQ constriction lesion.

  Laboratory examination was an important tool in Barium meal study showed a hypersegmentation

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  UDWH FRXOG EH IRXQG ,Q SDWLHQWV 0DQWRX[ WHVW enema would show spasm and edema in ileocaecal ZDV SRVLWLYH 5DGLRORJLF H[DPLQDWLRQ HYHQ LWV OHVV region. Double contrast examination may showed

  VSHFL¿FLW\ ZDV VWLOO QHHGHG IRU LQWHVWLQDO WXEHUFXORVLV irregulity of distal ileum wall. Ultrasonography could diagnosis.

  VKRZ DQ DVFLWHV O\PSKDGHQRSDWK\ ZLWK FDVHRXV ]RQH Radiologic examination has an important role

  In CT RU FDOFL¿FDWLRQ DQG LOHRFDHFDO ZDOO WKLFNHQLQJ in intestinal tuberculosis diagnosis. Among several

  VFDQ LOHRFDHFDO WXEHUFXORVLV ZDV VHHQ DV K\SHUSODVWLF PRGDOLWLHV SODLQ [ UD\ RI WKRUD[ DQG DEGRPLQDO UHJLRQ lesion with symmetrical circumferential thickening in

  XOWUDVRQRJUDSK\ &7 VFDQ DQG EDULXP PHDO ZDV WKH caecum and terminal ileum. A further disease would PRVW FRPPRQO\ XVHG .KDQ HW DO UHSRUWHG RI

  FDXVH DQ DGKHUHQW ORRS ORFDO DQG PHVHQWULDO O\PSK intestinal tuberculosis suggestion using combination node enlargement seen as central mass in ileocaecal

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  6RPHWLPHV QDUURZLQJ RI LQWHVWLQDO OXPHQ XOFHUDWLRQ CT Scan was one of the best modalities to examine and lesion in hepatic flexure was present. This DEGRPLQDO RUJDQV )URP UDGLRORJLF H[DPLQDWLRQ radiologic examination was relatively fast and cost pulmonary tuberculosis coincidence was found

  HIIHFWLYH EXW FDQQRW H[FOXGH &KURQ¶V GLVHDVH DQG LQ SDWLHQWV ZKLOH DPRQJ WKHP KDYH DQ ₄ abdominal malignancy as differential diagnosis. Tri Hapsoro Guno, Barry A Putra, Telly Kamelia, Dadang Makmun

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  Mostly it was found as pink nodule in caecum with

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  2WKHU SRVVLEOH ¿QGLQJV ZDV HGHPDWRXV SVHXGRSROLSRLG ileocaecal folds and deformity in ileocaecal valve. Differential diagnosis of this findings was colon carcinoma.

  'XULQJ FRORQRVFRS\ H[DPLQDWLRQ ELRSV\ ZDV also can be donne for pathologic and microbiologic H[DPLQDWLRQ $FWXDOO\ SDWKRORJLF H[DPLQDWLRQ was nor reliable because of its lesion that found in submucosal layer while colonoscopy procedure can RQO\ WDNH PXFRVDO OD\HU ,Q D FDVH UHSRUW JUDQXORPD ZLWK FDVHDWLRQ ZDV IRXQG LQ RI RQH WKLUG SRVLWLYH result. Acid fast staining result was varous. Positive culture did not always correlate to the presence of granuloma. Combination of both histopathology and culture from biopsy was expected to increase

  This patient has been undergo two colonscopy procedure. First colonoscopy found mass of ascenden colon with fragile and bloody characteristic that occlude lumen about 60 cm from anus. Pathologic H[DPLQDWLRQ RI ELRSV\ VDPSOH IURP ¿UVW FRORQRVFRS\

  VKRZHG DQ LQ¿OWUDWH ZLWKLQ ODPLQD SURSULD ZLWK FKURQLF inflammatory cell and also eosinophil with mild cript distortion suggestive for active chronic colitis without any sign of malignancy. Because of there is FRQWUDGLFWLRQ DPRQJ FRORQRVFRS\ DQG SDWKRORJ\ UHVXOW the secondary colonoscopy was proposed.

  Second colonoscopy showed a granular polypoid PDVV LQ DSSHQGL[ LOHRFDHFDO YDOYH DQG GLVWDO terminal ileum with ileocaecal stenosis then biopsy

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  Secondary pathologic examination showed an LQ¿OWUDWHG ODPLQD SURSULD IURP FKURQLF LQÀDPPDWRU\ FHOO 301 FHOO DQG HRVLQRSKLO ZLWK ¿EURWLF WLVVXH and wider cript distances. There were also found D JUDQXORPD FRPSRVHG RI HSLWKHORLG FHOO GDWKLD ODQJKDQV FHOO DQG O\PSKRF\WH LQ¿OWUDWLRQ 9LOOLRXV

  VKRUWHQLQJ FRQFOXGHG DV JUDQXORPDWRXV LOHLWLV FDXVHG by Mycobacterium tuberculosis infection. PCR TB HVDPLQDWLRQ VKRZHG D QHJDWLYH UHVXOW EXW FOLQLFDO H[DPLQDWLRQ HSLGHPLRORJLFDO GDWD FRORQRVFRS\ DQG pathology examination result as mention above made LQWHVWLQDO WXEHUFXORVLV DV WKH ¿QDO GLDJQRVLV RI WKLV FDVH

  Based on WHO guidelines for extrapulmonary TB LQIHFWLRQ SDWLHQW UHFHLYHG VWDQGDUG ¿UVW OLQH GUXJV for TB. Short-course chemotherapy was proven to be effective as standard therapy in pulmonary tuberculosis FDVH DQG DOVR IRU H[WUDSXOPRQDU\ WXEHUFXORVLV because of paucibasilar condition that commonly found. Tuberculosis standard therapy was divided LQWR WZR PDLQ SKDVH LQLWLDO SKDVH RU EDFWHULFLGDO phase and continuation phase or sterilization phase.

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