Endoscopic ultrasound-guided gastrojejunostomy to the rescue as a “bridge therapy” for tubercular duodenal obstruction

Excerpt

A 23-year-old-lady presented to the gastroenterology department at the Postgraduate Institute of Medical Education and Research, Chandigarh with periumbilical pain for six months, non-bilious vomiting for three months and weight loss (12 kgs). Clinical examination revealed multiple, matted lymph nodes in the axilla and right supraclavicular region, fine needle aspiration cytology (FNAC) of which revealed caseous necrosis with granulomatous inflammation (acid- fast bacilli [AFB] positive). Esophagogastroduodenoscopy (EGD) revealed duodenal stricture (D1/D2) and she had undergone six sessions of endoscopic balloon dilatations, without any symptomatic relief in her outlet symptoms, at an outside center, before being referred to our hospital. Her laboratory parameters revealed anemia (hemoglobin 8.6 mg/dL), hypoalbuminemia (2.1 g/dL), hypokalemia (2.3 mEq/L), raised erythrocyte sedimentation rate (ESR) (86 mm/h) and 13 mm Mantoux test. Contrast-enhanced computed tomography (CECT) abdomen showed multiple conglomerate lymph nodes in peri-gastric/peri-portal region with gastric outlet obstruction (Fig. 1A). Repeat EGD revealed pin-point D1/D2 stricture, with surrounding multiple polypoidal lesions, sans any ulcerative lesions (Fig. 1B) and biopsy of the stricture showed ill-defined granulomas with Langhans’ type of giant cells (AFB negative), consistent with tuberculosis (TB) as the etiology (Fig. 1C). In view of poor response to endoscopic dilatations, malnourished clinical status and need for anti-tubercular therapy (ATT), (which comprises oral tablets), a multi-disciplinary team meeting explored different treatment options and patient opted for endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ).

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