RECTAL TUBERCULOSIS SIMULATINGMALIGNANCY
— A Case Report and Review
SAMEER A REGE, PHILIP UMMAN, QUENTIN NUNES,AMITA JOSHI*,
*Department of General Surgery and Pathology, Seth GS Medical College
and KEM Hospital, Parel, Mumbai 400 012.
Tuberculosis is known to involve any
segment of gastrointestinal tract, however involvement distal to ileocaecal
junction is rare. We report a case of rectal tuberculosis, which simulated malignancy,
clinically and radiologically. Histopathology confirmed the diagnosis. Though
treated with antitubercular treatment, patient had to be subjected to definitive
Tuberculosis can affect any part of gastrointestinal tract (GIT) from the oesophagus
to the anal canal. Though tuberculosis of GIT is frequently
encountered in tropical countries, tuberculosis of bowel distal to ileocaecal
junction is rare and is rarely considered as a differential diagnosis of rectal
stricture. Gupta et al have reported an incidence of 4.5%
of rectal tuberculosis. Commonly rectal tuberculosis presents
as carcinoma, however it may present with haematochezia, intestinal obstruction.
We report a patient with rectal tuberculosis who developed intestinal obstruction
due to rectal growth stimulating malignancy.
A 40 year old male presented to us with constipation on and off with bleeding
per rectum since 2 months. He gave no history of obstipation, abdominal distension,
and constipation alternating with diarrhoea. He had no history of tuberculosis
or any medical illness.
On examination, he was average built and nourished with pulse 82/min and blood
pressure of 120/80 mm Hg. On palpation, abdomen was soft with no lump palpable.
Bowel sounds were normal. Per rectal digital examination revealed hard, circumferential
growth in rectum about 6 cm from anal verge admitting only the tip of the finger.
Plain radiograph of chest and abdomen were normal. Computerised tomography of
abdomen and pelvis (CT scan) revealed circumferential growth in rectum extending
upto rectosigmoid junction with normal liver as seen in Fig. 1. Punch Biopsy
were taken and sent for histopathological examination. As patient was being
investigated, he developed acute intestinal obstruction, which did not respond
to conservative management and had to be subjected to sigmoid loop colostomy.
Histopathology revealed granuloma in submucosa of rectum suggesting tuberculosis
(Fig. 2). Patient was started on 4-drug antitubercular treatment, which was
given for 3 months, and was kept under follow-up.
|Fig.1 Computerised tomography
of the pelvis
showing circumferential thickening of the
rectum with mucosal irregularity.
of the rectal biopsy showing epitheloid granuloma in the rectal submucosa.
Patient still complained of bleeding per rectum and repeat clinical examination
and CT scan pelvis revealed similar picture and hence he was subjected for abdominal
exploration. Intraoperative, a hard circumferential thickening was noted from
sigmoid extending to middle third of rectum infiltrating the para-rectal tissues.
Rest of the bowel was normal with no tubercules, strictures and no lymphadenopathy.
Resection of involved rectum and sigmoid colon with a stapled colo-rectal anastomosis
was done. Patient was started on orals on 4th postoperative day and discharged
on the 10th day on antitubercular chemotherapy. He is totally asymptomatic at
follow-up of 6 months. Histopathology, confirmed the diagnosis.
Tuberculosis of gastrointestinal tract may be primary or secondary to a primary
focus elsewhere. Primary intestinal tuberculosis is usually
because of bovine tubercle bacilli through milk.5 Decreased incidence of primary
tuberculosis has been seen due to pasteurisation of milk. Bockus et al have
reported 70% of cases of primary infection with tuberculosis to have hyperplastic
or hypertrophic forms while secondary lesions to be of ulcerative types in gastrointestinal
Tuberculosis of GIT can involve any portion of bowel extending from oesophagus
to anus however, involvement of bowel distal to ileocaecal junction is infrequently
seen. In addition, Davis has stated that hyperplastic lesions
are probably the rarest in rectal lesions. However, Gupta
et al have reported an incidence of 4.5% (three cases) of rectal tuberculosis.
Clinically, patients with rectal tuberculosis may present as growth and simulate
carcinoma. These patients may present with bleeding per-rectum, constipation,
alternating with diarrhoea, intestinal obstruction or pain while passing stools.[3,4]
Rectal TB can present with annular stricture or with ulceration of mucosa with
fibrosis. Its radiological and endoscopic appearances may be extremely similar
to malignant rectal lesion and only biopsy can clinch the diagnosis.
Our patient was also diagnosed as rectal carcinoma on clinical and radiological
grounds. However, histopathology proved it to be rectal tuberculosis.
Antitubercular drugs have changed the dismal outlook for patients with secondary
tuberculous enteritis.5 Chemotherapy also has made surgery safe and often curative.
Many reports however suggest that the hypertrophic form of gastrointestinal
tuberculosis do not respond to drug therapy.5 Surgical treatment may be required
if: a) Stenosis persists after 3 to 6 months of antitubercular treatment. b)
It is difficult to differentiate from malignancy. c) Malignancy and tuberculosis
Our patient was treated with four drug antitubercular drugs, which did not show
any radiological change and hence was any radiological change and hence was
subjected to resection.
In summary, tuberculosis of rectum can simulate malignant both clinically and
radiologically but biopsy can confirm diagnosis.
We are thankful to the Dean, Dr.
Kshirsagar for allowing us to publish hospital data.
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