A curious case of a LOL with mild chronic diarrhea & vomiting. Nir Bar

Transcription

1 A curious case of a LOL with mild chronic diarrhea & vomiting Nir Bar

2 Case presentation E.G. 81 y.o. F, w+2, Ashkenazi Jew nursing home resident, BADL independent PS- rec. vomiting, abdominal pain, diarrhea PMH COPD (50 PY), IHD, DM, HTN PSH appendectomy 2007 H&E- acute appendicitis CT- terminal ileitis treated with ABX Ileocolonoscopy normal

3 Case presentation 6 admissions for vomiting, diarrhea rec. falls Abdominal CT: 8 exams Skipping chronic ileitis, dilated ileal loops, contrast in the rectum Previous GI consult: IBS

4 Current episode 2018 Vomiting >20/d, awakens from sleep, gastric juice, worsened by food? for years 2-3/d Abdominal pain Diffuse nonspecific Diarrhea 10/d, blood &mucus; years on/off Suspects weight loss, denies fever No Extra intestinal manifestations FHX- negative for IBD

5 P.E. No lymphadenopathy Clear lungs Current episode 2018 Cardio RRR no murmurs Abd bowel sounds: hypermotility, tender negative peritoneal signs. No HSM PR- ext. hemorrhoids, normal colored stool no tumor or perianal disease

6 CBC WBC 7.2k HGB 12.7 MCV 90 PLT 240 Labs Chemistry CR 1 ALB 43 K 3.0 CRP 7 (<5)

7 XR

8 CT

9 Endoscopy EGD -Mild esophagitis and hiatal hernia Normal colon and TI Recommended- VCE, calprotectin Normal ileum Normal cecum

10 Stool Negative bacteria/parasites CDT - negative

11 81 YO F Summary Recurrent vomiting and abdominal pain, diarrhea: 6 years ; weight loss Mild elevation of inflammatory markers Imaging- chronic skipping ileitis ±mild loop dilations Upper & lower endoscopy - nonrevealing

12 What is your DD

13 Differential diagnosis diarrhea/abd pain Immune mediated IBD, Celiac, Bechet, Hereditary angioedema, Microscopic colitis Vascular ischemic colitis Infectious amebiasis, TB, PMC, CMV, AIDS Functional Irritable bowel syndrome Metabolic Lactose intolerance Neoplastic lymphoma, CRC, melanoma Drugs - NSAIDS Other- amyloidosis

14 Differential diagnosis vomiting GI SBO, Crohn s dis, gastric outlet obstruction Neoplastic metastasis, external pressure Neuro EICP, gastroparesis, migraine Drugs many (anti-dm) Vestibular Meniere disease, labrynthitis Functional cyclic vomiting syn. Endo hypo/hyperpth, hyperthy, Addison s Other- acute intermittent porphyria

15 Management No papilledema, neg head CT meds replacement no effect Corticosteroids were started Biologic Tx work up was sent Vomiting improved slowly Surgical consult while vomiting asked for repeat imaging

16 Management - Repeat imaging More loops inflamed, improved dilation, now duodenal/jejunum involvement: Before After

17 Push upper endoscopy was normal

18 Anti-TNF? VCE? Balloon endoscopy? What s next?

19 Further work up Stool: ZN (neg) and positive culture for MTB Gastric juice positive for ZN and culture Sputum neg culture X2, PCR neg CT thorax nonspecific tree in bud. Negative QuantiFERON (IGRA)

20 The history of intestinal TB 1912 royal society publishing - Enteritidis chronicæ pseudotuberculosæ bovis 1980 arch int med - TB enteritis and peritonitis: report of 36 hospital cases 1993 AJG - Tuberculosis of the GI tract and peritoneum 2005 AFP - Extrapulmonary Tuberculosis: An Overview 2014 WJG - Abdominal TB of the GI tract: Revisited

21 The great masquerader Differentiating from Crohn s disease is a challenge

22 Epidemiology- increased incidence 1950 s: Intestinal TB A common reason for SBO 1960 s: reduced incidence Better hygiene, milk pasteurization, anti-tb drugs 1970 s TB classified as rare 1991 in NY: 3673 new cases of sys TB WHO declares a global emergency M worldwide, 1.3M deaths Debi, U WJG 2014 Burzynski. J - Semin Respir Crit Care Med 2008 Horvath KD AJG 1998

23 AIDS Prison Immigration Developing countries Incidence Access to healthcare Nursing homes

24 בישראלTB

25 Extra-pulmonary TB (Isr) 995 cases reported, 5% HIV pos 7% abdominal TB Mor IJTBL 2013

26 Age at CD diagnosis May be diagnosed in any age, but mostly before 4 th decade Ekbom gastroenterology 1991

27 Abdominal TB TB lymphadenopathy 8% Peritoneal TB 43% Gastrointestinal TB 50% visceral TB Debi, U WJG 2014

28 Ingestion Spread Infected food or milk 1 ry intestinal TB Infected sputum -2 ndry intestinal TB Hematogenous spread from distant tubercular focus Contagious - from infected adjacent foci Through lymphatic channel Akhan O - Eur Radiol 2002 Debi, U WJG 2014

29 Pathophysiology Infects lymphoid tissue of the submucosa > caseating granuloma > deeper layers> peritoneum Portal spread to liver/spleen pancreas (rare) Akhan O - Eur Radiol 2002 Debi, U WJG 2014

30 Gastrointestinal TB Ileocecal TB- most common 42% Associated with jejunal involvement Mimics Crohn s disease Jejunu-ileal 35% Colon 12%, anorectum 7% Stomach 2% Rare<0.5%- esophagus, duodenum Horvath j AJG 1998 Balasubramanian R, -Int J Tuberc Lung Dis 1997;

31 Gastrointestinal TB Colicky abdominal pain 90% Weight loss 66% fever 35 50% Vomiting Night sweat GIB melena / hematochezia SBO Perforation Horvath j AJG 1998 Marshall JB AJG 1993 Sharma R.. Imaging Science Today 2009

32 PCR Epidemiology Clinical suspicion Imaging Diagnosis Stain & cultures H&E Horvath j AJG 1998 Debi, U WJG 2014

33 Intestinal TB tests accuracy Horvath j AJG 1998

34 TST and IGRA in active disease 25/200 patients with active pulm. TB had anergic TST Meta analysis of pulmonary TB in non-hiv: TST Sensitivity 88% IGRA Sensitivity 84% Meta analysis for intestinal TB- IGRA Sensitivity 81% NPV 87% (Tspot>QFN-G) Normal CXR: in 35% of intestinal TB Nash CHEST 1980 Metcalfe JID 2011 Ng JGH 2014

35 Clinical manifestations Crohn s disease Intestinal TB Perianal disease Spiking fever Pulmonary TB Imaging Crohn s disease Symm. wall thickening Creeping fat Comb sign Intestinal TB Asymm. wall thickening Necrotic mesenteric LN Ascites Small homogenous pericecal lymph nodes

36 Debi, U WJG 2014 Pereira Eur j radio 2005

37 Endoscopy Crohn s disease Longitudinal ulcers Aphthous ulcers Cobblestoned mucosa Preserved ICV Multiple skip lesions Anorectal lesions Intestinal TB Transverse ulcers Hypertrophic mucosa Scars/fibrous bands Gaping/destroyed ICV Hyperemic nodules

38 Debi, U WJG 2014

39 Transverse ulcer in TB

40 Crohn s disease Single granulomas Architectural distortion distant from granulomatous inflammation Histology Intestinal TB Caseating granulomas Positive AFB Confluent ( 5/biopsy), large submucosal granulomas Ulcers lined by epithelioid histiocytes Disproportionate submucosal inflammation

41

42 Treatment Negative results should not alter treatment Medical Tx- 4 drugs Isoniazid Rifampin Pyrazinamide Ethambutol Anand et al 1998 Horvath j AJG 1998

43 Treatment surgery Reserved for failed medical Tx partial SBO: 70% resolve with med. 8% surgery Opt for elective surgery Obstruction Fistula Perforation Bleeding Endoscopic dilatation??? Drain tubes may result in fistulas Anand et al 1998 Horvath j AJG 1998

44 Back to our patient Transferred to Shmuel Harofe Completed full 2 months Tx with 4 drugs (INH, RIF, PZA, EMB) Dramatic clinical improvement : improved diarrhea, vomiting No major adverse events

45 Take home massages Intestinal TB should be suspected in the right clinical settings No single diagnostic test Neg tests for latent TB do not rule out Stool cultures for TB are a valid option