When Tuberculosis Bleeds: Intestinal Tuberculosis Presenting With Hematochezia

Intestinal tuberculosis is an uncommon but clinically significant manifestation of tuberculosis that often presents with nonspecific gastrointestinal symptoms. Although the ileocecal region is most frequently involved, overt gastrointestinal bleeding is an unusual presentation, particularly in elderly patients who may lack classic constitutional symptoms. An elderly man presented to a community hospital in Guam with hematochezia one week after the diagnosis of pulmonary tuberculosis and initiation of rifampin, isoniazid, pyrazinamide, and ethambutol. Colonoscopy revealed a large semi-circumferential ulcer in the terminal ileum with a non-bleeding visible vessel. Histopathologic evaluation demonstrated necrotizing granulomatous inflammation, and acid-fast bacilli staining confirmed mycobacterial infection, establishing the diagnosis of intestinal tuberculosis. Despite appropriate anti-tuberculous therapy, the presence of concurrent pulmonary and intestinal disease reflected an advanced disease burden and poor prognosis. Given advanced frailty and clinical status, the patient and his family elected to pursue comfort-focused care. This case highlights intestinal tuberculosis as an uncommon cause of gastrointestinal bleeding and emphasizes its diagnostic overlap with conditions such as Crohn's disease. It underscores the importance of biopsy in granulomatous ileal disease and the need to maintain clinical suspicion for tuberculosis, particularly in patients from endemic regions or with relevant epidemiologic risk factors.