Correspondence Address:
Aminder Singh
Department of Pathology, Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana - 141 001, Punjab
India

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A 40-years-old man presented with six episodes of blood in vomitus of 15 days duration. The vomitus contained altered blood only with no food particles. General physical examination was unremarkable. Per-abdominal examination revealed mild epigastric tenderness. Ultrasonography (USG) abdomen revealed an isoechoic mass (3 × 2.3 cm) with a central cystic area (1.8 cm) posterior to the body of the pancreas. On color Doppler, the lesion appeared to be in continuity with the splenic artery giving an impression of aneurysmal dilatation of the splenic artery. Upper gastrointestinal endoscopy revealed a deep ulcer in the fundus region of the stomach along the lesser curvature. Contrast-enhanced computed tomography showed a heterogenous hypovascular poorly enhancing space-occupying lesion measuring 3.8 × 3.4 × 2.6 cm, which involved the upper part of the distal body of the pancreas, peripancreatic tissue, and perigastric tissue [[Figure 1], panels A and B]. The lesion was encasing and obliterating segments of the splenic artery and splenic vein. The adjacent gastric wall along the lesser curvature showed a deep ulcer. We also identified enlarged lymph nodes in mesenteric, portocaval, aortocaval, and right iliac fossa regions. Keeping the extent of the lesion and diffuse lymphadenopathy in consideration, an imaging possibility of this being a gastric malignancy with lymph nodal metastasis was rendered. Repeated episodes of vomiting containing blood led to distal pancreatectomy with splenectomy and subtotal gastrectomy. Grossly, an ulcer (2 × 1 cm) was identified in the stomach along the lesser curvature. Peripancreatic tissue along the upper part of the pancreas showed ill-defined gray–white areas. However, the rest of the pancreatic parenchyma and splenic parenchyma was unremarkable. Histopathological examination revealed numerous large epithelioid cell granulomas with Langhans and foreign body giant cell reaction present within the gastric wall [[Figure 1], panel E], pancreatic parenchyma [[Figure 1], panel C], and peri-pancreatic tissue [[Figure 1], panel D]. However, no caseation necrosis was apparent. Ziehl–Neelsen (ZN, 20%) stain showed the presence of acid-fast bacilli (AFB) [[Figure 1], panel C inset]. confirming the diagnosis of abdominal tuberculosis. On retrospective evaluation, the patient was found to be immunocompetent and did not show pulmonary involvement. Also, there was no prior history of tuberculosis. He was started on anti-tubercular therapy (ATT) and responded to the treatment at 2 months.{Figure 1}

Gastrointestinal tuberculosis (GITB) is the sixth most prevalent form of extra-pulmonary tuberculosis that commonly involves the terminal ileum and colon.[1] Gastric involvement is rarely encountered, even in regions with a high prevalence of tuberculosis (TB) such as India. GITB may occur as a secondary manifestation of pulmonary TB or uncommonly as an isolated involvement and usually occurs in immunocompromised patients.[2] According to the World Health Organization (WHO), India is the highest TB burden country in the world having an estimated incidence of 26.9 lakh cases in 2019 with Punjab state comprising 2% of total cases. Yet, only a handful of cases of gastric TB have been reported in the literature to date. To the best of our knowledge, this is the first report of its kind with concomitant involvement of the stomach and pancreas.

GITB is the sixth most prevalent form of extra-pulmonary tuberculosis that commonly involves the terminal ileum and colon followed by peritoneum and mesentery. Disseminated abdominal tuberculosis involving multiple organs can occur through various routes such as direct extension, hematogenous spread, and retrograde lymphatic spread from lymph nodes.[3] Gastric involvement by TB has been reported from 0.5 to 3% of all gastrointestinal cases.[4] Antrum in the lesser curvature area is the most commonly involved part of the stomach as was witnessed in our case too.[5] Gastrointestinal TB mostly presents with non-specific symptoms such as abdominal pain, nausea, weight loss, fever, night sweats, fatigue, and malaise, which usually lead to delayed diagnosis and complications in the form of bleeding, perforations, fistulous communications, and gastric outlet obstructions. GITB is usually associated with regional abdominal lymphadenopathy as well. Such a situation can be mistaken for malignancy both clinically and radiologically directing toward surgical intervention.

In our case, massive blood in vomitus and alarming radio-imaging signs (gastric ulcer on lesser curvature with a perigastric and peripancreatic mass involving the surface of the pancreas with extensive abdominal lymphadenopathy) led to the clinical suspicion of advanced gastric malignancy and extensive surgery. Thus, we emphasize that gastrointestinal TB mostly presents with non-specific symptoms leading to diagnostic difficulty. Clinical awareness and a high index of suspicion at early stages may guide toward diagnostic interventions including endoscopic and image-guided biopsy. The establishment of diagnosis on TB on these biopsies may help avoid unnecessary surgical intervention.

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