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.
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]
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.
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.
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. 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. Presented patient had both stricture formation and
evidence of obliterative endarteritis. Technetium 99m labeled RBC scan can help
in localising the bleeding lesion.
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.
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.