Duodenal tuberculosis with a choledocho-duodenal fistula

A 22-year-old man visited our hospital (National Cancer Center Hospital Eas t) complaining of fatigue and anorexia. A laboratory investigation demonstr ated a biochemical 'picture' of obstructive jaundice. An abdominal CT showe d a low density mass in the retropancreatic area with multiple enlarged per iportal lymph nodes. Upper gastrointestinal endoscopy revealed active ulcer ation on the dorsal wall of the descending part of the duodenum, and histop athology of the biopsy specimen revealed an ulcer with reactive inflammator y cell infiltration; no tumor cells were detected. The possibility of neopl asm had been ruled out by the use of CT and angiography. The jaundice recov ered spontaneously and the abdominal mass gradually decreased in size. Endo scopic retrograde pancreatography showed no evidence of pancreatic disease; however, endoscopic retrograde cholangiography showed a choledocho-duodena l fistula. This patient showed hypersensitivity against the tuberculin skin test and Mycobacterium tuberculosis was successfully detected in gastric j uice by using a polymerase chain reaction method and culture. Biopsy sample s obtained from the duodenal ulcer at the second upper gastrointestinal end oscopy showed chronic inflammation with an epithelioid granuloma, suggestin g tuberculosis. We thus diagnosed this case as a duodenal tuberculosis with a choledocho-duodenal fistula. To the best of our knowledge, there has bee n no report available of duodenal tuberculosis being the cause of a choledo cho-duodenal fistula. (C) 2001 Blackwell Science Asia Pty Ltd.