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ABDOMINAL SURGERY

Official Journal of the American Society of Abdominal Surgeons, Inc.

This article originally appeared in the Winter 2012 / Spring 2013 issue of the Journal.

Tuberculosis of Rectum Mimicking Malignancy. A Case Report and Review of Literature.

Dr. Ali Bendjaballah – Pr. M. Taieb

Surgical Department
Ain Taya Hospital
Algiers, Algeria

Address for correspondence:
Dr. Ali Bendjaballah
Department of General Surgery
Ain Taya Hospital
Algiers, Algeria
Tel: +213-551-764-640
E-mail: ali_bendjaballah@yahoo.fr


ABSTRACT

Gastrointestinal tract (GIT) is commonly affected by tuberculosis; however isolated tuberculous involvement of the rectum is rare. A tuberculosis origin must be considered when the cause of perianal and rectal lesion is unclear to avoid delay in the diagnosis and treatment.

Tuberculosis (TB) of gastrointestinal tract (GIT) may be primary focus elsewhere. We report an uncommon case of primary isolated rectal tuberculosis in a 47 year old male, who presented with anal discharge of pus and painful defecation associated with bleeding per rectum. It clinically and first histologically imitated malignancy (carcinoma or GIST) but second biopsy showed tuberculosis. Patient was started on anti tuberculosis treatment and he responded well.

Keywords: Tuberculosis, extrapulmonary, gastrointestinal, rectal echo endoscopy, anti tuberculosis treatment, malignant tumor.

INTRODUCTION

Tuberculosis continues to be a major source of morbidity and mortality in the world; 30%-50% of world population has TB (3 billion) = 8-10 million/year, more than 3 million are in Sub-Saharian Africa, and 5,000 people die/day = 2.3 million/year.

Multiple causes are responsible for this condition:

  • Worsening economic situations, multiple drug resistance
  • HIV pandemic
  • Reject of national tuberculosis control programmes
  • Large number of displaced persons living in poor conditions as a result of conflicts and wars

Resurgence in tuberculosis during the HIV era produces a new spectrum of presentations for the surgeon and, therefore, invasion by tubercle bacilli is often seen at unusual sites of the gut and reported in literature.5

Tuberculosis around the anus is a rare extrapulmonary form of the disease.1 It is necessary to recognized it due to a specific treatment. Tuberculosis can affect any part of gastrointestinal tract GIT from the esophagus to the anus. Though tuberculosis of GIT is encountered in tropical countries, tuberculosis of bowel distal or ileocaecal junction is rare and is rarely considered as a differential diagnosis of proctological disorders.2 Tuberculosis of GIT may be primary or secondary to primary focus to elsewhere.3

While the rate of patients with extrapulmonary tuberculosis has increased in the last few years (about 5% of all cases) displaying a wild spectrum of its clinical manifestations, the anal manifestations still is rare (0.7%) according to available published data.4 The most frequently observed anorectal tuberculous lesions are suppurations and fistulae. Due to the varied presentation of anal TB, it should be suspected in all lesions not responding to the conventional treatment.6

SUMMARY

Tuberculosis can affect any part of gastrointestinal tract (GIT) from the esophagus to the anus. Around the anus it is a rare extrapulmonary form of the disease, it should be suspected in all lesions not responding to the conventional treatment. In absence of pulmonary tuberculosis, diagnosis of rectal tuberculosis is very difficult as it mimics Crohn’s disease or malignancy.

CASE REPORT

A 47 year old male presented with a history of pain and burning sensation in the anal region after defecation and tenesmus associated with purulent discharge from the anus with history of mild bleeding per rectum in the last few days. There was no history of altered bowel habits, cough, hemoptysis, and fever or weight loss. He denied any past history of tuberculosis or contact with tuberculosis patient.

General and systemic examination of the patient was normal. Examination of respiratory and cardiovascular revealed no abnormality. Per abdomen examination was unremarkable.

Rectal examination showed: indurated mass in the anterior rectal wall about 5 cm from anal verge measuring about 5.5 cm-by-3.5 cm. No fistula in the anal verge.

Complete blood count was within normal limit except slight anemia: Hb =11.1g/dl. CEA level was also normal. Chest X-ray returned normal and sputum for AFB was negative. Ultrasound examination of the pelvic region was normal.

Colonoscopy was performed and shown:

  • Aspect of extrinsic compression or sub mucous rectal formation (abscess, or sub mucous extrinsic malignant tumor, GIST)
  • multiples biopsies are performed

Histopathology result: aspect of adenoma (tubulous and villous) with high grade of dysplasia.

The histopathologycal result of second biopsies was suggestive of tuberculosis.

The patient was started on Anti-Koch’s Treatment (AKT) for six months. He responded very well to this anti tuberculosis therapy and after seven months of follow-up he is completely asymptomatic.

DISCUSSION

Gastrointestinal tuberculosis represents 1% of extrapulmonary tuberculosis and only sporadic cases of anal tuberculosis have been reported in the literature.8, 9

Gastrointestinal (GI) tract is the sixth commonest site for extrapulmonary tuberculosis, comprising only 3%-4% of all extrapulmonary involvement.

Approximately 20%-25% of cases of tuberculosis involving the GI tract have simultaneous pulmonary disease.10 Colonic tuberculosis with isolated involvement of anorectum is even rarer. In a series of 37 patients described by Mukewar S et al, only 5% of patients had involvement of the rectum.11

Primary intestinal tuberculosis is usually because of bovine tubercle bacilli through milk. Decreased incidence of primary tuberculosis has been seen due to pasteurization of milk.12 Rectal TB can present with annular stricture or with ulceration of mucosa with fibrosis. The radiological and endoscopic appearances may be extremely similar to malignant rectal lesion and only biopsy can confirm the diagnosis and histopathologycal study is the key for the diagnosis of rectal tuberculosis.13

In absence of pulmonary tuberculosis, diagnosis of rectal tuberculosis is very difficult as it mimics Crohn’s disease or malignancy.14

Crohn’s disease is a debilitating expensive disease that is growing in incidence in both developing and developed countries.15

Anorectal tuberculosis may present in six forms as:

  1. fistula-in-ano, which is the commonest manifestation;
  2. ulcer with undermined edge which is the next frequent form;
  3. stricture which is short annular and firm with nodular surface which needs to be differentiated from malignancy,
  4. multiple small mucosal ulcer as a part of military disease,
  5. lupoid form presenting as a sub mucosal nodule with mucosal ulceration,
  6. verrucous form with smooth warty excrescences.17

The clinical features of anal tuberculosis, which include anal pain or discharge, multiple or recurrent fistula-in-ano and inguinal lymphadenopathy are not characteristically distinct from other anal lesions.18

Colorectal tuberculosis is common in developing countries; and its diagnosis is still difficult. Abdominal pain, fever, anorexia, weight loss, and change in bowel habit are seen in more than 50% of the patients.19

Since tuberculosis causes obliterative endarteritis, massive bleeding per rectum associated with colonic TB is rare. However, massive haematochezia is associated with rectal TB resulting from mucosal trauma caused by the scybalous stool traversing the stricturous segment.20

Bleeding per rectum in rectal tuberculosis is found in only 3%-4% of cases while constipation can be seen in as much as 37% of cases.21

Our patient too, presented with per rectal bleeding and pain during defaecation with tenesmus. He had indurated mass in the anterior rectal wall about 5 cm from anal verge measuring about 5.5 cm-by-3.5 cm and was bleeding on touch. A case reported by Gupta, showed multiple (eight) external openings in tubercular anal fistulae with evidence of tuberculosis in one of the tracts.22

As excised fistula-in-ano are not habitually subjected to histopathological examination, it may also be agreed that some cases of tubercular fistula-in-ano are missed and the incidence of rectal, anal or perianal tuberculosis may not be as low as reported in literature.23, 24, 25

However, non-recurrent fistulas may also be tuberculous. So, to prevent recurrence, all fistulas should be sent for histology for examination. It is also concluded that a tuberculous origin must be considered when the cause of perianal lesion is unclear to avoid undesirable delay in the diagnosis and treatment.26

The main differential diagnosis for gastrointestinal tuberculosis remains the Crohn’s disease or malignancy. A clinical manifestation varies from asymptomatic skin tags to severe, debilitating perineal destruction and sepsis. However, the histological differential diagnosis of Crohn’s disease and intestinal tuberculosis can be very challenging, as both are chronic granulomatous disorders with overlapping histological features.16

The biopsy reports alone can’t show the evidence of Crohn’s disease or malignancy. This may be explained by the fact that malignancy is already diagnosed because of its clinical features before the development of fistulous communications at a later stage.

Clinical and procto-sigmoidoscopic examination may reveal nodularity, ulceration, tight strictures, recto-vesical or recto-urethral fistula.29

Majority of cases investigated by Mukewar S et al showed either ulceration (92%) or nodule (54%) on Colonoscopy.11 Strictures often develop in anorectal region and are usually situated within 10 cm of anal verge. Fibrosis in this region may lead to an increase of presacral space which can be detected by MRI.20

Rectal tuberculosis should be considered as a diagnostic possibility in patients presenting with one or more of these features. To confirm presence of tuberculosis and to exclude malignancy, biopsy and histological examination is mandatory. Co-existence of tuberculosis and adenocarcinoma in rectum has been described although this association remains controversial.30 Histological examination demonstrates features of chronic granulomatous inflammation with caseation necrosis. Repeated biopsies may be required in some cases as tuberculous lesions may be submucosal in nature.28 Demonstration of AFB in biopsy specimen or culture is the most specific investigation although diagnostic yield in either procedure is usually low.30

In absence of pulmonary tuberculosis, diagnosis of rectal tuberculosis is very difficult as it mimics Crohn’s disease or malignancy.33

Provisional diagnosis of carcinoma of rectum was considered in our patient in view of colonoscopy result (Aspect of extra rectal compression or sub mucous rectal formation "abscess, sub mucous or extra rectal malignant tumor"), and histopathology result: aspect of adenoma (tubulous and villous) with high grade of dysplasia. However MRI and proctoscopic biopsies revealed granulomatous lesion with caseation which is characteristic of tuberculosis.

Treatment of tuberculosis lesions of anus and rectum should include conventional surgical treatment of anal sepsis and specific medical anti tuberculosis treatment. 31 Anti tuberculosis drugs have changed the dismal outcome of patients with ano rectal tuberculosis.

They have also made surgery safe and often curative. In most of cases the patients are treated with combination of four anti tuberculosis chemotherapeutics.32

Surgical treatment may be required if:

a) Stenosis persists after 3 to 6 months of antitubercular treatment.
b) It is difficult to differentiate from malignancy.
c) Malignancy and tuberculosis coexist.19

Our patient responded well to anti TB drugs for six months duration. This is an unusual case of rectal TB responding well to AKT.

The response was very well and there was no rectal pain, no bleeding per rectum and no more discharge from the anus. The treatment is two-fold in such patients of rectal tuberculosis: surgical for drainage with biopsy and medical for the tuberculosis.

Therefore, we can treat a patient with rectal tuberculosis by chemotherapy rather than subjecting the patient to abdominoperineal resection by misdiagnosing the case as malignancy.

Recurrences are unusual after the start of anti-tuberculous therapy. Therefore, an early diagnosis is a must in such patients to prevent recurrences as well as further surgeries of such an easily curable disease.6

Many reports however suggest that the “hypertrophic form” of gastrointestinal tuberculosis do not respond to drug therapy.19

CONCLUSIONS

Rectal TB can present with annular stricture or with ulceration of mucosa with extra luminal mass. However its radiological and endoscopic appearances may be extremely similar to malignant rectal lesion and only histological examination can confirm the diagnosis.

Tuberculosis in rectum should be strongly considered as differential diagnosis in patient presenting with rectal mass keeping in mind that the prognosis with anti-TB treatment is very satisfactory, sparing the patient of unwarranted surgical intervention unless complications develop.

Therefore, in all cases of rectal and/or anal suspected tuberculosis lesion, histopathological examination of the excised fistula or rectal biopsy is mandatory and once tuberculosis is confirmed, antituberculous treatment should be immediately started to ensure early healing and cure of the disease. Appropriate anti-tuberculous therapy leads to healing within 6 months.

 

REFERENCES

1. Harland R W, Varkey B, Anal tuberculosis: report of two cases and literature review. American J. Gastroenterology. 1992;87:1488-1491.

2. Shan YS, Yan JJ, Sy ED, Jin YT, Lee JC. Nested polymerase chain reaction in the diagnosis of negative Ziehl-Neelsen stained Mycobacterium tuberculosis fistula-in-ano: report of four cases. Dis Colon Rectum. 2002;45:1685-8.

3. Iwase A, Shiala S, Nakaya Y, Sakamoto K, Aoki S, Matsuoka R, Nagayama T. An autopsy case of severe tuberculosis Associated with anal fistula and intestinal perforation. Kikkaku. 1997;72:515-518.

4. Clarke DL, Thomson SR, Bissetty T, Madiba TE, Buccimazza I, Anderson F. A single surgical unit’s experience with abdominal tuberculosis in the HIV/AIDS era. World J Surg. 2007;31:1087-96.

5. Lax JD, Haroutiounian G, Attia A, Rodriguez R, Thayaparan R, Bashist B. Tuberculosis of the rectum in a patient with acquired immune deficiency syndrome: report of a case. Dis Colon Rectum. 1988;31:394-7.

6. Tubercular Fistula-in-Ano Iram Bokhari, Syed Sagheer Hussain Shah, Inamullah, Zahid Mehmood, Syed Umer Ali and Asadullah Khan Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7):401-403

7. Zahidul Haq, MD. Shahriar Mahbub, MD. Titu Miah, MD. Billal Alam, Riaz Ahmed Chowdhury, Ham Nazmul Ahasan. Tuberculosis at an unusual site J. Medicine of Bangladesh. 2010;11:67-69

8. Romelaer C, Abramowitz L. Anal abscess with a tuberculous origin: report of two cases and review of the literature. Gastroenterol Clin Biol. 2007;31:94-6.

9. Myers SR. Tuberculous fissure-in ano. J R Soc Med. 1994;87:46.

10. Chong V H, Lim K S. Gastrointestinal tuberculosis. Singapore Med J 2009;50:638-646

11. Mukewar S, Mukewar S, Dua KS. Tuberculosis of the colon: endoscopic features with prospective follow-up after anti-tuberculosis treatment. Gastrointest Endosc. 2007;65:AB253.

12. Rege SA, Umman P, Nunes Q , Joshi A*, Rohandia OS. Rectal tuberculosis simulating malignancy — A Case Report and Review. Bombay Hospital Journal. 2002;44:2.

13. Puri AS, Vij JC, Kumar N, et al. Diagnosis and outcome of isolated rectal tuberculosis. Dis colon Rectum. 1996; 39(10):1126-9.

14. Panton ON, Sharp R, English RA, Atkinson KG. Gastrointestinal tuberculosis–The great mimic still at large. Dis Colon Rectum. 1985;28(6):446-50.

15. Panés J, Gomollón F, Taxonera C, Hinojosa J, Clofent J, Nos P. Crohn’s disease: a review of current treatment with a focus on biologics. Drugs. 2007;67:2511-37.

16. Kirsch R, Pentecost M, Hall Pde M, Epstein DP, Watermeyer G, Friederich PW. Role of colonoscopic biopsy in distinguishing between Crohn’s disease and intestinal tuberculosis. J Clin Pathol. 2006;59:840-4.

17. Rai RR, Nijhawan S, Bhargava N, Nepalia S, Pokhrana DS. Rectal tuberculosis–a case report. Indian J Med Res. 1993:35-37.

18. Gupta PJ. Ano-perianal tuberculosis- solving a clinical dilemma. Afr Health Sci. 2005;5:345-7.

19. Singh V, Kumar P, Kamal J, Prakash V, Vaiphei K, Singh K, Clinicocolonoscopic profile of colonic tuberculosis, India. Am J Gastroenterol. 1996;91(3):565-8.

20. Sharma MP, Bhatia V. Abdominal tuberculosis Review Article. Indian Journal Med Res. 2004;120:305-15.

21. Patankar T, Babulkar J, Prasad S, et al. Isolated rectal tuberculosis masquerading as malignancy. Bombay Hosp J. 2009;51(02)

22. Gupta PJ. A case of multiple (eight external openings) tubercular anal fistulae: a case report. Eur Rev Med. Pharmacol Sci. 2007;11:359-61.

23. Shukla HS, Gupta SC, Singh G, Singh PA. Tubercular fistula-inano. Br J Surg. 1988;75:38-9.

24. Chung CC, Choi CL, Kwok SP, Leung KL, Lau WY, Li AK. Anal and perianal tuberculosis: a report of three cases in 10 years. J R Coll Surg Edinb. 1997;42:189-90.

25. Alvarez Conde JL, Gutiérrez Alonso VM, Del Riego Tomás J, García Martínez I, Arizcun Sánchez-Morate A, Vaquero Puerta C. Perianal ulcers of tubercular origin: a report of 3 new cases. Rev Esp Enferm Dig. 1992; 81:46-8.

26. Gupta PJ. Ano-perianal tuberculosis. Bratisl Lek Listy 2005;106:351-4.

27. Panés J, Gomollón F, Taxonera C, Hinojosa J, Clofent J, Nos P. Crohn’s disease: a review of current treatment with a focus on biologics. Drugs 2007;67:2511-37.

28. Rasheed S, Zinicola R, Watson D, et al. Intraabdominal and gastrointestinal tuberculosis. Colorectal Dis. 2007;9:773–783.

29. Khaniya S, Koirala R, Shakya VC, et al. Anorectal tuberculosis coexisting with adenocarcinoma: an unusual association. Cases Journal. 2009;2:143.

30. Samarasekera DN, Nanayakkara PR. Rectal tuberculosis: A rare cause of recurrent rectal suppuration. Colorectal Dis. 2008;10:846-847.

31. Alyoune M, Nadir S, Merzouk M, Mounadif A, Biadillah MC, Jamael D, Alaoui R, Cherkaoui A. Tuberculous anal fistula 13 cases. Ann Gastroenterol. Hepatol. Pari1994;30:9-11

32. Alvarez Conde JL, Guterrez Alonso VM, Del Riego Tomas Garcia Martinez I, Arizcum Sanchez-Morate A, Vaq uez Puerta C,Peri anal ulcers of tubercular origin. A report of three news cases. Revu Espagnol. Enferm. Dig. 1992;81:46-48

33. BM Subnis, GD Bakhshi, Aftab Shaikh, Ashok Borisa, Vinit Wakade Yatin Kher, Ashis Patnaik, C Alagappan, Nilofar Jamadar Primary Tuberculosis of Rectum Mimicking Malignancy: A Case Report. Bombay Hospital Journal, Vol. 50, No. 2, 2008.



Journal CoverOFFICIAL PUBLICATION OF:
The American Board of Abdominal Surgery
The American Society of Abdominal Surgeons, Inc.
Foundation for Abdominal Surgery

Louis F. Alfano, Jr., M.D., Editor-in-Chief
Diane M. Pothier, Executive Editor and
Director of Continuing Medical Education


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