Primary abdominal tuberculosis presenting as chronic dyspepsia

To the Editor: Tuberculosis (TB) continues to be a leading cause of preventable morbidity and mortality worldwide. Although Australia has the lowest rates in the world, more recently there has been a spike secondary to increased international travel and migration.1

TB can affect virtually any organ system in the body and can present with atypical or non-specific symptoms. A population-based study in America found that classical symptoms of cough and fever of > 2 weeks' duration and weight loss were variably present and were insensitive predictors for TB.2

A 51-year-old immunocompetent man who had migrated from Somalia 18 years previously presented with a 6-year history of being treated with proton pump inhibitors for chronic duodenal ulcers. Repeated gastroscopies showed oedematous thickened duodenum. He had a 6-month history of anorexia, nausea, vomiting and weight loss, and was referred for diagnostic laparoscopy for suspected gastrointestinal malignancy.

A computed tomography scan of the abdomen showed small coeliac axis lymph nodes and oedematous thickened duodenum (Box). Gastroscopic biopsy samples over the past 6 years had shown chronic inflammation but no granulomas. Laparoscopy showed florid peritoneal nodules suggestive of miliary TB. A biopsy sample was positive for polymerase chain reaction (Xpert MTB/RIF, Cepheid) and cultures for Mycobacterium tuberculosis. The patient was diagnosed with gastrointestinal TB. He responded well to antitubercular treatment.

Gastrointestinal TB is difficult to diagnose. From a review of 23 patients in India, the most common symptoms of duodenal TB were vomiting (14 patients), epigastric pain (13), and weight loss and anorexia (7).3 Patients with extrapulmonary TB may or may not have concomitant pulmonary TB.2

The ileocaecal region is most commonly involved, followed by the colon, jejunum, appendix, duodenum, stomach, sigmoid colon and rectum.4 Gastroduodenal TB is rare and is often misdiagnosed as peptic ulcer disease. Preoperative endoscopic biopsies have rarely shown underlying aetiology.3

Abdominal TB, although uncommon in developed nations, should be suspected in immunocompromised patients or people from highly endemic areas presenting with longstanding non-specific symptoms that do not resolve with standard therapy. Delayed diagnosis can lead to complications such as peritonitis, and intestinal obstruction and perforation. Therefore, early diagnosis and treatment improves patient outcomes without the need for surgical intervention.

An endoscopic image showing duodenal mucosal oedema