A case report of systemic lupus erythematosus and intestinal tuberculosis with lower gastrointestinal bleeding: A treatment approach utilizing parenteral nutrition.

RATIONALE: Limited literatures are available on lower gastrointestinal bleeding in systemic lupus erythematosus (SLE) combined with intestinal tuberculosis. Sharing the treatment experiences of a 26-year-old female patient diagnosed with this complex condition in this report may contribute valuable insights. PATIENT CONCERNS: The patient initially presented with abdominal pain and active gastrointestinal bleeding, leading to admission to the hospital. Over a 2-week period, she experienced persistent bleeding, with daily volumes ranging from 300 mL to 800 mL. DIAGNOSES: Lower gastrointestinal bleeding was diagnosed in this patient with concurrent systemic lupus erythematosus and intestinal tuberculosis. INTERVENTIONS: As her symptoms rapidly progressed, food and water intake had to be completely restricted. The parenteral nutrition was implemented. OUTCOMES: The medical team effectively controlled the bleeding, leading to a notable improvement in the patient's condition. Consequently, she was able to resume oral intake and was discharged from the hospital. LESSONS: This case highlights the significance of using parenteral nutrition in the management of lower gastrointestinal bleeding in patients with concurrent systemic lupus erythematosus and intestinal tuberculosis. Close monitoring and collaborative efforts among healthcare professionals are crucial to achieve successful outcomes in similar cases.

Evidence-based approach to diagnosis and management of abdominal tuberculosis.

Abdominal tuberculosis is an ancient problem with modern nuances in diagnosis and management. The two major forms are tuberculous peritonitis and gastrointestinal tuberculosis (GITB), while the less frequent forms are esophageal, gastroduodenal, pancreatic, hepatic, gallbladder and biliary tuberculosis. The clinicians need to discriminate the disease from the close mimics: peritoneal carcinomatosis closely mimics peritoneal tuberculosis, while Crohn's disease closely mimics intestinal tuberculosis. Imaging modalities (ultrasound, computed tomography, magnetic resonance imaging and occasionally positron emission tomography) guide the line of evaluation. Research in diagnostics (imaging and endoscopy) has helped in the better acquisition of tissue for histological and microbiological tests. Although point-of-care polymerase chain reaction-based tests (e.g. Xpert Mtb/Rif) may provide a quick diagnosis, these have low sensitivity. In such situations, ancillary investigations such as ascitic adenosine deaminase and histological clues (granulomas, caseating necrosis, ulcers lined by histiocytes) may provide some specificity to the diagnosis. A diagnostic trial of antitubercular therapy (ATT) may be considered if all diagnostic armamentaria fail to clinch the diagnosis, especially in TB-endemic regions. Objective evaluation with clear endpoints of response is mandatory in such situations. Early mucosal response (healing of ulcers at two months) and resolution of ascites are objective criteria for early response assessment and should be sought at two months. Biomarkers, especially fecal calprotectin for intestinal tuberculosis, have also shown promise. For most forms of abdominal tuberculosis, six months of ATT is sufficient. Sequelae of GITB may require endoscopic balloon dilatation for intestinal strictures or surgical intervention for recurrent intestinal obstruction, perforation or massive bleeding.

Differentiation of intestinal tuberculosis and Crohn's disease through an explainable machine learning method.

Differentiation between Crohn's disease and intestinal tuberculosis is difficult but crucial for medical decisions. This study aims to develop an effective framework to distinguish these two diseases through an explainable machine learning (ML) model. After feature selection, a total of nine variables are extracted, including intestinal surgery, abdominal, bloody stool, PPD, knot, ESAT-6, CFP-10, intestinal dilatation and comb sign. Besides, we compared the predictive performance of the ML methods with traditional statistical methods. This work also provides insights into the ML model's outcome through the SHAP method for the first time. A cohort consisting of 200 patients' data (CD = 160, ITB = 40) is used in training and validating models. Results illustrate that the XGBoost algorithm outperforms other classifiers in terms of area under the receiver operating characteristic curve (AUC), sensitivity, specificity, precision and Matthews correlation coefficient (MCC), yielding values of 0.891, 0.813, 0.969, 0.867 and 0.801 respectively. More importantly, the prediction outcomes of XGBoost can be effectively explained through the SHAP method. The proposed framework proves that the effectiveness of distinguishing CD from ITB through interpretable machine learning, which can obtain a global explanation but also an explanation for individual patients.

Gastroduodenal tuberculosis: a case series and a management focused systematic review.

INTRODUCTION: Gastroduodenal tuberculosis is an uncommon form of abdominal tuberculosis. AREAS COVERED: We report our experience with five cases of gastroduodenal tuberculosis and present results of a systematic review on gastroduodenal tuberculosis regarding clinical presentation, endoscopic, imaging findings, and the diagnostic and therapeutic approach. EXPERT OPINION: The presentation of gastroduodenal tuberculosis is diverse and may include nonspecific abdominal pain or dyspepsia like symptoms apart from gastric outlet obstruction. Endoscopy may show presence of growth, ulcer, narrowing, or fistula on endoscopy. Endoscopic biopsy, well-biopsy, or mucosal resection of an elevated lesion are helpful. On microscopy, granuloma with or without acid fast bacilli positivity can be found. For treatment, standard antitubercular therapy should be given for 6 months. In patients with tight stricture, endoscopic balloon dilatation can be helpful. Surgery is reserved for patient with diagnostic dilemma, refractory stricture, or complications like perforation or fistula. Future research should focus on improving diagnosis with use of modern microbiological techniques like PCR and Xpert MTB/RIF.

Obstructed ileocaecal tuberculosis with splenic tuberculosis and solid pseudopapillary tumour of tail of pancreas in an immunocompetent woman.

A 22-year-old young woman presented with fever, lower abdominal pain and vomiting for 20 days. She had persistent fever and abdominal pain. Fever panel was negative. Clinical features were suggestive of subacute small bowel obstruction. Contrast-enhanced CT abdomen showed thickening of distal ileum, ileocaecal junction and caecum with conglomerate necrotic nodal mass in the ileocolic mesentry along with a lesion in the tail of pancreas. Patient was discussed with multidisciplinary team and decided to undergo a single-stage procedure after adequate nutritional optimisation. During optimisation, she underwent acute obstruction and hence taken up for emergency laparotomy proceeded to right haemicolectomy with distal pancreatectomy and splenectomy 4 weeks after the time of admission. Histopathology showed ileocaecal tuberculosis and solid pseudopapillary tumour with margins free of tumour. Approach of obstructed ileocaecal tuberculosis in the setting of incidental diagnosis of solid pseudopapillary tumour of pancreas in a moribund patient was challenging.

Clinicopathological profile of gastrointestinal tuberculosis: a multinational ID-IRI study.

Data are relatively scarce on gastro-intestinal tuberculosis (GITB). Most studies are old and from single centers, or did not include immunosuppressed patients. Thus, we aimed to determine the clinical, radiological, and laboratory profiles of GITB. We included adults with proven GITB treated between 2000 and 2018. Patients were enrolled from 21 referral centers in 8 countries (Belgium, Egypt, France, Italy, Kazakhstan, Saudi Arabia, UK, and Turkey). One hundred four patients were included. Terminal ileum (n = 46, 44.2%), small intestines except terminal ileum (n = 36, 34.6%), colon (n = 29, 27.8%), stomach (n = 6, 5.7%), and perianal (one patient) were the sites of GITB. One-third of all patients were immunosuppressed. Sixteen patients had diabetes, 8 had chronic renal failure, 5 were HIV positive, 4 had liver cirrhosis, and 3 had malignancies. Intestinal biopsy samples were cultured in 75 cases (78.1%) and TB was isolated in 65 patients (86.6%). PCR were performed to 37 (35.6%) biopsy samples and of these, 35 (94.6%) were positive. Ascites samples were cultured in 19 patients and M. tuberculosis was isolated in 11 (57.9%). Upper gastrointestinal endoscopy was performed to 40 patients (38.5%) and colonoscopy in 74 (71.1%). Surgical interventions were frequently the source of diagnostic samples (25 laparoscopy/20 laparotomy, n = 45, 43.3%). Patients were treated with standard and second-line anti-TB medications. Ultimately, 4 (3.8%) patients died and 2 (1.9%) cases relapsed. There was a high incidence of underlying immunosuppression in GITB patients. A high degree of clinical suspicion is necessary to initiate appropriate and timely diagnostic procedures; many patients are first diagnosed at surgery.

Perianal Tuberculosis: Lessons Learned in 57 Patients From 743 Samples of Histopathology and Polymerase Chain Reaction and a Systematic Review of Literature.

BACKGROUND: Few data are published on perianal tuberculosis. OBJECTIVE: This study aimed to determine the best method to diagnose tuberculosis in patients with fistula-in-ano and to conduct a systematic review to determine the incidence and characteristics of tuberculosis fistula-in-ano. DATA SOURCES: The prospective study data and existing literature were derived from PubMed, Google scholar, and Scopus STUDY SELECTION:: Prospective analysis of patients with tuberculous fistula-in-ano treated between 2014 and 2018 was conducted, and a systematic review of studies describing ≥3 patients with tuberculosis fistula-in-ano was completed. INTERVENTION: Testing of tuberculosis was performed by histopathology or polymerase chain reaction of tissue or pus from the fistula tract. MAIN OUTCOME MEASURES: The primary outcomes measured were the detection rate of various tests to detect tuberculosis in fistula-in-ano and the prevalence rate of tuberculosis in simple versus complex fistulas. RESULTS: In 637 samples (410 patients) tested, tuberculosis was detected in 49 samples (43 patients). Additional samples (n = 106) sent in patients with a high index of suspicion tested positive in 14 more patients. Thus, overall, 63 samples tested positive in 57 patients (total: 743 samples in 410 patients were tested). Tuberculosis was detected in 2 of 181 patients (1.1%) in tissue (histopathology), in 28 of 341 patients (8.2%) in tissue (polymerase chain reaction), and in 19 of 115 patients (16.5%) in pus (polymerase chain reaction) samples. To detect tuberculosis, tissue (polymerase chain reaction) was significantly better than tissue (histopathology) (28/341 vs 2/181, p < 0.00001) and pus (polymerase chain reaction) was significantly better than tissue (polymerase chain reaction) (19/115 vs 28/341, p < 0.0009). Tuberculosis was significantly more common in complex fistulas than in simple fistulas (20.3% vs 7.2%, p = 0.0002). The systematic review (n = 199) highlighted that tubercular fistulas are more common in recurrent and complex fistulas and in tuberculosis endemic regions. LIMITATIONS: The true sensitivity and specificity of each testing modality could not be determined because not all patients with tuberculosis fistula-in-ano were tested by every diagnostic modality studied. CONCLUSIONS: The tuberculosis detection rate of polymerase chain reaction was significantly higher than histopathology. Among polymerase chain reaction, pus had higher detection rate than tissue. Tuberculosis was associated with more complex and recurrent fistulas.

Massive infected ascites in an immunocompetent patient with gastrointestinal tuberculosis.

Mycobacterium tuberculosisis highly endemic in the Philippines. The diagnosis is challenging with its non-specific presentation and the organism could extend to any of the organs. Interestingly, bacterial peritonitis arising spontaneously from gastrointestinal tuberculosis (TB) in an otherwise healthy, non-cirrhotic patient is quite unusual. In this paper, we discuss the case of a 27-year-old HIV-seronegative woman with massive intraperitoneal mixed bacterial and tuberculous abscess presenting 20 months after being diagnosed with bacteriologically confirmed gastrointestinal TB. Repeated large-volume paracentesis was done to drain out the infected ascites instead of inserting a percutaneously implanted catheter. Clinical improvement was noted and she was discharged after 12 days of intravenous antibiotics. She had completed 6 months of antituberculosis therapy and been well since then. The case has demonstrated that repeated paracentesis along with appropriate antibiotic regimen, may be a viable option for patients with TB and bacterial coinfected peritonitis. And possibly, peritoneal TB may increase the risk for (spontaneous) bacterial peritonitis.

Small bowel strictures.

PURPOSE OF REVIEW: Strictures of the small bowel are an underdiagnosed entity with significant morbidity because of obstruction and risk of perforation and penetrating disease. RECENT FINDINGS: Recent advances in imaging, enteroscopy, and therapeutic advances particularly in Crohn's disease have enabled gastroenterologists to target and individualize management of small bowel strictures, preventing untimely surgery and complications. SUMMARY: All patients with obstructive symptoms, suspected small bowel disease, and negative panendoscopy should be evaluated for small intestinal strictures with cross-sectional imaging and considered for capsule endoscopy. Furthermore, the role of device-assisted enteroscopy, initially employed as a diagnostic tool, has evolved into triaging and delivering further medical and interventional treatments.

Diagnosis of abdominal tuberculosis in Christchurch New Zealand: a case series.

AIM: Abdominal tuberculosis presents with non-specific symptoms, including generalised abdominal pain. Prompt and accurate diagnosis is critical to improving outcomes and avoiding complications. We conducted a retrospective review of cases of abdominal tuberculosis presenting to Christchurch Hospital to explore the epidemiology, clinical features and diagnostic modalities used. METHOD: Cases were identified by searching for relevant ICD discharge codes from January 1996 to January 2016. Data on age, clinical presentation, investigations and microbiological results were obtained. RESULTS: There were 20 patients diagnosed with abdominal tuberculosis over the study period. The median age was 34. Thirteen patients were male (65%), seven female (35%). The majority (11) were from Asia (predominantly India), five were African, and three were New Zealand Europeans. Abdominal pain was the most common presenting symptom (70%) followed by fevers (50%) and night sweats (50%). The C-reactive protein was elevated in 15 patients (75%), anaemia was found in 11 (55%) and nine had abnormal liver function tests (45%). Abdominal ultrasound (US) and computed tomography (CT) showed generic inflammatory change in all patients in this series (100%). Laparoscopy was undertaken in 10 (50%) patients, all of which had positive laparoscopic biopsies. Ascitic fluid was obtained in nine, with stains for acid-fast bacilli uniformly negative, however three (33%) had mycobacterial growth from culture. Six colonoscopies were performed: in three (50%) culture and/or histology was positive. Three lymph node biopsies and two formal laparotomies were the remaining diagnostic techniques employed with two biopsies and one laparotomy yielding positive results. Overall, of the 20 cases, 15 (75%) were able to be definitively confirmed, with the remaining five treated presumptively for probable abdominal tuberculosis. CONCLUSION: Abdominal tuberculosis is an uncommon presentation at our institution, with an average of one case each year. The typical patient was a young immigrant from Asia or Africa. Diagnostic laparoscopy was the most common and uniformly reliable means of obtaining a definitive diagnosis.

Tuberculosis intestinal simulando tumor de colon. informe de un caso / Intestinal tuberculosis simulating colon tumor. report of a case

Se presentó el caso de un paciente del sexo masculino de 40 años, de procedencia rural, con antecedentes patológicos de bronquiectasias y de un derrame pleural que curó espontáneamente. El mismo presentó manifestaciones compatibles con tuberculosis intestinal que debutó con tumoración en fosa iliaca derecha, fiebre y dolor abdominal. Se valoró el caso en el colectivo de Neumología, donde teniendo en cuenta la evolución clínica y resultado de los exámenes complementarios realizados, se decidió iniciar tratamiento específico antituberculoso con el diagnóstico de tuberculosis intestinal. Después de estos estudios, evolucionó favorablemente con el tratamiento protocolizado(AU)

It is presented the case of a male patient of 40 years, of rural origin, with a pathological history of bronchiectasis and a pleural effusion that cured spontaneously. The patient presented symptoms compatible with intestinal tuberculosis that began with a tumor in the right iliac fossa, fever and abdominal pain. The case was assessed in the Pneumology group, where taking into account the clinical evolution and the result of the complementary examinations, it was decided to initiate specific antituberculous treatment with the diagnosis of intestinal tuberculosis. After these studies, patient, s evolution was good with the protocolized treatment(AU)

[Simultaneous intestinal tuberculosis and adenocarcinoma].

Intestinal tuberculosis is a rare diagnosis, which may often be mistaken for mb. Crohn or cancer. We present a case of a 57-year-old man, who was diagnosed with intestinal tuberculosis. Due to increased abdominal pain, a computed tomography was performed, revealing a growing sigmoidal tumour, and the biopsies taken showed an adenocarcinoma. Further histological tests revealed no spread of cancer, and the patient could receive curative surgery. While intestinal tuberculosis can appear similar to colon cancer, it may also as in this case be an intercurrent disease.

A retrospective cohort study of 756 cases of abdominal tuberculosis: Two decades single centre experience.

AIM/OBJECTIVE: India accounts for the highest tuberculosis burden in the world, and abdominal tuberculosis has been an endemic surgical and gastroenterological problem. Aim of this study is to present our two decades experience on abdominal (gastrointestinal) tuberculosis. METHOD: 756 patients, who received standard antituberculous treatment with or without surgical treatment with the diagnosis of abdominal tuberculosis from January 1996 and May 2014, were reviewed retrospectively. On the basis of clinical presentation, four groups of clinical presentation were identified and various diagnostic measures used in different groups were studied. Numeric values were determined as percent or mean±standard deviation. Kruskal-Wallis test was used for quantitative results and chi-square test was used for qualitative results between groups. p value of less than 0.05 was considered to indicate the statistical significance. RESULTS: The duration of symptoms was variable in this study. Out of 756 patients, 64 patients gave definite past history of tuberculosis. Most of the patients in the acute pain abdomen group required surgery while most patients in chronic pain group responded well to medical management. There was significant difference in mortality among the four groups (p=0.025). CONCLUSION: Prognosis seems significantly related to the severity of disease, with graver prognosis and less symptomatic improvement in more seriously ill presentations.

Absceso intrabdominal secundario a tuberculosis intestinal en el Hospital General Dolisie de la República del Congo / Intra-abdominal abscess secondary to intestinal tuberculosis in general hospital Dolisie, Republic of Congo

La incidencia de TB intestinal es desconocida, ya que puede ser asintomática y por su naturaleza a menudo resulta en diagnósticos erróneos, por lo que se debe tener un alto índice de sospecha en poblaciones de alto riesgo. Los abscesos intrabdominales en el curso de esta es una complicación poco frecuente, con una incidencia entre 2 y 30 por ciento. Presentamos un paciente masculino de 52 años de edad, con masa abdominal en mesogástrio, asociada a dolor abdominal y pérdida de peso. Se comienza su estudio con Rx. de tórax y ecografía abdominal, el cual reporta masa de 90 x 47 mm en el peritoneo, es intervenido quirúrgicamente y drenado por absceso intrabdominal. Se diagnostica TB intestinal, su evolución fue satisfactoria después de iniciado el tratamiento antituberculoso. Ante un paciente con síntomas de abdomen agudo, es importante realizar un diagnóstico temprano de TB intestinal. Esto evitaría una intervención innecesaria, porque el diagnóstico de la TB intestinal es médico. Si se realiza la intervención, puede confirmarse el diagnóstico mediante las lesiones encontradas; acción que impediría una resección intestinal innecesaria pues el tratamiento antituberculoso resolvería la TB. Generalmente, el diagnóstico se realiza durante una cirugía o por procedimientos invasivos con otros propósitos, por ser esta de difícil diagnóstico clínico y que la irregularidad del tratamiento antituberculoso es un importante factor de riesgo para el desarrollo de complicaciones en la TB intestinal diagnosticada. Esta es altamente efectivo en la resolución de complicaciones de moderada gravedad como la obstrucción intestinal y los abscesos intrabdominales(AU)

The incidence of intestinal tuberculosis is unknown since it may be symptom-free and lead to frequent misdiagnoses, so one should highly suspect of intestinal tuberculosis in high risk populations. The intra-abdominal abscesses are rare complications, with an incidence rate of 2 to 30 percent. Here is the case of a 52 years-old male patient who had an abdominal in her mesogastrium associated to abdominal pain and weight loss. The first testing was thorax X-ray and abdominal ultrasound, which revealed the presence of a 90x74mm mass in the peritoneum. As a result, he was operated on including intrabdominal abscess drainage. The final diagnosis was intestinal tuberculosis, being the recovery satisfactory after the anti-tuberculosis treatment. It is fundamental to make emphasis on the importance of early diagnosis of intestinal tuberculosis in patients with acute abdomen symptoms in risk groups since this may avoid surgical treatment. The diagnosis based on macroscopic findings in case of surgical treatment may also avoid unnecessary intestinal resections. Generally speaking, the diagnosis is made during a surgery or by invasive procedures with other purposes since the clinical diagnosis is difficult; irregular anti-tuberculosis treatment is a significant risk factor for the development of complications in diagnosed intestinal tuberculosis. It is highly effective in the resolution of moderate-severity complications such as intestinal obstruction and intra-abdominal abscesse(AU)

Abdominal tuberculosis: an old disease surprising young doctors.

Tuberculosis remains a worldwide public health concern. Atypical extrapulmonary presentations may delay the diagnosis and treatment. We present the case of an adult woman admitted to the emergency department with bowel obstruction. The putative intraoperative diagnostic hypothesis was ovarian cancer with peritoneal dissemination. Histopathological analysis showed a chronic granulomatous inflammatory disease with acid-fast bacilli. The patient was started on an alternative parenteral antituberculosis drug combination until oral feeding was available. Currently, 5 months after surgery, she is asymptomatic. Abdominal tuberculosis is the most frequent extrapulmonary site with a wide range of clinical presentations. Emergency laparotomy may be necessary in patients who present with acute abdomen. Bowel obstruction due to adhesions and strictures is not infrequent. However, tuberculous abdominal cocoon presentation as in our patient is rare. Treatment with parenteral alternative drug regimens for tuberculosis is mandatory until the oral route is available.

Gastrointestinal Tuberculosis.

Gastrointestinal tuberculosis (TB) is a fascinating disease which can be observed both in the clinical context of active pulmonary disease and as a primary infection with no pulmonary involvement. It represents a significant clinical challenge because of the resurgence of TB as well as the diagnostic challenges it poses. A high clinical suspicion remains the most powerful tool in an era of medicine when reliance on diagnostic technology increases. Antimicrobial therapy is the mainstay of therapy, but surgical and endoscopic interventions are frequently required for intestinal TB. Gastrointestinal TB is truly the "great mimic" and continues to require the astute clinical acumen of skillful clinicians to diagnose and treat.

Paediatric abdominal tuberculosis in developed countries: case series and literature review.

OBJECTIVE: To provide an insight into the presentation, diagnosis and management of paediatric abdominal tuberculosis (TB) in developed countries. METHODS: The records of all children at the Montreal Children's Hospital (MCH) admitted with abdominal TB between 1990 and 2014 were reviewed. An automated and manual literature search from 1946 to 2014 was performed. RESULTS: (1) CASE SERIES: six cases were identified at the MCH. All were male between 5 and 17 years of age. All were from populations known to have high rates of TB (aboriginal, immigrant). Three underwent major surgical interventions and three underwent ultrasound (US) or CT aspiration or biopsy for diagnosis. (2) LITERATURE REVIEW: 29 male (64%) and 16 female subjects (36%) aged between 14 months and 18 years were identified, including the MCH patients. All patients except one were from populations with a high incidence of TB. Most presented with a positive tuberculin skin test (90%), abdominal pain (76%), fever (71%) and weight loss (68%). On imaging, 22 (49%) were classified with gastrointestinal TB with colonic wall irregularity (41%) and 19 (42%) with peritoneal TB with ascites (68%). A positive culture was obtained in 33 (73%) patients. Three cases used CT- or US-guided aspiration or biopsy to obtain tissue samples. A surgical intervention was performed in 34 (76%) children; 13 (38%) of these were for diagnosis. CONCLUSIONS: Diagnosis based on clinical features (abdominal pain, fever and weight loss) and CT- or US-guided aspiration or biopsy may encourage physicians to adopt a more conservative approach to abdominal TB.