Post gastrectomy mass: to be TB or not to be TB.

Learning objectives were (1) to recognize the relationship between gastrectomy and Mycobacterial tuberculosis infection; and (2) to recognize the surveillance guidelines for post gastrectomy patients. A 73-year-old male with Billroth 2 gastrectomy for PUD in 1980 presented in June 2003 with 6 months of abdominal pain, weight loss and vomiting. He was diagnosed with Mycobacterium kansasii pulmonary infection in January 2003, started on 3 drugs that he could not tolerate. Abdominal ultrasound, CT and GI series with small bowel follow through in January 2003 were negative. Workup in June 2003 with EGD and biopsy showed gastric stump ulceration. Biopsy showed adenocarcinoma, no AFB or granulomas. Because of his poor performance comfort care was opted. Although gastric adenocarcinoma is common world wide, incidence in the USA has declined. Predisposing factors include H pylori infection, atrophic gastritis, pernicious anemia and gastric resection >15 years ago. Studies show 80% incidence of gastric stump cancer in patients with Billroth 2 gastrectomy. Systemic follow-up of patients who undergo stomach surgery for peptic ulcer disease is recommended, as early detection is the most important factor contributing to successful treatment. In creased incidence of pulmonary M tuberculosis infection after gastric resection is also seen. M kansasii, an atypical mycobacterium, presents in immunocompetent individuals as lung disease, cellulitis, arthritis or lymphadenitis. However to our knowledge increased M kansasii infection in gastrectomized patients has not been reported. This case emphasizes the need for diligent follow-up of gastrectomized patients and begs the question: Does partial gastrectomy also makes one susceptible to pulmonary infection by non-tuberculous mycobacteria?

Tripura Mantha Bala, MD, and Mukta Panda, MD. University of Tennessee, Chattanooga Unit, Chattanooga, TN.