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| Year : 1986 | Volume
: 32
| Issue : 3 | Page : 161-2,160A |
Primary tuberculosis of the large bowel (a case report).
Deodhar SD, Patel VC, Bharucha MA, Vora IM
How to cite this article:
Deodhar S D, Patel V C, Bharucha M A, Vora I M. Primary tuberculosis of the large bowel (a case report). J Postgrad Med 1986;32:161-2,160A |
While tuberculosis of the small bowel is a very common condition in our country, isolated primary tuberculosis of the large bowel is quite uncommon. We had a case of this type under our care at K.E.M. Hospital recently. The rarity of this condition prompted us to present this report.
A 46 year old male farmer was admitted or 20th February 1985 with complaints of lower abdominal pain, alternating constipation and diarrhoea and loss of weight of four months' duration. The pain was colicky in nature, felt more in the left lower abdomen and relieved by passage of flatus and faeces. There was no history of pulmonary tuberculosis or contact with a tuberculous patient.
On examination, a well-defined, firm, smooth, non-tender, freely mobile, intro-abdominal mass measuring 7.5 cm x 5 cm was detected in the left iliac fossa. Rest of the abdominal examination, pelvic examination and proctoscopy revealed no abnormality. With a clinical suspicion of carcinoma of sigmoid colon, the patient was investigated. The barium enema showed multiple strictures of the large bowel [Fig. 1]. An I.V.P. showed a soft tissue mass in the left iliac fossa not connected with the urinary system. Haemoglobin was 10.10 gm% and ESR was 54 mm in the first hour (Westergren). The rest of the investigations including a plain X-ray of the chest were within normal limits.
At operation, a firm mass 7.5 cm x 5 cm in the wall of the proximal half of sigmoid colon was found; it could be easily dissected from the surrounding structures. There were multiple stricturous lesions of the descending, transverse and ascending colon. However, the small bowel was entirely free of disease; there were no other lesions in the abdominal cavity.
A subtotal colectomy was carried out and continuity was established by ileo-sigmoid anastamosis. Post-operative recovery was uneventful, and the patient was discharged when frequency of stools became normal.
The excised specimen showed three strictures varying in length from 2.5 cm to 5 cm, one in the ascending colon, one in the transverse colon and one in the descending colon merging with the thickened and irregularly hyperplastic wall of the sigmoid colon. There was minimal, superficial ulceration of the mucosa at the stricturous sites. Sigmoid colon showed irregularly hypertrophied mucosa [Fig. 2]. In between the colon showed dilatation and thinned-out wall.
Microscopically, there were foci of superficial ulcerations of the mucosa. There were multiple single or confluent granulomas in the submucosa and in the serosa. They consisted of epithelioid cells arranged in parallel and orderly fashion with, occasional Langhan's giant cells, surrounded by lymphocytes and fibrosis. Early central caseation was seen in some of the granulomas [Fig. 3]. Ziehl-Neelsen staining revealed acid-fast bacilli in a submucosal granuloma. Histopathological diagnosis was hyperplastic tuberculosis of the colon.
On discharge the patient was put on multiple drug anti-tuberculous treatment (streptomycin, I.N.H., ethambutol). When last seen four months after surgery, the patient's general condition was satisfactory and he had gained three pounds of weight.
Tuberculosis of the ileocaecal region is a very common entity. But isolated tuberculous lesions of the colon without involvement of the small bowel are rare.[2],[4],[5] A few cases of tuberculosis of colon reported so far had also pulmonary tuberculosis.[3],[6] However, our case had extensive colonic tuberculous disease without any pulmonary lesion.
Both the forms, ulcerative and hyperplastic, may be seen in the colon. Ulcerative lesions give rise to fibrous strictures. The patients complains of abdominal pain, diarrhoea, intestinal colic and later on presents with signs of intestinal obstruction. The transverse colon is more often involved.[3] Rarely, the entire colon may be affected by the tuberculous process, giving rise to thickening and fixity of the entire colon.[2],[6] Such cases give history of blood and mucus in stools and may be mistaken for amoebiasis or malignancy.[4] Our patient also presented with alternating diarrhoea and constipation and probable pre-operative diagnosis was malignant lesion of the sigmoid colon. According to Davis,[1] ulcerative variety is more common than hyperplastic; however the hyperplastic variety may show ulcers, but these ulcers tend to be superficial (as in our case).
Demonstration of true caseation is most important for diagnosis,[3] because non-caseating, tubercle-like, nodular granulomas and areas of fibrinoid necrosis are frequently found in regional colitis and ilitis. It is also stated[3] that where possible, presence of acid fast bacilli should be confirmed and guinea pig innoculation should also be carried out. In our case histological section [Fig. 3] showed caseating epithiloid granulomas and Langhans' giant cells with presence of acid fast bacilli in serosa and submucosa, thus confirming the diagnosis.
Resection is the treatment of choice since hyperplastic lesions rarely respond to chemotherapy.[3],[6] For isolated tuberculosis of the colon, local colonic resection is adequate. In transverse colon where the disease is common, often there is very little difficulty in performing such local resection. As our case had extensive disease of the large bowel, a subtotal colectomy had to be carried out. If a patient presents with obstruction, a two stage procedure may be advisable.
Thanks are due to the Dean, K. E. M. Hospital for permission to publish this case report.
| 1. | Davis, J. W.: Hyperplastic tuberculosis of the rectum. Amer. J. Surg., 93: 490-492, 1957.  |
| 2. | Gupta, S. and Vyas, P. B.: Primary hyperplastic tuberculosis of the coon. J. Assoc. Phys. India, 16: 617-620, 1968. |
| 3. | Hancock, D. M.: Hyperplastic tuberculosis of the distal colon Brit. J. Surg., 46: 63-68, 1958-1959. |
| 4. | Joshi, M. J.: "Surgical Diseases in the Tropics". Macmillan India Limited, Bombay, Calcutta, Madras, 1982, pp. 3-51. |
| 5. | Tandon, H.D.. Prakash, A.T.M ., Rao, V.B., Prakash, O.M. and Nair, S K.: Ulceroconstrictive disorders of the intestine in Northern India: a pathological study. Ind. J. Med. Res., 54: 129-141, 1966. |
| 6. | Virmani, P.: Ulcerative tuberculosis of the colon--an unusual case. Brit. J. 5urg., 5-;: 550-551. 1962-63. |
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