A six-year-old female presented with severe abdominal pain and bilious
vomiting since 6 hours. For the last 6 months she was being treated
with antihelminthics, anti-spasmodics and antacids for
intermittent/colicky abdominal pain.
Examination showed a cachexic, pale child with
tachycardia and tachypnea. Abdomen was mildly distended with no
visible loops. Palpation revealed tenderness and guarding in upper
abdomen. Liver and spleen were not palpable. Per rectal examination
showed bogginess.
Investigations showed hemoglobin of 7.8 g/dL
Erythrocyte sedimentation rate was 31 mm/hr. All other serum
investigations were within normal limits. X-ray abdomen showed
massive gas under diaphragm. X-ray chest was normal.
Ultrasonography showed free fluid in Morrisons and Douglas pouch.
 |
|
Fig. 1. Stricture in the terminal part of
duodenum with tubercles (marked with two arrows) and a
perforated ulcer. (marked with one arrow) and dueodenum marked
with black single arrow. |
Exploration revealed a stricture in the terminal
part of duodenum, tubercles and a (Fig. 1) perforated ulcer
proximal to the stricture. Mesenteric lymph nodes were enlarged and
appeared caseating. Rest of the viscera were normal. The perforation
was closed in two layers and omentopexy was done. Side to side
duodeno-jejunostomy followed, for non-passable stricture. Mesenteric
lymph nodes were biopsied. Histopathology confirmed tuberculosis.
Antitubercular treatment was initiated. Postoperative course was
uneventful.
Tuberculosis of stomach and duodenum is rare(1)
even in patients with pulmonary tuberculosis. Duodenal perforation
proximal to tubercular stricture is exceptional. Extreme variety of
gastric and duodenal tuberculosis is attributed to factors like
sparsity of lymphoid structures, intact mucosa, rapid passage of
ingested organisms and acidity of the stomach.
The possible routes of infection are directly
through mucosa, hematogenous, lymphatic and from adjacent structures
in continuity(2) through serosa. Extensive lymphadenopathy is common.
The above two reasons make our case more rare.
The treatment of gastric and duodenal tuberculosis
is primarily medical with anti-tuberculosis drugs(3). Surgery is
indicated in cases with obstruction or perforation of an ulcer.
Paras R Kothari,
Bharati Kulkarni,
Department of Pediatric Surgery,
L.T.M. Medical College and
General Hospital,
Sion, Mumbai 400 022, India.
E-mail:
[email protected]
