Gastric tuberculosis mimicking submucosal tumor: a case series

The patient is a 25-year-old woman of Han ethnicity who had upper abdominal discomfort and distension. The patient had no other symptoms and no previous history of other diseases. Gastroscopy revealed a mucosal protrusion of the posterior wall of the gastric antrum, with a slightly depressed central area (Fig. 1a, far view and Fig. 1b, near view). EUS revealed hypoechoic lesions (14.8 mm X 20.8 mm), with irregular boundaries and nonhomogeneous inner echo; the gastric wall was thickened and deformable, and the five-layer structure had disappeared. Enlarged lymph nodes were observed outside the gastric wall and hypoechoic lesions were associated with the lymph nodes (Fig. 1c and d). Repeated deep excavation biopsy along the central depression and histopathological examination (HE staining) revealed chronic granulomatous inflammation (Fig. 1e 200X and Fig. 1f 400X). Therefore, we considered the lesion to be tuberculosis, and we performed erythrocyte sedimentation rate (ESR) (45 mm/h) and tuberculin purified protein derivative (PPD) (+) analyses, chest computed tomography (CT) (no obvious abnormalities), abdominal ultrasonography (ascites and some enlarged lymph nodes), an ascites test (exudate, ADA: 45 U/L), and colonoscopy (no tuberculosis or other lesions). The patient was diagnosed with gastric tuberculosis and tuberculous peritonitis and administered regular anti-tuberculosis drug treatment. One year later, the patient’s gastric tuberculosis and ascites had completely subsided. Based on gastroscopic examination, the gastric mucosal protrusion of the posterior wall of the gastric antrum had disappeared, and a white mucosal depression that resembled an ulcer scar had formed (Fig. 1g). EUS showed that the hypoechoic lesions in the posterior wall of the gastric antrum had disappeared, the wall of the stomach was thinner, and the enlarged lymph nodes outside the gastric wall had also disappeared (Fig. 1h).

The patient is a 52-year-old woman of Miao ethnicity, and she had experienced upper abdominal swelling and pain for 6 months. She had lost 3 kg of weight over the previous 2 months. In the previous week, she had a low fever (axillary temperature: 37.5–38.0 degrees centigrade) and night sweats. Ten years prior, she had pulmonary tuberculosis and was cured. There was no previous history of other diseases. Gastroscopy revealed a mucosal protrusion with central erosion of the fundus ventriculi (Fig. 2a). EUS showed hypoechoic lesions (20.2 mm X 25.0 mm), with irregular boundaries and nonhomogeneous inner echo, a poorly structured and thickened gastric wall, and enlarged lymph nodes outside the gastric wall (Fig. 2b). Moreover, the hypoechoic lesions were associated with lymph nodes (Fig. 2c). Repeated deep excavation biopsy along the central erosion and histopathological examination (HE staining) demonstrated chronic granulomatous inflammation with caseous necrosis, which is consistent with tuberculosis (Fig. 2d). By combining her history, EUS and pathological findings, the patient was diagnosed with gastric tuberculosis. We also conducted ESR analysis (50 mm/h), PPD (+), chest CT (some calcified spots), and abdominal ultrasonography (some enlarged lymph nodes in the upper abdomen). The patient was given standard anti-tuberculosis treatment for 13 months and had a good response.

The patient was a 16-year-old boy of Han ethnicity who was a local high school student; he had experienced upper abdominal pain and fatigue for 3 months. At the time of admission to our hospital, he had lost 4 kg in weight. He had no other symptoms and no previous history of other diseases. Gastroscopy revealed a mucosal protrusion with a smooth surface in the fundus of the stomach (Fig. 3a). A miniature ultrasonic probe and EUS revealed a hypoechoic lesion (10.8 mm X 22.4 mm) that was suspected of having originated from the muscularis propria of the gastric wall; the internal echo was uniform, and the boundary was clear (Fig. 3b and c). Based on our experience and these findings, we considered the lesion to be an interstitial tumor. After communicating with the patient and his family, they decided to choose minimally invasive surgery, namely, endoscopic submucosal dissection (ESD), under general anaesthesia. After completing the preoperative examination (chest CT: obsolete pulmonary tuberculosis and abdominal ultrasonography: no obvious abnormalities), we performed ESD on the patient. During the operation, we did not find any lesions originating from the muscularis propria. However, after opening the muscularis propria, we were surprised to find a lesion with a relatively complete package and multiple nodules on the surface. This lesion severely compressed the muscularis propria and pushing it into the gastric lumen, and it was continuous with a lump similar to the enlarged lymph node outside the gastric wall (Fig. 3d and e). After the lesion was successfully removed, a histopathological examination (HE staining) was routinely performed. Surprisingly, the pathological results revealed chronic granulomatous inflammation with caseous necrosis, which is consistent with tuberculosis (Fig. 3f 200X and Fig. 3g 400X). We next performed ESR (35 mm/h) and PPD (+) analyses. The patient was eventually diagnosed with gastric tuberculosis and given anti-tuberculosis treatment for half a year, at which point the lesion in the fundus of the stomach had disappeared, leaving a slight white mucosal depression with scar formation (Fig. 3h and i).