92 ,,
-ILEO-GCAECAL TUBERCULOSIS
CASE REPORT
By A. E. MORTIMER WOOLF, M.B., F.R.C.S.Consulting Surgeon, Queen Mary's Hospital for the
East End
In March, I942, I was asked to see a man aged34 with pain in the region of the umbilicus,which had persisted for three and a half months.The pain was colicky in nature and at the onsetoccurred chiefly in the evenings. During somedays he was quite free, but when the pain cameon the passing of wind made no difference. Aboutsix weeks after the onset the pain came on everynight and at times during the day. At this timethere was no vomiting and his bowels were openregularly. He saw a physician who advised hisgoing for a holiday, but the pain got worse andeventually an X-ray by a barium meal and enemashowed a filling defect in the region of the caecum.I was then asked to see him again. For the pastthree weeks he had gone off his food, partly be-cause he was somewhat afraid that food mightcause the pain. He had lost weight and looked ill.On examination a very definite mass could
be felt in the right iliac fossa. It was firm,irregular and somewhat nodular. It could bemoved from side to side and also moved onrespiration. The diagnosis seemed to rest be-tween a carcinoma of the caecum and a tumour ofinflammatory nature. On re-examining the X-ray,although there was a filling defect there seemed tobe little, if any, infiltration. This was unlikemalignant disease and suggested that the massmight be inflammatory. He was admitted tohospital. During the week he was in, beforeoperation, he vomited.
Previous HistoryApart from an operation for left inguinal hernia
six months before the onset of the present symp-toms, he had had no previous illness of note.
OperationThe abdomen was opened by an incision in the
right linea semilunaris. The caecum, small in-testine (for about a foot) and a portion of theascending colon were infiltrated with smallnodules which were especially marked over thecaecum and the small intestine. The ileumshowed no suggestion of a' hose pipe.' This didnot look like regional ileitis nor did- it look like
malignant disease. My opinion was that thelesion was tuberculous. About a foot and a halfof small intestine, together with the caecurn,ascending colon and hepatic flexure were resectedand the cut end of the ileum was anastomosed tothe transverse colon by end-to-end anastomosis.Recovery was uneventful and the wound healed byfirst intention. The pathological report showed acharacteristic tuberculous lesion.
Ileo-caecal tuberculosis is a much rarer diseasethan was formerly thought. This case, however,is a true example of it and differs in many respectsfrom Crohn's disease.
RADIOLOGY
By J. M. CORALL, M.B., CH.B., D.M.R.
Investigation. This should include barium mealand barium enema, each being complementary tothe other. The former provides for examinationof the lower ileum as well as the caecum andascending colon, in addition to giving evidenceof hypermotility of the intestinal tract. The headof the meal may be in the rectum while some isstill in the stomach (Brown, I930) (see also Fig. i).The enema gives a truer picture of the actualdegree of narrowing of the caecum and ascendingcolon since the pressure mitigates to an appreciableextent deformities due to irritability and spasmwhich the meal cannot overcome. The extent ofactual organic contracture is therefore more easilyassessed. A rrLarker is placed on any palpable massfelt. The degree of fixation or otherwise of the areais determined on screen examination together withtenderness and its distribution on palpation. Themucosal pattern is studied fluoroscopically andmultiple spot films are preferable to show mucosalchanges and the constancy of the filling defects.
Interpretation. (a) The most important X-rayevidence of ileo-caecal tuberculosis is the markedintolerance of the caecum to barium. With thebarium meal the ileum and transverse colon areseen filled, while the caecum is mostly empty(Fig. 2).
(b) Stierlin's sign shows either a gap or a thintrickle of barium in the caecum due to spasm orcombination of spasm and narrowing of the lumenby encroaching granulation tissue. Fig. 3 iHlus-trates a classical Stierlin's sign. Although con-sidered nearly pathognomonic of caecal tubercu-
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February 1950 Cliniical Section 93
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FIG. i.-Barium meal, showing the head of the meal inthe rectum whilst some is still in the stomach.
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FIG. 2.-Barium meal, showing the ileum and the trans-verse colon filled whilst the caecum is almost empty.
....... .. .4*.: s .FIG. 3.-A typical Stierlin s sign.
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d ;Eia, aFIG. 4.-Barium meal still present in loops of lowerileum after 24 hours.
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94 POSTGRADUATE MEDICAL JOURNAL February I950
FIG. 5.-Barium enema, showing almost completeobstruction in the ascending colon.
losis, this sign has been demonstrated in Crohn'sdisease (Shanks, 1939).
(c) Deformity of the caecum is constant; thebarium shadow tends to be funnel-shaped orconical with the apex downwards, due to thicken-ing of the wall and narrowing of the lumen. Theoutline is usually irregular.
(d) Sometimes areas of half density are seenprojecting into the barium-filled lumen, giving anappearance of 'finger-printing.' This may occurin about 8 per cent. of cases (Blumberg, 1927).
(e) Irregular narrowing of the terminal ileum issometimes seen, due to spread from the caecum(Fig. 2).
(f) Later, when obstruction predominates, thebarium meal may show dilated loops of terminalileum (Fig. i), which in addition lose their mucosalmarkings. Barium may still be present in theseloops at 24 hours (Fig. 4).
(g) Ileal stasis and segmentation of the lowerileum are suggestive of ulceration which acceleratesthe transit of the barium meal below and retardsit above (Feldman, 1948) (Fig. 4).
(h) Mucosal studies of the caecum may showdestruction of the mucosal pattern.
(i) In the air contrast barium enema a ' cobbled'appearance of the mucosal surface of the caecummay be seen in early stages of ulceration before thecondition has progressed to luminal deformity(Boles, I934).
(j) Sometimes the mass of granulation tissue inthe caecum is so great that, in the barium enema,
obstruction is almost complete (Fig. 5).(k) On palpation, during fluoroscopy of the
ileo-caecal region, tenderness is present. Rigidityand fixation of the caecal walls are usual.
(1) Complications such as fistulous tracks orintussusception may be demonstrated.
Differential Diagnosis. The radiographic ap-pearances of ileo-caecal tuberculosis, carcinoma ofthe caecum and actinomycosis (in the absence of aclassical Stierlin's sign) may be so similar thatonly with all the clinical data available can a firmdiagnosis be made. Even then, cases will arise inwhich the diagnosis will still remain in doubt.Spread to the ileum favours tuberculosis. Local-ized appendicular abscess and retro-peritonealabscess leave the mucosal pattern intact. Crohn'sdisease involves usually the terminal ileum, but thecaecum may be involved. The narrowing of theterminal ileum is irregular and Kantor's ' stringsign' may be demonstrated (Kantor, I934).Amoebic ulceration and localized ulcerative colitismay be considered if clinically suspect.The closest integration of the radiological
findings with the clinical data is essential in mostinstances before a firm diagnosis can be made.
BIBLIOGRAPHYBLUMBERG (1927-28), J'. Lab. & Clin. Med., 13, 405.BOLES and GERSHON-COHEN (I934), J. Am. Med. Ass., 103,
I 841.BROWN and SAMPSON (1930), Int. T.B., Ed. 2.FELDMAN (1948), Clin. Roent. of the Dig. Tract., 58I.KANTOR, J. L. (I934), J. Amer. Med. Assoc., 103, 2016.SHANKS, KERLEY, TWINING, X-ray Diagnosis, Vol. z.
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