Multimodal Diagnosis and Management of Gastric Tuberculosis: A Case Report

Summary

This case report presents a stepwise multimodal workflow for diagnosing gastric tuberculosis, integrating gastroscopy, cross-sectional imaging, endoscopic ultrasound, histopathology, and molecular testing to confirm infection when superficial biopsies are non-diagnostic.

Abstract

Gastric tuberculosis is an exceptionally rare form of extrapulmonary tuberculosis and often presents with non-specific symptoms and endoscopic appearances, frequently mimicking submucosal tumors, peptic ulcer disease, or malignancy. These overlaps, together with the limited yield of superficial biopsies, can delay definitive diagnosis. Here, researchers report a case of gastric tuberculosis and emphasize the methodological advantage of a multimodal diagnostic strategy that integrates endoscopy, cross-sectional imaging, histopathology, and molecular testing to progressively narrow diagnostic uncertainty. Gastroscopy revealed a localized gastric lesion, while imaging provided complementary lesion characterization and suggested possible extra-gastric involvement, prompting further evaluation for granulomatous infection. Repeated endoscopic sampling did not establish a diagnosis, and laparoscopic partial gastrectomy was therefore performed to obtain adequate deep tissue for comprehensive assessment. Histopathological examination demonstrated granulomatous inflammation with caseous necrosis, and molecular testing supported infection with Mycobacterium tuberculosis complex, confirming gastric tuberculosis. The postoperative course was uneventful, and the patient subsequently received standard antituberculous therapy. Symptoms resolved, and no recurrence was observed during long-term follow-up. This case highlights practical diagnostic challenges and provides a reproducible, stepwise approach that may help clinicians suspect, differentiate, and confirm gastric tuberculosis earlier in similar presentations.

Introduction

Gastric tuberculosis is an exceptionally rare manifestation of Mycobacterium tuberculosis infection in the human body¹. Its incidence is extremely low, and even in regions with a high tuberculosis burden, gastric involvement is typically reported as accounting for less than 1% of gastrointestinal tuberculosis cases². This low incidence has been attributed to several local protective factors, including the bactericidal effect of gastric acid, the integrity of the gastric mucosal barrier, and rapid gastric emptying, which collectively reduce sustained bacillary contact with the gastric wall

Protocol

This protocol was performed in compliance with the guidelines of the Institutional Human Research Ethics Committee of Dongguan People’s Hospital under approval number LW 2026-001. Written informed consent was obtained from the patient prior to all diagnostic, therapeutic, and follow-up procedures.

1. Patient eligibility and initial assessment

1. Medical history
   1. Recorded the chief complaint and documented symptom onset, duration, location, character, aggravating factors (e.g., postprandial or nocturnal), and relieving factors.
   2. Recorded associated symptoms (e.g., belching, nausea, vomitin....

Results

Initial assessment results
A 70-year-old woman presented with abdominal pain for one month. She reported no known tuberculosis exposure and denied constitutional or alarm symptoms, including nausea, vomiting, fever, and significant weight loss. Her medical history included well-controlled hypertension and type 2 diabetes mellitus, managed with chronic oral medications. On physical examination, she was alert and hemodynamically stable. No jaundice or palpable superficial lymphadenopathy was noted. The.......

Discussion

Gastric tuberculosis is an uncommon manifestation of gastrointestinal tuberculosis and can arise through hematogenous or lymphatic dissemination, direct extension from adjacent lesions, or implantation in the setting of impaired mucosal defense. Because symptoms are non-specific and endoscopic appearances often overlap with peptic ulcer disease, malignancy, lymphoma, and subepithelial tumors, diagnosis is frequently delayed and may require a stepwise approach that integrates clinical context with tissue-based confirmatio.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Acid-fast stain kit (Ziehl–Neelsen)	BD Difco	215073	For AFB staining; auramine stain acceptable alternative
Centrifuge (2,000–3,000 × g)	Eppendorf	5810 R	Plasma separation for IGRA
Coverslips	Citotest	10212424C	For microscopy preparation
CT scanner (multi-detector)	Siemens Healthineers	SOMATOM Definition AS+	Any ≥64-slice CT acceptable; record kVp, slice thickness, phases
Disposable biopsy forceps	Boston Scientific	1395 (Radial Jaw 4)	For mucosal/surface biopsies; any sterile single-use forceps acceptable
DNA extraction kit (FFPE)	QIAGEN	56404 (QIAamp DNA FFPE Tissue Kit)	If using FFPE sections for PCR
DNA extraction kit (tissue)	QIAGEN	69504 (DNeasy Blood & Tissue Kit)	For fresh tissue DNA extraction
ELISA plate reader	BioTek (Agilent)	Synergy H1	For IGRA ELISA readout (if using kit requiring reader)
EUS ultrasound processor	Olympus	EU-ME2	Any equivalent EUS processor acceptable
EUS-FNA/FNB needle, 22G	Cook Medical	EchoTip Ultra (22G)	If your case used FNA/FNB; record gauge and number of passes
Gastroscope	Olympus	GIF-HQ190	Standard diagnostic gastroscope; equivalent models acceptable
Grocott’s methenamine silver (GMS/PASM) kit	Abcam	ab150680	For fungal screening (PASM/GMS)
H&E staining kit or reagents	Sigma-Aldrich (Merck)	HT110116	Hematoxylin and eosin staining
IGRA test kit	Qiagen	QuantiFERON-TB Gold Plus	Whole-blood IGRA; record interpretation criteria
Image analysis / labeling software	NIH	ImageJ/Fiji	For adding scale bars/annotations to histology images
Insufflator	Karl Storz	ENDOMAT	Maintain pneumoperitoneum; record pressure used
Laparoscope	Karl Storz	26003BA	10 mm laparoscope; equivalent acceptable
Laparoscopic specimen retrieval bag	Applied Medical	Endo Catch II	For safe extraction of specimen
Laparoscopic stapler (wedge/partial gastrectomy)	Medtronic	Endo GIA	Use institutional stapler; record cartridge type if relevant
Laparoscopic tower (camera + light source)	Karl Storz	IMAGE1 S	Any equivalent laparoscopic imaging system acceptable
Linear EUS echoendoscope	Olympus	GF-UCT180	Linear EUS recommended for sampling; equivalent acceptable
Microscope slides	Citotest	188105	For cytology smears
Microtome	Leica Biosystems	RM2235	For 3–4 μm sectioning
Mounting medium	Sigma-Aldrich (Merck)	6522	Coverslipping
MTB complex PCR kit (validated)	Sansure Biotech	MTB DNA Diagnostic Kit	Use your institution’s validated MTB complex PCR; record target and Ct threshold
Nonionic iodinated contrast (for CT)	GE Healthcare	Omnipaque 350	Use institutional standard contrast; record concentration and dose
Paraffin embedding system	Leica Biosystems	HistoCore Arcadia	Any equivalent embedding system acceptable
PAS staining kit	Sigma-Aldrich (Merck)	395B	For fungal screening
PCR clean workflow supplies (filter tips)	Thermo Fisher Scientific	2069G	Use aerosol-resistant tips to reduce contamination
Power injector for contrast	Bayer	MEDRAD Stellant	Any injector acceptable; record injection rate and saline flush
Real-time PCR instrument	Roche	LightCycler 480 II	Any validated real-time PCR system acceptable
Specimen container (leak-proof)	Thermo Fisher Scientific	02-544-208	For formalin-fixed tissue transport
Statistical/figure software	GraphPad Software	Prism	If used for plotting; optional
Syringe (10 mL)	BD	309604	For suction during FNA when used
Video gastroscope system (diagnostic upper GI endoscopy)	Olympus	CV-190 (processor), CLV-190 (light source)	Any equivalent endoscopy platform is acceptable; record model used
10% Neutral Buffered Formalin	Sigma-Aldrich (Merck)	HT501128	Fixation of biopsy and resection specimens
37 °C incubator	Thermo Fisher Scientific	Heratherm	For IGRA incubation
95% Ethanol	Sigma-Aldrich (Merck)	459844	Immediate fixation of cytology slides