Commonest site for intra-abdominal tuberculosis is ileocecal region.[
5] Involvement of stomach is considered to be rare. Usually gastric tuberculosis is secondary to pulmonary tuberculosis. [
3] Primary and isolated gastric tuberculosis without evidence of lesions elsewhere is uncommon. [
1] The reason for relative rarity is attributed to bactericidal property of gastric acid, scarcity of lymphoid tissue in gastric wall and intact gastric mucosa of the stomach. The possible routes of infection include direct infection of the mucosa, hematogenous spread or extension from neighbouring tuberculous lesion. [
4] Commonly these patients mimic peptic ulcer disease or malignancy but at times clinical presentation may be misleading. Okoro EO and Komolafe OF [
6] reported two patients of gastric tuberculosis with unusual presentations. One of their patients was elderly man suspected to have abdominal malignancy but subsequently found to be extensive, complicated gastric tuberculosis coexisting with chronic peptic ulcer disease. The second patient was female who developed gastro-bronchial fistula due to tuberculosis, which was evident radiologically. A report by Chetri K [
7] et al has shown a case of gastric tuberculosis presenting as non-healing gastric ulcer. Out of 5, three of our cases presented with gastric outlet obstruction, which is the most common presentation of gastric tuberculosis. [
8] These 3 patients had to undergo subsequently laparotomy for relieving obstruction and tissue diagnosis. One of these 3 showed features of portal hypertension with splenomegaly, which was due to old tuberculous lymphadenitis causing portal vein thrombosis. Wig JD [
9] et al reported a case of isolated gastric tuberculosis presenting as massive hematemesis. This patient was found to have benign gastric ulcer along the lesser curvature. The diagnosis of tuberculosis was done on histopathological examination showing caseating epitheloid cell granulomas. It is well known fact that probably due to lack of accurate clinical diagnosis, most patients end up with surgical intervention and the diagnosis of gastric tuberculosis is made after surgery. Remaining 2 patients presented with dysphagia and a mass lesion at gastroesophageal junction. Tuberculous lesions of the stomach are usually located on lesser curvature of the antrum and often involve the duodenum but the finding of a tuberculous ulcer at the gastroesophageal junction is uncommon. [
10] The diagnosis of tuberculosis requires demonstration of caseating epitheloid granuloma or presence of acid-fast bacilli in tissue. When granulomas are non-caseating, small and discrete, the differential diagnosis on histology includes Crohn's disease, sarcoidosis, syphilis, mycotic lesions and exposure to beryllium, silicates or reserpine.[
4,
11] Petroianni A et al have reported a case of abdominal tuberculosis mimicking Crohn's disease in an immigrant girl from Peru. In all of our 5 cases, granulomas were composed of caseation necrosis and epitheloid cells. We were able to demonstrate AFB bacilli in all of them. Other possibilities of granulomatous lesions were ruled out clinically keeping in mind high incidence of tuberculosis in India. The clinical response to ATT and repeat endoscopic examination also supported the diagnosis.