Vishal Sharma et al report that a 30-year-old man who was a resident of North India presented to emergency services with 2 episodes of painless hematemesis. He did not have a history of disease and his clinical examination was unremarkable. However, esophagogastroscopy revealed a submucosal lesion in the antrum with an ulcer on the top.
Computed tomography identified a nonenhancing hypodense lesion in the wall of the stomach in the antrum. Endoscopic ultrasound showed a well-defined heteroechoic lesion arising from the muscularis propria. Sharma et al performed fine-needle aspiration expecting to find a stromal tumor of the stomach.
However, cytologic examination of the aspirated material showed it to be paucicellular, with epithelioid cell granulomas identified by H&E (see figure D). Ziehl Neelsen staining identified acid-fast bacilli (see figure E). The authors therefore made a diagnosis of gastric tuberculosis. The patient was treated with a 4-drug combination (rifampicin, isoniazid, pyrazinamide, and ethambutol). After 2 months, he had gained 4 kg.
Sharma et al explain that the stomach is an uncommon location of tuberculosis, even in endemic regions. Although patients with gastroduodenal tuberculosis usually present with gastric outlet obstruction, loss of weight, and loss of appetite, they can also have hematemesis.
Endoscopic findings in patients with gastric tuberculosis include ulcers, thickened folds, nodules, and submucosal lesions. Biopsies can contain epithelioid cell granulomas with caseous necrosis, but acid-fast bacilli is uncommon. However, endoscopic ultrasound aids in diagnosis, because it allows material to be obtained for cytology analysis.