SAO PAULO
M e lly s s a n d e F a c c in , S o ra ia R a c h id Y o u s s e f, V a le ria M o z e tic , W ils o n R o b e rto C a ta p a n i
Inguinal hernia incarceration as a
form of intestinal tuberculosis
College of Medicine of the University Foundation of ABC (UFABC)
Discipline of Gastroenterology at the Federal University of Sao Paulo - Sao Paulo, Brazil
W e re p o rt th e ca se o f a 4 1 ye a r-o ld m a le w h o ca m e to th e e m e rg e n cy ro o m w ith a co m p la in t o f a b d o m in a l p a in , a n d w a s d ia g n o se d to h a ve a n a cu te o b stru ctive a b d o m e n d u e to a rig h t in g u in a l h e rn ia in ca rce ra tio n . D u rin g su rg e ry, a n in te stin a l g ra n u lo m a to u s in fla m m a tio n w a s o b se rve d a d h e re d to th e h e rn ia l sa c. T h e h isto p a th o lo g ic stu d y co n firm e d th e d ia g n o sis o f tu b e rcu lo sis. W e p re se n t a re vie w o f th e d iffe re n t clin ica l fo rm s o f in te stin a l tu b e rcu lo sis a n d th e d ifficu ltie s e n co u n te d in th e d iffe re n tia l d ia g n o sis o f su ch , e m p h a sizin g th e u n co m m o n p re se n ta tio n d e scrib e d in o u r p a tie n t.
UNITERMS: A b d o m in a l tu b e rcu lo sis. A cu te a b d o m e n . In g u in a l h e rn ia .
INTRODUCTION
T
uberculosis is a disease caused byMycobacteriumtuberculosis, and the intestinal form is less frequent
than the pulmonary form as a cause of
hospitalization, although it is not uncommon, especially
in less developed countries. Necropsies reveal that 50-80
percent of patients with a pulmonary lesion and cavitations
have an accompanying intestinal infection. Intestinal
infection may occur through hematogenic spreading,
through swallowing of infected sputum, or contiguity with
peritoneal lesions. Morphologically, this appears in two
forms, the ulcerati ve and the hypertrophic, the latter is
more frequent when there is no pulmonary tuberculosis,
occurring more frequently in the cecum and terminal ileum.
Address for correspondence:
M e lly s s a n d e F a c c in
F a c u ld a d e d e M e d ic in a d o A B C A v . P rin c ip e d e G a le s , 8 2 1
S a n to A n d re /S P - B ra s il - C E P 0 9 0 6 0 -6 5 0 .
This is a universal disease, with an incidence that is
progressively rising due to Acquired Immunodeficiency
Syndrome and to increasing poverty worldwide.
C A S E
DESCRIPTION
M.A.S., 41 year-old white male, had been having
morning fever and diarrhea alternated with constipation
for one month. He had also noticed an increase in volume of his inguinal hernia, which he had already been aware
of. A few hou rs before bei ng attended, he began
experiencing intense abdominal pain, which caused him
to go to the emergency room. At first physical examination,
the patient presented a 38C armpit temperature with
abdominal distention and diminished air-fluid sounds, a
visible tumefaction in right inguinal area with signs of
inflammation, and a presence of the Blumberg sign. There
was no hepatic or splenomegalia. Laboratory exams
F A C C IN , M .; Y O U S S E F , S .R .; M O Z E T IC , V . & C A T A P A N I, W .R . - In g u in a l h e rn ia in ca rce ra tio n a s a fo rm o f in te stin a l tu b e rcu lo sis
1098
revealed the following results: hemoglobin of 11.9 g percent; a 36 percent hematocrit; and 7200 leukocytes, of which three percent were bands, 83 percent were segmented, 2 percent were eosinophils, 9 were percent lymphocytes, and 3 percent were monocytes. The erythocytementation rate during the first hour was 80 mm. During surgery a thickened hernial sac was noted, which contained small intestine and multiple nodules that had caused its adherence to the deep inguinal ring and impeded its reduction. The patient underwent an exploratory laparotomy in which numerous white nodules in the peritoneum, liver, small intestine, stomach, and colon were observed. After resection of the hernial sac, the. histological examination macroscopically revealed an elevated yellow lesion, 5cm in length with a firm, white surface. There were no perforations or bowel stenosis. Microscopically, there were numerous granulomas formed by epitheloid cells and giant cells with peripheral nuclei. These lesions presented central caseous necrosis similar to tuberculoid granulomas. The patient received an antituberculosis scheme composed of isonyazid, rifampicin, and pirizinamid for 6 months, and presented good clinical and laboratorial evolution. After 6 months, the symptoms had disappeared, the hemogram was normal, the erythrocytedimentation rate was 1Omm in the first hour, and mucoprotein was 2mg percent.
D IS C U S S IO N
also agree as to the most frequent sign on examination: tenderness abdominal, especially in right iliac fossa. The presence of a palpable mass in this area was observed in 10-9 percent of the cases. Anemia is also frequently found.
Emergency surgery rates for abdominal tuberculosis are around 20-35 percent. Under these conditions preoperative suspicion of tuberculosis occurred in only 10 percent of the cases presented by ASTON and DE COSTA3. AL-HADEED et al.2, in nine patients with a diagnosis of tuberculosis after emergency surgery, showed that correct preoperative diagnosis had not been made of any of the patients and preoperative hypothesis had been perirenal abscess, intestinal occlusion, acute appendicitis, peritonitis, subfrenic abcess. Therefore, intestinal tuberculosis can mimic several other surgical conditions. On the other hand, when ASTON and DE COSTA3 and AL-HADEED chose laparotomy for diagnosis, correct preoperative diagnosis increased significantly, being near 75% and 40% respecti vely.
It is important to note the great number of patients struck by abdominal tuberculosis with no radiological alterations in the lungs!. 2.4. Other laboratory exams are
also very inspecific. For ASTON and DE COSTA, the greatest isolated diagnostic value is the intradermal reaction of Mantoux, although for AKINOGLU and BILGIN4, it was positive were in only 22 of 41 patients with tuberculosis. In patients with ascites, these authors report that adenosine deaminase (ADA) dosage is useful for diagnosis, resulting in abnormal levels in all 24 patients having this condition, while bacterial testing was positive
A review of four recent articles on the surgical treatment of this condition, one of which was a prospecti ve study3 and three of which were retrospecti ve studies I.
2.4agree, along general lines, about the clinical characteristics of this condition, thus creating the possibility of comparing them with this specific case. These studies show that the disease presents non-specific signs and symptoms. Abdominal pain is the most frequent complaint, whether it be recent or more prolonged. Symptoms such as fever, anorexia and weight loss are also frequent, with their description usually coming from patients submitted to
diagnostic surgery. The studies F ig u re 1 - T u b e rc u lo id g ra n u lo m a . C le a r id e n tific a tio n o f a m u lti-n u c le i g ia n t c e ll. 2 0 0 x .
1 0 9 9
in o n ly tw o . D e fin ite d ia g n o sis m a y b e o b ta in e d b y fin d in g
g ra n u lo m a s c o n ta in in g c e n tra l c a se o u s n e c ro sis in th e
h isto p a th o lo g ic m a te ria l. In so m e c a se s th e re a re
su g g e stiv e le sio n s, a lth o u g h w ith o u t n e c ro sis. In th e se
c a se s, h isto p a th o lo g ic fin d in g c o m b in e d w ith c lin ic a l
m a n ife sta tio n s a n d a fa v o ra b le e v o lu tio n a fte r tu b e rc u lo sis
tre a tm e n t su p p o rts th is d ia g n o sis.
S e v e ra l c h a ra c te ristic s in o u r c a se s c o in G id e w ith
d e sc rip tio n s in th e lite ra tu re . A s a lre a d y m e n tio n e d , th e a b se n c e o f lu n g le sio n s in th o ra c ic ro e n tg e n o g ra m s is v e ry
c o m m o n , a s w e ll a s h ig h e riy tro c y te se d im e n ta tio n ra te s
a n d th e a b se n c e o f le u k o c y to sis. T h e tu b e rc u lo id
g ra n u lo m a th a t w a s fo u n d (F ig . I )su g g e ste d a d ia g n o sis
fo r su c h , c o n firm e d b y a g o o d e v o lu tio n a fte r sp e c ific
tre a tm e n t. W h a t m a y b e a n u n c a n n y fin d in g is th a t o u r
p a tie n t, w h o u n d e rw e n t e m e rg e n c y su rg e ry , m a y h a v e
p re se n te d b o w e l in c a rc e ra tio n in th e in g u in a l h e rn ia a s a
re su lt o f th e tu b e rc u lo sis, sin c e it w a s firm ly a d h e re d to
th e h e rn ia l sa c , w ith n o u lc e ra tio n s, ste n o sis o r p e rfo ra tio n s
p re se n t. In fa c t, th e la tte r is w h a t le a d s to e m e rg e n c y
su rg e ry , w h ile th e h y p e rp la stic fo rm , a s in o u r p a tie n t's c a se , is e v id e n c e d d u rin g e le c tiv e la p a ro to m y p e rfo rm e d
to d iffe re n tra te th is d ia g n o sis fro m fo r a C ro h n 's d ise a se
o r ly m p h o m a . It is p o ssib le th a t h a d th e re b e e n n o
a d h e re n c e to th e sa c , a n d h a d th e d ise a se e v o lv e d fo r a
lo n g e r tim e , d ia g n o sis w o u ld h a v e b e e n m a d e th ro u g h
ro u tin e in v e stig a tio n o r e le c tiv e la p a ro to m y . A s fa r a s w e
k n o w , th e re h a s b e e n n o re p o rte d c a se sim ila r to th is
p a tie n t's, th is b e in g a n o th e r u n c o m m o n fo rm o f
p re se n ta tio n a m o n g n u m e ro u s a b d o m in a l m a n ife sta tio n s
o f th is d ise a se .
A C K N O W L E D G M E N T S
T h e a u th o rs w ish to th a n k D r. M a ria R e g in a R e g is
S ilv a , P h D , h e a d o f th e D isc ip lin e o f A p p lie d P a th o lo g y
a t th e F e d e ra l U n iv e rsity o f S a o P a u lo , a n d M a ria T e re sa
G ia n o tti G a llu p o , fro m th e D isc ip lin e o f A n a to m ic a l
P a th o lo g y o f th e C o lle g e o f M e d ic in e o f th e U F A B C , fo r
th e ir h e lp w ith th e h isto lo g ic a l e x a m in a tio n s a n d
p h o to g ra p h s.
R E S U M O
R e la t a m o s u m c a s o d e p a c ie n t e d o s e x o m a s c u lin o . 4 1 a n o s , q u e d e u e n t r a d a e m S e r v i9 0 d e E m e r g e n c ia c o m q u e ix a d e d o r a b d o m in a l, s e n d o f e it o d ia g n 6 s t ic o d e a b d o m e a g u d o o b s t r u t iv o p o r e n c a r c e r a m e n t o d e h e r n ia in g u in a l
a
d ir e it a . A c ir u r g ia , e v id e n c io u - s e a l9 a in t e s t in a l c o m a c o m e t im e n t o in f la m a t 6 r io g r a n u lo m a t o s o , a d e r id a a o s a c o h e r n ia r io . 0 e s t u d o a n a t o m o p a t o l6 g ic o d o m a t e r ia l c ir u r g ic o c o n f ir m o u 0 d ia g n 6 s t ic o d e t u b e r c u lo s e . A p r e s e n t a m o s u m a r e v is a o s o b r e a s d if e r e n t e s f o r m a s c lin ic a s d a t u b e r c u lo s e in t e s t in a l e d if ic u ld a d e s e n c o n t r a d a s p a r a s e u d ia g n 6 s t ic o d if e r e n c ia l, e n f a t iz a n d o a in u s it a d a f o r m a d e a p r e s e n t a 9 a o d e s c r it a e m n o s s o p a c ie n t e .R E F E R E N C E S
1 . A k in o g lu A , B ilg in I. T u b e rc u lo u s e n te ritis a n d p e rito n itis.
C a n J S u rg 1 9 8 8 ;3 1 (1 ):5 5 -8
2 . A I-H a d e e d i S , W a lia H S , A I-S a y e r H M . A b d o m in a l
tu b e rc u lo sis. C a n J S u rg 1 9 9 0 ;3 3 (3 ):2 3 3 -7 .
3 . A sto n N 0 , D e C o sta A M . A b d o m in a l tu b e rc u lo sis. B r J
C lin P ra c t 1 9 9 0 ;4 4 (2 ):5 8 -6 3 .
4 . U n d e rw o o d M J, T h o m p so n M N , S a y e rs R D , H a ll A W .
P re se n ta tio n o f a b d o m in a l tu b e rc u lo sis to g e n e ra l su rg e o n s.
B r J S u rg 1 9 9 2 ;7 9 : 1 0 7 7 -9 .
F A C C I N , M . ; Y O U S S E F , S . R . ; M O Z E T I C , V . & C A T A P A N I , W . R . - I n g u in a l h e r n ia in c a r c e r a t io n a s a f o r m o f in t e s t in a l t u b e r c u lo s is
