Discussion :
the diagnosis of abdominal tuberculosis is always misdiagnosed because
of its various clinical manifestations. It is known as a great mimicker
especially when it can affect abdominal organs without pulmonary
infection, and malignant tumors are the most incriminating as a
preoperative diagnosis [2], [5].
Gastric tuberculosis is an extremely rare form whether it was a primary
or secondary infection [1]. Debi et al. Explain the reasons for its
rarity, such as the bactericidal properties of gastric acid, the
scarcity of lymphatic tissue in the gastric wall, and the thick gastric
mucosa with an intact stomach [6].
Moreover, mesenteric tuberculose lymphadenitis is extremely rare as a
cause of intestinal manifestations involving the gastric wall such in
our case[1]. Recording to the literature, A few cases were reported,
showing tuberculosis lymphadenopathy mimicking submucosal gastric tumors
such as in our case.
Primary gastric tuberculosis (without involving any other organ)is
generally located on the antrum or prepyloric region involving the
duodenum, and this location is explained by the presence of lymphoid
follicles[1], [4]. There are six types of gastric tuberculosis
in pathological forms: 1. Tubercular ulcers 2. Miliary tubercles 3.
Hypertrophic 4. Tuberculous pyloric stenosis 5. Solitary tuberculoma 6.
Tubercular lymphadenitis [2].
Clinically, patients generally present nonspecific upper abdominal pain
such as epigastric pain, associated with weight loss, anorexia,
weakness[4]. So that’s why the majority of patients with gastric
tuberculosis are often diagnosed after surgery because of the lack of
symptoms[1].
Endoscopy is helpful to diagnose this pathology, especially by biopsy
results. It can show ulcers, mass, or extrinsic compression[7].
However, in our case, gastric cancer was suspected and the biopsy did
not help to confirm our diagnosis. The poor yield of the biopsy is
explained by the submucosal lesion that may not reveal granulomas and
that is difficult in obtaining tissues[7], [8].
Endoscopic ultrasonography is also very helpful, especially in the case
of submucosal lesions or related lymph node enlargement [7]; because
it can differentiate between an extrinsic compression and a
subepithelial gastric tumor by identifying the relationship between the
lesion and the gastric wall[9].
Morphologically, No specific imaging findings can help diagnose
tuberculosis rather than malignancy because there are no pathognomonic
characteristics showed radiological modalities [5].
Resuming combined radiographic and endoscopic imaging can facilitate an
early diagnosis without unnecessary surgical resection, but it is always
difficult to have a final diagnosis by endoscopic biopsy so that we can
perform a surgical biopsy using frozen section examination[8].
Conclusion:
Abdominal tuberculosis, lymphadenitis tuberculosis present a diagnostic
challenge and a dilemma for clinicians, it can mimic a long list of
differential diagnoses such as our case of tuberculosis lymphadenitis
eroding the gastric wall. In these cases, endoscopy biopsy is the best
modality to diagnose it, but it could not be made preoperatively and it
requires surgery for diagnosis using intraoperative frozen biopsy.
Conflict of interest for all authors: The authors declare no
competing interest.
Funding : None.
Compliance with Ethical Standards: The patient has provided
both verbal and written consent for the publication of This article. It
was made sure that his identity will be kept a secret at all levels.
Consent: Written informed consent was taken from the patient
regarding the publication of this case report. It was made sure that his
identity will be kept a secret at all levels. A copy of a written
request is available for review if requested.
Acknowledgments: There were no acknowledgments to mention it.
Author contributions : All authors were involved in the
researching, writing, and editing of the manuscript.
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Figure 1: Esophagogastroduodenoscopy shows a submucosal compression or
anterior submucosal lesion, and a fistulous orifice located in the bulb.
Figure2: Abdominal computed tomography demonstrates an exophytic,
heterogenous gastric formation with a necrotic center.
Figure3: Radial endoscopic ultrasound shows round mass Located in the
gastric antrum, hypoechoic, discrete heterogeneous, without blood
vessels, far from the stomach wall.
Figure 4: the surgical findings indicated: (Figure4A) a bulky mass
adjacent to the antrum with posterior development invading the
transverse mesocolon / (figure4B) A second mass of 3 cm in the greater
omentum in contact with the left gastric artery, which may be a huge
adenopathy