Tuberculosis (TB) remains one of the leading causes of death globally. Although abdominal or peritoneal TB is a recognised site for extrapulmonary TB to manifest, the diagnosis is often delayed due to the non-specific nature of the presenting clinical features. We present the diagnostically challenging case of a 32-year-old patient with recurrent episodes of fever and a non-productive cough that was initially treated as community-acquired pneumonia with oral antibiotics. A computed tomography scan of the thorax was unrevealing, aside from a large volume of ascites within the partially imaged upper abdomen. The patient did not report any abdominal symptoms and the abdominal examination was unremarkable. Subsequently, a transvaginal ultrasound, a contrast-enhanced computed tomography scan of the abdomen and pelvis, and magnetic resonance imaging of the abdomen and pelvis confirmed a large volume of ascites in the absence of any definite aetiology. A peritoneal biopsy was required before the diagnosis of peritoneal TB was eventually confirmed. This case highlights the importance of considering peritoneal TB in patients presenting with treatment-resistant chest symptoms and persistent pyrexia of undetermined aetiology, even in the absence of abdominal signs and symptoms.
Background: Gastrointestinal illness is a major cause of morbidity in travellers and is a common reason for presentation to healthcare services on return. Whilst the aetiology of imported gastrointestinal disease is predominantly infectious, outcomes are variable due to a range of phenomena such as post-infectious irritable bowel syndrome, drug resistance and occult pathology (both infectious and non-infectious). Previous studies have focussed on predictors of aetiology of gastrointestinal disease in travellers; we present a retrospective study combining both aetiological and early outcome data in a large cohort of returned travellers. Method: We identified 1450 patients who attended our post-travel walk-in clinic with gastrointestinal symptoms between 2010 and 2016. Demographic, travel, clinical and laboratory data was collected through case note review. Logistic regression analysis to examine correlates of aetiology and outcome were performed in R (CRAN Project 2017). Results: Of 1450 patients in our cohort 153 reported bloody diarrhoea and 1081 (74.6%) reported non-bloody diarrhoea. A definitive microbiological diagnosis was made in 310 (20.8%) of which 137 (9.4%) had a parasite identified and 111 (7.7%) had a bacterial cause identified. Factors associated with a parasitological diagnosis included history of travel to South Asia (aOR=2.55; 95%CI 1.75-3.70, p<0.0001) and absence of bloody diarrhoea (aOR=0.22; 95%CI 0.066-0.53, p<0.005). Factors associated with a bacteriological diagnosis included male gender (aOR=1.69; 95%CI 1.10-2.62, p<0.05), an age <37 years on presentation (aOR=2.04; 95%CI 1.25-3.43, p<0.01), white cells on stool microscopy (aOR=3.52; 95%CI 2.09-5.86, p<0.0001) and a C-reactive protein level of >5iu/dL (aOR=4.68; 95%CI 2.91-7.72, p<0.0001). The majority (1235/1450, 82.6%) reported full symptomatic resolution by the first follow up visit; factors associated with lack of symptomatic resolution included female gender (aOR=1.45 95%CI 1.06-1.99, p<0.05), dysenteric diarrhoea (aOR=2.14 (95%CI 1.38-3.25, p<0.0005) and elevated peripheral leukocyte count (aOR=1.58 95%CI 1.02-2.40, p<0.05).Conclusions: In a cohort of returned travellers, we were able to identify multiple factors that are correlated with both aetiology and outcome of imported gastrointestinal syndromes. We predict these data will be valuable in the development of diagnostic and therapeutic pathways for patients with imported gastrointestinal infections.
Background Surveillance for colorectal cancer (CRC) is necessary in patients with inflammatory bowel disease (IBD). Patients with ulcerative colitis (UC) have a similar CRC risk to those with Crohn’s colitis (CC). British Society of Gastroenterology (BSG) guidelines from 2010 outlined recommendations for screening including surveillance intervals and pancolonic dye spraying with targeted biopsies. We aimed to identify reasons why the first surveillance colonoscopy is not being performed as advised, including the role of poor bowel preparation and disease activity. Methods Retrospective study of all IBD colonoscopies over a 7 year period (2011–2018) across two sites at a tertiary London based hospital trust. 214 patients were identified and exclusion criterion was applied (not first surveillance/diagnosis prior to year 2000/PSC/inadequate data). 93 patients were included for analysis. Results 26 (28.0%) surveillance colonoscopies were performed prior to 10 years of diagnosis (ie. before BSG guideline recommendation). 22 (23.7%) surveillance colonoscopies performed after the recommended interval. Dye spray was performed in only 2 patients (2%). Reasons cited for not dying were only given in 4 (4.3%) cases, and included poor bowel prep or active disease. No reason was given in 87 (93%) cases. Targeted biopsies were performed in 24 (25.8%) patients, with random biopsies in 56 (60.2%) patients. Conclusion The first IBD surveillance colonoscopy is only being performed at the correct time interval in approximately 50% of cases with over a quarter being performed too soon and almost a quarter being performed too late. Pan-colonic dye spray is used in only 2% and targeted biopsies are taken in only 1 in 4 patients. Poor bowel preparation and disease activity do not appear to be limiting factors in the use of dye spray. We conclude that appropriate initial colitis surveillance is not being performed in the majority despite published guidelines. Organisational factors such as sufficient time allocated to dye spray colonoscopy, along with endoscopist skill, may be contributing factors.
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