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Journal of Postgraduate Medicine, Vol. 48, Issue 1, 2002 pp. 72-73 Letter to the Editor Isolated Gastric Tuberculosis Presenting as Haematemesis Bandyopadhyay SK, Bandyopadhyay R*, Chatterjee U* Departments of Medicine and Pathology*, Institute of Post Graduate Medical Education and Research, & University College of Medicine*, Kolkata - 20, India. E- mail: drsanjay_b@rediffmail.com Code Number: jp02023 Sir, A 30-years-old lady, with a body weight of 38 kg, presented with history of recurrent bouts of haematemesis and heartburn for last one month. She also complained of passage of black, tarry stool. There was no history of smoking, analgesic use, alcohol intake, and risk factors for chronic liver disease. She received proton pump inhibitors and sucralfate for three weeks with partial relief of heartburn. On examination, there was pallor without any jaundice or lymphadenopathy. Systemic examination was unrevealing. An endoscopy done showed a large ulcer, 2.5 cm. in width with irregular margin, on the anterior wall of antrum close to the lesser curvature without any stigmata of recent bleeding; surrounding mucosa was normal. Duodenum and oesophagus was normal. Biopsies were taken that showed small,well-circumscribed granulomata in the mucosa and submucosa with several Langhan's giant cells. There was no evidence of caseation and the overlying mucosa appeared normal. Stain for acid-fast bacilli were negative. Culture was not done. The patient was further investigated; ESR was107 mm in the first hour, Mantoux test produced an induration of 22 mm and chest X-rays were normal. Abdominal ultrasound, colonoscopy and liver biopsy was normal. Serology for human immunodeficiency virus was negative. Enzyme linked immuno sorbent assays for IgM and IgG anti-mycobacterium antibodies were positive. A diagnosis of granulomatous gastritis of tubercular aetiology was made and she was put on four drug antituberculous treatment. Patient gradually regained weight and had improved appetite. A repeat endoscopy showed distortion of mucosal folds near the antrum without any ulcer. Isolated gastric tuberculosis is a rare condition, even in parts of the world where intestinal tuberculosis is common. The incidence of gastric tuberculosis is 0.03 to 0.21 percent of all the routine autopsies.1 The rarity of gastric tuberculosis is due to presence of gastric acid, continuous motor activity of stomach and scarcity of lymphatic follicles in the gastric wall.2 Ulcerative lesions are the commonest; others are hypertrophic lesions, miliary tubercles and tuberculoma. Gastric tuberculosis typically centers in the antrum and along the lesser curvature. Presenting symptoms are often related to gastric outlet obstruction or are similar to those of peptic ulcer disease and rarely with haematemesis.3 Upper gastrointestinal endoscopy plays an important role in diagnosis. Ulcers, single or multiple, and hypertrophic nodular lesions surrounding a stenotic pyloric channel are described.3 On biopsy, granulomas are either caseous or non- caseous. Stains for acid fast bacilli are frequently negative and the diagnosis is either by culture or presence of confirmed tuberculosis elsewhere. Non-caseating granulomas are also caused by Crohn's disease, sarcoidosis and idiopathic granulomatous gastritis. Clinical and histopathological features help in differentiation.4,5
Bandyopadhyay SK, Bandyopadhyay R*, Chatterjee U* Departments of Medicine and Pathology*,
References
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