Small bowel tuberculosis causing massive obscure gastrointestinal bleeding in an immunocompromised patient.

A 50-year-old male presented with passage of maroon colored stools for one week. This was associated with postural symptoms and prior to his transfer to us he had received multiple packed red cell transfusions elsewhere. The patient had undergone a renal transplant elsewhere 18 years ago and was presently receiving steroids and everolimus. The patient underwent esophagogastroduodenoscopy and colonoscopy which were normal. On colonoscopy, fresh and altered blood was observed in the colon and terminal ileum. In view of ongoing bleeding, a computed tomography angiography was done which was normal. The patient was started on intravenous octreotide and the bleeding subsided. The patient underwent capsule endoscopy which revealed multiple areas of narrowing and ulcerations lesions in distal jejunum and proximal ileum (Fig. 1 A,B). The patient excreted the capsule 28 h later. The patient underwent laparotomy with resection of the involved area. The resected small bowel revealed a large ulcer (Fig. 2A). The histopathology revealed evidence of tuberculosis with numerous epithelioid cell granulomas with Langhans type giant cells (Fig. 2B) and the stain for acid-fast bacillus was positive. Chest X-ray was normal and tuberculin skin test was positive. The patient was started on quadruple anti-tubercular therapy and his symptoms improved.

Figure 1

(A,B) Capsule endoscopy: Large ulcers with narrowing of the small bowel

Figure 2

(A) Ulcer in the resected specimen. (B) Microphotograph showing ulceration of the epithelium with crypt abscess and epithelioid cell granulomas in the lamina propria (H&Ex 20X)

Small bowel tuberculosis is an unusual cause of massive gastrointestinal bleeding although it has occasionally been reported [1,2]. Small bowel tuberculosis usually involves the ileocecal junction and involvement of small bowel without involvement of ileocecal junction as in our case is very rare [3]. Small bowel tuberculosis has been diagnosed by capsule endoscopy in a patient with evidence of small bowel strictures [4] Capsule findings reported in small bowel tuberculosis include strictures, ulcers, and lymphangiectasia [1,2,4]. Small bowel tuberculosis must be considered as a cause of obscure gastrointestinal bleeding in patients from tropical countries.