Non-specific granulomatous inflammatory lesions of small bowel.RD Bapat, DK Ravishankar, O Rohandia, AS Joshi, IM Vora
Dept of Surgery, Seth GS Medical College, Bombay.
Correspondence Address: Source of Support: None, Conflict of Interest: None PMID: 0010740689
Source of Support: None, Conflict of Interest: None
The entity of nonspecific granulomatous inflammatory lesions(NSGIL) of the small bowel is a diagnostic and therapeutic dilemma. Data of 52 histopathologically proven cases of NSGIL seen by us between 1986 and 1991 were analysed. All these patients presented with either intestinal obstruction or perforation. They were thoroughly evaluated and investigated for tuberculosis. Of the 52 patients, 6 patients received antitubercular therapy (ATT) before and after surgery and 32 patients only after surgery. Fourteen patients did not receive ATT. Surgical procedures undertaken included stricturoplasty, resection/anastomosis and simple suturing of perforation. No complications were seen in patients who received ATT; however, six of 14 patients who did not receive ATT developed wound sepsis and 2 developed partial wound dehiscence. Many of these NSGIL lesions could be tuberculous in etiology though typical caseating granulomas were not seen.
Keywords: Adolescent, Adult, Aged, Antitubercular Agents, administration &dosage,BCG Vaccine, administration &dosage,Child, Child, Preschool, Female, Granuloma, complications,pathology,Human, Intestinal Diseases, complications,pathology,Intestinal Obstruction, etiology,surgery,Intestinal Perforation, etiology,surgery,Intestine, Small, Male, Middle Age, Treatment Outcome, Tuberculosis, Gastrointestinal, drug therapy,
Mathew Bailie first described the entity of “non specific granulomatous ulcerations of the small bowel” in 1905. The histopathological features of this condition now known as "non specific granulomatous inflammatory lesions" (NSGIL) of the small bowel, included chronic inflammatory granulomas with epithelioid and Langhans giant cells in the absence of caseation, [Figure - 1]. NSGIL differs from tuberculous lesions in that tuberculous granulomas typically have caseation in addition to the other above mentioned features.
In 1988, Bapat, et al showed that in animals immunised earlier with BCG vaccine for tuberculosis, subsequent inoculation of tubercular bacilli leads to lesions with histology similar to NSGIL. NSGIL may therefore be a variant of tuberculosis occurring following prior immunisation and possibly also following partial or inadequate antituberculous therapy (ATT).
The aim of this study was to analyse the clinical and histopathological features of patients with NSGIL, to identify causative factor(s) wherever possible and to evaluate the response to ATT given empirically in some patients.
During the period 1986 to 1991, 106 patients with small bowel lesions were seen by us and clinically suspected to have tuberculosis. On investigation, 54 showed evidence of pulmonary or nodal tuberculosis either at the time of presentation or in the past. The data of the remaining 52 patients histopathologically proven as NSIGL, were therefore analysed.
The patients presented with sub-acute intestinal obstruction or perforation. All underwent thorough clinical evaluation and investigation for tuberculosis. Barium study and ultrasonography were done to detect the site of obstruction and nodal involvement. The patients were subjected to emergency or elective surgery according to presentation; e.g. Of the 52 patients, 36 underwent emergency surgery (16 for perforation of ulcer and 20 for acute intestinal obstruction requiring stricturoplasty). In the remaining 16 elective surgery, (stricturoplasty in 8 patients and resection and anastomosis in others) was carried out. The presenting symptoms for them were colicky abdominal pain, vomiting, irregular bowel habits and abdominal distension. The ulcer edge or resected segment and regional lymph nodes, wherever found, were sent for histopathology.
Six patients had received ATT for 6 weeks preoperatively on a strong clinical suspicion. In all six, ATT was continued post- operatively. Thirty-two patients were given ATT empirically postoperatively only and 14 did not receive ATT.
The 52 patients included 34 males and 18 females, aged 5-70 years (mean 32.5). Twenty-eight of them had been immunised with BCG in childhood. There was no evidence of pulmonary tuberculosis radio-logically, no lymph node enlargement was found clinically in any of the patients. In all the patients irrespective of ATT, there were non-specific granulomatous lesions.
Forty-seven cases histopathologically showed non-caseating granulomas scattered in various layers of the small intestine. Five patients showed interesting findings like granulomatous reaction around cholesterol crystals (2), vegetable fibres (2) and ova of Strongyloides stercoralis (1). No postoperative complications were seen in the 38 patients who received ATT; however six of the 14 patients who did not receive ATT had wound infection and 2 had partial wound dehiscence.
The mortality was 4/52 (7.69%), two patients died due to leak and two patients due to septicemic shock. The patients who received ATT were followed up for 6 months and had no complications.
The clinical presentations in both the groups (tuberculosis and NSGIL) were similar and included weight loss, loss of appetite, malaise and varying degree of gastrointestinal symptoms. Twenty-eight patients with NSGIL had received BCG immunisation in childhood.
In an experimental study, Bapat et al had shown that inoculation with tuberculous organisms produced non-caseating granulomatous inflammatory lesions on histopathology if the host immune environment had been enhanced by immunising earlier with BCG. In India, BCG vaccination is widely practised, in the present study, 28 of 52 patients with NSGIL had received BCG immunisation. This may suggest that NSGIL is a variant of tuberculosis arrested before caseation by enhanced host immunity or due to complete or incomplete course of ATT taken in past. Better out come in this study in patients with NSGIL who received ATT also supports this.
Five patients showing serosal granulomas around cholesterol clefts, vegetable fibres and ova of Strongyloides stercoralis could be due to perforation. However, a possibility of Strongyloides stercoralis or cholesterol clefts as an etiological factor cannot be totally ruled out. In India where tuberculosis is endemic, it may be advisable to offer ATT to patients with NSGIL if no other definitive cause is detected histopathologically.
Thus, the purpose of the study was to show that the lesion in post ATT group and non ATT group are all non-specific granulomatous lesions.
We thank Dr (Mrs) PM Pai, Dean, King Edward Memorial Hospital for allowing us to publish this data.
[Figure - 1]