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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Case of the Month
Case of the Month
Ileocecal and transverse colonic tuberculosis mimicking synchronous colonic malignancy
Ileocecal and transverse colonic tuberculosis mimicking synchronous colonic malignancy
Contributed by: Anjali Bhoir
Contributed by: Anjali Bhoir
Clinical profile:
Clinical profile:
A 55-year-old man presented with on and off constipation, dull abdominal pain associated with weight loss, low-grade fever and loss of appetite for one year. He was not known to have Pulmonary Kochs. On examination, he was vitally stable and soft, non-tender abdomen with normal digital per rectal examination.
A 55-year-old man presented with on and off constipation, dull abdominal pain associated with weight loss, low-grade fever and loss of appetite for one year. He was not known to have Pulmonary Kochs. On examination, he was vitally stable and soft, non-tender abdomen with normal digital per rectal examination.
Radiological findings:
Radiological findings:
Abdominal radiograph (Erect) shows an abnormally distended and faecalised bowel loop in the right lumbar region and right subhepatic region, suggestive of faecalised ascending colon and hepatic flexure.
Abdominal radiograph (Erect) shows an abnormally distended and faecalised bowel loop in the right lumbar region and right subhepatic region, suggestive of faecalised ascending colon and hepatic flexure.
Ultrasonogram of the abdomen-
Ultrasonogram of the abdomen-
A. and C. Grey scale longitudinal and axial section of the IC junction shows asymmetric circumferential thickening with loss of mural architecture.
A. and C. Grey scale longitudinal and axial section of the IC junction shows asymmetric circumferential thickening with loss of mural architecture.
B. The ascending colon is dilated up to 6.2cm
B. The ascending colon is dilated up to 6.2cm
D and E. Colour and Spectral Doppler of the thickened IC junction shows monophasic arterial flow.
D and E. Colour and Spectral Doppler of the thickened IC junction shows monophasic arterial flow.
F. There is tight stricture with mural thickening near the hepatic flexure of the transverse colon.
F. There is tight stricture with mural thickening near the hepatic flexure of the transverse colon.
A Contrast enhanced CT abdomen was done for further evaluation.
A Contrast enhanced CT abdomen was done for further evaluation.
The coronal image of Contrast enhanced CT of the abdomen shows pulled up IC junction. There is short segment asymmetric circumferential proliferative enhancing thickening and loss of mural architecture.The ascending colon is abnormally dilated and faecal loaded.
The coronal image of Contrast enhanced CT of the abdomen shows pulled up IC junction. There is short segment asymmetric circumferential proliferative enhancing thickening and loss of mural architecture.The ascending colon is abnormally dilated and faecal loaded.
Axial image of CECT Abdomen shows short segment enhancing circumferential thickening with loss of mural architecture in the proximal third of transverse colon. The colonic loop proximal to it is dilated and faecal loaded.
Axial image of CECT Abdomen shows short segment enhancing circumferential thickening with loss of mural architecture in the proximal third of transverse colon. The colonic loop proximal to it is dilated and faecal loaded.
Axial sections of CECT Abdomen show enlarged homogeneously enhancing mesenteric and retroperitoneal lymph nodes, few of them show calcification.
Axial sections of CECT Abdomen show enlarged homogeneously enhancing mesenteric and retroperitoneal lymph nodes, few of them show calcification.
There is asymmetric short segment circumferential thickening of the IC junction and proximal part of the transverse colon with abnormally dilated and faecal loaded ascending colon. Above features are suggestive of Intestinal Tuberculosis.
There is asymmetric short segment circumferential thickening of the IC junction and proximal part of the transverse colon with abnormally dilated and faecal loaded ascending colon. Above features are suggestive of Intestinal Tuberculosis.
Radiological diagnosis:
Radiological diagnosis:
Intestinal Tuberculosis.
Intestinal Tuberculosis.
Figure 1:Abdominal radiograph(Erect)- There is an abnormally distended and faecalised bowel loop in the right lumbar region and right subhepatic region, suggestive of faecalised ascending colon and hepatic flexure.
Figure 2: Ultrasonogram of the abdomen -
A. and C. Grey scale longitudinal and axial section of the IC junction shows asymmetric circumferential thickening with loss of mural architecture.
B. The ascending colon is dilated up to 6.2cm
D and E. Colour and Spectral Doppler of the thickened IC junction shows monophasic arterial flow.
F. There is tight stricture with mural thickening near the hepatic flexure of the transverse colon.
Figure 3: The coronal image of Contrast enhanced CT of the abdomen shows pulled up IC junction with short segment asymmetric circumferential proliferative enhancing thickening and loss of mural architecture.The ascending colon is abnormally dilated and faecal loaded.
Figure 4: Axial image of CECT Abdomen shows short segment enhancing circumferential thickening with loss of mural architecture in the proximal third of transverse colon. The colonic loop proximal to it is dilated and faecal loaded.
Figure 5: Axial sections of CECT Abdomen show enlarged homogeneously enhancing mesenteric and retroperitoneal lymph nodes, few of them show calcification.
Surgical Treatment:
Surgical Treatment:
The patient underwent right hemicolectomy.
The patient underwent right hemicolectomy.
Image of the resected bowel loops shows proliferative growth at the IC junction (area within the yellow circle) and dilated ascending colon with gangrenous changes (Black solid arrow).
Image of the resected bowel loops shows proliferative growth at the IC junction (area within the yellow circle) and dilated ascending colon with gangrenous changes (Black solid arrow).
Terminal ileum (white solid arrow), mesentery (white asterisk), transverse mesocolon (yellow asterisk) and middle colic artery (red solid arrow)
Terminal ileum (white solid arrow), mesentery (white asterisk), transverse mesocolon (yellow asterisk) and middle colic artery (red solid arrow)
Figure 6:Image of the resected bowel loops shows proliferative growth at the IC junction (area within the yellow circle) and dilated ascending colon with gangrenous changes (Black solid arrow).
Terminal ileum (white solid arrow), mesentery (white asterisk), transverse mesocolon (yellow asterisk) and middle colic artery (red solid arrow)
Fig. 7 Histopathological slides show Immature multinucleated giant cell(blue solid arrow), mature multinucleated giant cells (black solid arrows) and areas of necrosis (black asterisk).
Pathological diagnosis:
Pathological diagnosis:
Ileocecal tuberculosis
Ileocecal tuberculosis
Discussion:
Discussion:
Tuberculosis is a disease whose incidence has increased principally as a consequence of HIV infection and use of immunosuppressive drugs. Mycobacterium tuberculosis is the pathogen responsible for most cases of intestinal TB. Mycobacterium bovis, an organism found in contaminated dairy products, is responsible for some cases.
Tuberculosis is a disease whose incidence has increased principally as a consequence of HIV infection and use of immunosuppressive drugs. Mycobacterium tuberculosis is the pathogen responsible for most cases of intestinal TB. Mycobacterium bovis, an organism found in contaminated dairy products, is responsible for some cases.
The abdomen is the most common site of extrapulmonary tuberculosis. It may be confused with several different conditions such as inflammatory bowel disease, cancer and other infectious diseases. Delay in the diagnosis may result in significantly increased morbidity, and therefore an early recognition of the condition is essential for proper treatment.
The abdomen is the most common site of extrapulmonary tuberculosis. It may be confused with several different conditions such as inflammatory bowel disease, cancer and other infectious diseases. Delay in the diagnosis may result in significantly increased morbidity, and therefore an early recognition of the condition is essential for proper treatment.
Lungs are the primary involved organs and abdominal involvement occurs in about 11-12% of patients with extra-pulmonary tuberculosis.
Lungs are the primary involved organs and abdominal involvement occurs in about 11-12% of patients with extra-pulmonary tuberculosis.
Clinical features: Patients of Gastrointestinal Tuberculosis usually present with chronic abdominal pain, constitutional symptoms and a right lower quadrant mass. Diagnostic testing for gastrointestinal TB includes stool studies for M. tuberculosis and, where available, endoscopy for biopsies with multiple dedicated samples sent for both culture/NAAT in saline and histopathology to maximize diagnostic yield.
Clinical features: Patients of Gastrointestinal Tuberculosis usually present with chronic abdominal pain, constitutional symptoms and a right lower quadrant mass. Diagnostic testing for gastrointestinal TB includes stool studies for M. tuberculosis and, where available, endoscopy for biopsies with multiple dedicated samples sent for both culture/NAAT in saline and histopathology to maximize diagnostic yield.
The abdominal presentation may involve different structures such as gastrointestinal tract, genitourinary tract, solid organs (liver, spleen, pancreas), gallbladder, aorta and its branches, peritoneum and lymph nodes, frequently with concomitant involvement of those organs
The abdominal presentation may involve different structures such as gastrointestinal tract, genitourinary tract, solid organs (liver, spleen, pancreas), gallbladder, aorta and its branches, peritoneum and lymph nodes, frequently with concomitant involvement of those organs
Intestinal tuberculosis may mimic several other conditions such as lymphoma, Crohn's disease, amebiasis, adenocarcinoma, among others. Imaging findings are not pathognomonic, but may be highly suggestive of the disease as considered in conjunction with clinical findings, immunological conditions and the demographic origin of the patient
Intestinal tuberculosis may mimic several other conditions such as lymphoma, Crohn's disease, amebiasis, adenocarcinoma, among others. Imaging findings are not pathognomonic, but may be highly suggestive of the disease as considered in conjunction with clinical findings, immunological conditions and the demographic origin of the patient
The intestinal presentation of abdominal tuberculosis is quite common .The mechanism which may lead to bowel involvement by the disease:
The intestinal presentation of abdominal tuberculosis is quite common .The mechanism which may lead to bowel involvement by the disease:
1.Iingestion of infected material in active pulmonary tuberculosis
1.Iingestion of infected material in active pulmonary tuberculosis
2.Reactivation of a quiescent intestinal focus resulting from hematogenous dissemination in the childhood
2.Reactivation of a quiescent intestinal focus resulting from hematogenous dissemination in the childhood
3.Hematogenous dissemination of active tuberculosis, or direct spread from other organs
3.Hematogenous dissemination of active tuberculosis, or direct spread from other organs
Sites of involvement- Ileocecal valve, terminal ileum and cecum(most common).
Sites of involvement- Ileocecal valve, terminal ileum and cecum(most common).
Main imaging findings of intestinal tuberculosis- Symmetrical or asymmetrical wall thickening, extrinsic compression by enlarged lymph nodes which, on their turn may represent heterogeneous masses as associated with adherent loops and mesenteric thickening
Main imaging findings of intestinal tuberculosis- Symmetrical or asymmetrical wall thickening, extrinsic compression by enlarged lymph nodes which, on their turn may represent heterogeneous masses as associated with adherent loops and mesenteric thickening
Complications: Perforation and fistulas are the most frequent gastrointestinal, with incidence of 7.6%; the small bowel and the colon are the most common sites. Other complications include vascular complications, intussusception and obstruction of the small bowel
Complications: Perforation and fistulas are the most frequent gastrointestinal, with incidence of 7.6%; the small bowel and the colon are the most common sites. Other complications include vascular complications, intussusception and obstruction of the small bowel
The differential diagnosis for intestinal tuberculosis include Crohn's disease, lymphoma, amebiasis and adenocarcinoma. The presence of pulmonary compromise at chest radiography may help in the diagnostic rationale in spite of the fact that it is absent in up 50-60% of cases
The differential diagnosis for intestinal tuberculosis include Crohn's disease, lymphoma, amebiasis and adenocarcinoma. The presence of pulmonary compromise at chest radiography may help in the diagnostic rationale in spite of the fact that it is absent in up 50-60% of cases
Imaging findings:
Imaging findings:
Barium studies-The earliest manifestation is spasm and hypermobility with edema of the ileocacecal valve. Thickening of an incompetent ileocecal valve has been described as being characteristic of tuberculosis. Shallow ulceration with elevated margins is seen at double-contrast enema examination. Advanced gastrointestinal tuberculosis characteristically appears as napkin ring stenoses, with a conical, shrunken cecum retracted out of the right iliac fossa by mesocolon retraction.
Barium studies-The earliest manifestation is spasm and hypermobility with edema of the ileocacecal valve. Thickening of an incompetent ileocecal valve has been described as being characteristic of tuberculosis. Shallow ulceration with elevated margins is seen at double-contrast enema examination. Advanced gastrointestinal tuberculosis characteristically appears as napkin ring stenoses, with a conical, shrunken cecum retracted out of the right iliac fossa by mesocolon retraction.
CT findings- The most common finding is mural thickening, which is typically concentric but if eccentric tends to involve the medial cecal wall. Localized lymphadenopathy is usually seen. Skip areas of concentric mural thickening with associated luminal narrowing with or without proximal dilatation can occur elsewhere in the bowel, findings that strongly suggest tuberculosis in the presence of ileocecal involvement. The following points help differentiate Intestinal tuberculosis from Crohn’s disease.
CT findings- The most common finding is mural thickening, which is typically concentric but if eccentric tends to involve the medial cecal wall. Localized lymphadenopathy is usually seen. Skip areas of concentric mural thickening with associated luminal narrowing with or without proximal dilatation can occur elsewhere in the bowel, findings that strongly suggest tuberculosis in the presence of ileocecal involvement. The following points help differentiate Intestinal tuberculosis from Crohn’s disease.
Management of intestinal tuberculosis:
Management of intestinal tuberculosis:
Surgical treatment:
Surgical treatment:
Surgical intervention is reserved for complications of tuberculosis—fibrosis, strictures, and acute abdomen—or when there is uncertainty in the diagnosis.
Surgical intervention is reserved for complications of tuberculosis—fibrosis, strictures, and acute abdomen—or when there is uncertainty in the diagnosis.
Histopathological findings:
Histopathological findings:
Caseating granulomas, often confluent and numerous, often cuff of lymphocytes, lymphoid hyperplasia, aphthous to deep ulcers, often architectural distortion
Caseating granulomas, often confluent and numerous, often cuff of lymphocytes, lymphoid hyperplasia, aphthous to deep ulcers, often architectural distortion
AFB stains more likely to be positive in necrotic areas and histiocytes, bacteria may be rare to abundant
AFB stains more likely to be positive in necrotic areas and histiocytes, bacteria may be rare to abundant
Hyalinization and calcification with chronicity / treatment
Hyalinization and calcification with chronicity / treatment
References:
References:
[1]da Rocha, Eduardo Lima et al. “Abdominal tuberculosis: a radiological review with emphasis on computed tomography and magnetic resonance imaging findings.” Radiologia brasileira vol. 48,3 (2015): 181-91. doi:10.1590/0100-3984.2013.1801
[1]da Rocha, Eduardo Lima et al. “Abdominal tuberculosis: a radiological review with emphasis on computed tomography and magnetic resonance imaging findings.” Radiologia brasileira vol. 48,3 (2015): 181-91. doi:10.1590/0100-3984.2013.1801
[2]Tuberculosis: A Radiologic Review
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Joshua Burrill, Christopher J. Williams, Gillian Bain, Gabriel Conder, Andrew L. Hine, and Rakesh R. Misra
RadioGraphics 2007 27:5, 1255-1273
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Timeline:
Timeline:
Acknowledgements:
Acknowledgements:
We are grateful to the Departments of Surgery and Pathology at our institution for providing the operative and histopathology images and their descriptions.
We are grateful to the Departments of Surgery and Pathology at our institution for providing the operative and histopathology images and their descriptions.
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