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Iv Commonwealth Congress On Diarrhoea And Malnutrition; Karachi, Pakistan; Meeting Of The Commonwealth Association Of Pediatric Gastroenterology And Nutrition; November 21-24, 1997

INFLAMMATORY BOWEL DISEASE OR ABDOMINAL TUBERCULOSIS?

Shah, Uzma

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Journal of Pediatric Gastroenterology & Nutrition: August 1998 - Volume 27 - Issue 2 - p 268
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Abstract POS25

In endemic areas such as Pakistan, abdominal tuberculosis is an important differential diagnosis in disease presenting with chronic abdominal pain, fever and malabsorption. Patients infected with Mycobacterium Tuberculosis(Mtb) may present with ileocecal infection, weight loss and bleeding per rectum. Histological findings are usually atypical and demonstration of acid fast bacilli or a positive culture are required for diagnosis. A similar clinical presentation may occur in patients with inflammatory bowel disease(IBD). In contrast to the West, the incidence of IBD in Asian children has been low. We present 3 cases where IBD was mistaken for intestinal tuberculosis.

Case #1 is a 6 year old who developed chronic blood diarrhea at 2 months of age. A diagnosis of allergic colitis was made. Her problems persisted and she developed malnutrition, hypoalbuminemia, and intermittent fever and was started on treatment for tuberculosis. She did not improve and developed perianal disease. She was referred to us, at 6 years of age at which point an endoscopy revealed, strictured and fibrotic areas over the entire colon with involvement of the terminal ileum.

Case#2 is an 11 year with a history of mucoid, bloody stools 4 years prior to presentation to us. She had short stature, abdominal pain, joint pains, oral ulcers and intermittent fever and had been treated for possible abdominal tuberculosis by her primary physician with no improvement in symptoms. Radiological investigation revealed a nodular thickened terminal ileum. Endoscopy revealed patchy areas of aphthous ulceration with rectal sparing.

Case#3 is an 8 year old male with a 3 year history of abdominal pain, weight loss and malabsorption. He was treated for abdominal tuberculosis by his physician for 1 year. He had anemia, hypoalbuminemia and abdominal pain, aggravated on eating wheat. Duodenal histology suggested celiac disease with improvement on dietary gluten exclusion. A year later, he developed chronic bloody diarrhea. Radiological investigation showed mucosal thickening of the distal small bowel with ulceration of the terminal ileum.

In all 3 cases histologically, crypt abscesses, crypt distortion, branching, a chronic inflammatory infiltrate and skip areas with intervening normal mucosa were found. Crohn's disease was suspected though granulomas were not identified. Cultures for Mtb and staining for acid fast, bacilli was negative. Resolution of symptoms with weight gain occurred on treatment with Meselamine.

We conclude that although abdominal tuberculosis is an important differential to consider, it is critical to recognize that IBD is a strong possibility and may be under-reported in Pakistan.

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