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ILEAL TUBERCULOSIS PRESENTINGAS A CASE OF MASSIVE RECTAL BLEEDING

DHARMESH J BALSARKAR*, MOHAN A JOSHI**
*Lecturer; **Professor, Department of General Surgery, LTMMC and LTMG Hospital, Sion, Mumbai - 400 022.

Massive rectal bleeding is an uncommon presentation of ileal tuberculosis. We report a case of a young female, who presented to us with massive rectal bleeding. All emergency investigations, including angiography were within normal limits. The case of the massive bleeding could be identified only after an exploratory laparotomy. This case is presented to highlight the shortcomings of investigations and to stress the need of exploratory laparotomy, if cause cannot be found.

INTRODUCTION

Ileal tuberculosis is one of the commonly encountered surgical emergencies; the incidence of intestinal tuberculosis in presence of active pulmonary tuberculosis is between 3-90%.1 Varied acute presentations of ileal tuberculosis are encountered, like sub acute intestinal obstruction due to stricture or adhesions, tuberculous stricture perforation. Massive rectal bleeding is considered a rare presenting symptom of intestinal tuberculosis.[1,2]

CASE REPORT

Sixteen year old, female patient presented to us with persistent bleeding per rectum since one day. No other positive history was elicited. On examination, patient was pale. She had a pulse rate of 120/minute and blood pressure was 90/60 mm of Hg. Per rectal examination showed the presence of fresh blood. Ryles tube showed the presence of clear bile. Patient was stabilized haemodynamically. Upper gastrointestinal endoscopy performed was normal. Emergency investigations showed Hb of 4 gm%. An emergency angiography was performed to locate the source of bleeding, which was reported to be normal. Patients bleeding per rectum still continued, hence a colonoscopy was performed, which could not be completed since the whole colon was filled with blood and blood clots. Hence a decision to explore the patient in view of persistent bleeding per rectum was undertaken after adequate blood transfusion (Hb being 8 gms% at the time of exploration). At laparotomy the whole colon and terminal ileum was full of blood and a non-passable stricture was seen in the terminal ileum one and a half feet from the ileo-caecal junction. (Fig. 1) Rest of the bowel was unremarkable. A resection anastomosis of the stricture was performed. (Fig. 2) Histopathology showed the presence of epitheloid granulomas and Langhans type of giant cells and evidence of endarteritis, suggestive of tuberculous aetiology. Patient was started on four anti-tubercular drugs, and had an uneventful post-operative recovery.


Fig.1 Fig.2
Fig.1 Itra-operative findings of stricture in terminal ileum with associated mesenteric lymphadenopathy and the presence of blood in the distal loop of ileum (the bowel proximal to stricture appears pale and the distal bowel appears dark due to the presence of blood)

Fig.2 Resected specimen showing
the stricture in the terminal ileum.


DISCUSSION

Intestinal tuberculosis presenting with lower gastrointestinal bleed is rare and accounts for about 5% of cases of lower gastrointestinal bleeding.[1,2] In the presence of active pulmonary tuberculosis, vague abdominal pain, weight loss and passage of small amount of blood per rectum could suggest the possibility of intestinal tuberculosis.[1] Presented patient had no evidence of active pulmonary tuberculosis. Pathologic findings of short diseased segment of ileum is common, although it is unusual to have proximal ileum involvement without the involvement of terminal ileum; presented patient had solitary stricture in the terminal ileum. The granulomas in the bowel was may be noncaseating with circumferential ulcers, which can lead to bowel obstruction.1 Massive gastrointestinal bleed occurs because of underlying obliterative endarteritis within the ulcer cater.[1] Presented patient had both stricture formation and evidence of obliterative endarteritis. Technetium 99m labeled RBC scan can help in localising the bleeding lesion.[2]

In the presence of active pulmonary tuberculosis, intestinal tuberculosis can be considered as a differential diagnosis of massive rectal bleeding especially in endemic areas of tuberculosis.

REFERENCES


1.Sherman HI, Johnson R, Brock T. Massive gastrointestinal bleeding from tuberculosis of small intestine. Am J Gastroenterol 1978; 70 : 314-6.

2. Watanabe T, Kudo M, Kayaba M, Shirane H, Tomita S, Orino A, Todo A, Chiba J. Massive rectal bleeding due to ileal tuberculosis. J Gastroenterol 1999; 34 (4) : 525-9.


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