Tuberculous mesenteric lymphadenitis presenting as pyloric stenosis

A 17-year-old Filipina with a three-year history of intermittent, projectile vomiting and weight loss was admitted. A diagnosis of peptic ulcer disease was made, but she was unresponsive to antiulcer therapy. Fever, anorexia, cough, and exposure to tuberculosis were denied. Chest x-ray was normal. On barium swallow, the stomach and duodenal bulb were dilated. Endoscopic antral biopsy showed chronic inflammation. Computed tomography revealed enlarged periportal and peripancreatic lymph nodes and an intrahepatic mass. Liver biopsy failed to show any acid-fast bacilli. On laparotomy, the pyloroduodenal area was extrinsically compressed by surrounding lymph nodes, which, on biopsy, contained granulomatous inflammation with caseation necrosis and Langhan's giant cells. Gastrojejunostomy was done and antituberculous drugs were given. Pyloric stenosis due to tuberculosis is rare, but it should be considered in patients who come from areas where the disease is endemic. Medical management for such cases may suffice.