ORIGINAL ARTICLE

Utility of Gastric Lavage for Diagnosis of Tuberculosis in Patients

who are Unable to Expectorate Sputum
Parvaneh Baghaei, Payam Tabarsi, Parisa Farnia, Amir Hoseyn Radaei1,
Mehdi Kazempour, Yazdan Ali Faghani1, Mehdi Mirsaeidi, Atieh Novin, Ehsan Chitsaz,
Davoud Mansouri, Mohammad Reza Masjedi, Ali Akbar Velayati
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Clinical Tuberculosis and Epidemiology Research Center, N. R. I. T. L. D, Masih Daneshvari Hospital, Shaheed Beheshti
University of Medical Science and Health Services, 1Azad Medical University, Tehran, Iran
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ABSTRACT
Background: There are number of patients who are unable to expectorate sputum specimens. In this study, we used gastric lavage
(GL) test for diagnosis of tuberculosis (TB) in patients who were unable to produce sputum. Materials and Methods: Patients
who were unable to produce sputum specimens were included in the study to confirm TB disease. Gastric lavage sampling was
performed and sent for acid fast bacillus smear and culture under special laboratory conditions and sterilized methods. Further
bronchoscopy for broncho-alveolar lavage was done on patients with negative GL smear results. Drug susceptibility tests were
performed on 48 GL culture positive cases. Results: Eighty-five patients were included in the study; who were hospitalized at our
referral center for suspected TB. GL smears were reported to be positive in 37 cases (66.07%) and culture in 85.7%. The total
number of smear and culture-positive cases in this study was 48 (85.7%). Forty cases (87%) of drug-sensitive, 1 case (2.2%) of
isoniazid and rifampin-resistant TB (multi-drug resistant; MDR), and 5 cases of resistant to one drug were detected. There have
not been observed any complications after the GL method. Conclusion: It seems that regarding the high number of positive GL
cultures (85.7%), GL can be effective for diagnosis of patients who have suspicious tuberculosis symptoms and are unable to
produce sputum especially in resource limited areas.

Key words: Acid fast bacillus, Broncho-alveolar lavage, Gastric lavage, Isoniazid, Rifampin, Tuberculosis

INTRODUCTION each of these procedures have their own advantages and

disadvantages. Bronchoscopy for BAL requires special

I ncreasing incidence of tuberculosis (TB) as well as

the escalating trend of resistance to anti-TB drugs has
attracted much attention during the past decades and has
facilities and is not accessible in many regions because
of the limited resources. Additionally, bronchoscopy is
not feasible for all patients due to its invasive nature.[3,4]
turned out the need for early microbiological confirmation Although the SI method has yielded favorable results,
of TB and drug sensitivity testing more than ever.[1] On its use mandates having access to isolation rooms with
the other hand, approximately 50% of patients with negative pressure which is not currently available in many
suspected active TB are either unable to produce sputum health care facilities.[3,5] The GL method is preferred in
or demonstrate a negative sputum smear for acid fast diagnosis of TB in children who swallow their sputum
bacillus (AFB).[2] Thus, in such cases developing alternative and cannot expectorate.[6-8] However, this method has
methods to obtain sputum specimens are necessary. reportedly yielded different results in various studies. The
Sputum induction (SI), bronchoalveolar lavage (BAL), main shortcoming is in most of the previous studies, the
and gastric lavage (GL) procedures are among the most limited rate of positive culture in GL specimens which
common methods to obtain required samples. However,
makes its positive smear results unreliable.[9,10]
Access this article online
Therefore, in order to confirm the clinical and radiological
Quick Response Code:
Website: findings in patients with suspected active TB who are
www.jgid.org not able to give sputum samples, we used GL to obtain
specimens for bacteriologic confirmation.
DOI:
10.4103/0974-777X.91054 Address for correspondence:
Dr. Parvaneh Baghaei, E-mail: [email protected]

Journal of Global Infectious Diseases / Oct-Dec 2011 / Vol-3 / Issue-4 339

 Baghaei, et al.: Diagnosis of tuberculosis

In this study, we attempted to determine the diagnostic 3000 g for 30 minutes and decanted, leaving a volume
accuracy of GL in the aforementioned population. of 1-2 ml of sediment. Following this procedure, the
sediment was neutralized with few drops of N-hydrochloric
MATERIALS AND METHODS acid and washed with 10 ml phosphate buffered saline
(0.067M, pH 6.8). The remaining sediment was reconstituted
The study was carried out in the Mycobacteriology in 2 ml of sterile phosphate buffered saline. 200 µl of this
suspension was inoculated into LJ culture slant. Smears were
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Research Center at Masih Daneshvari Hospital which is

the National Research Institute of Tuberculosis and Lung prepared from the concentrated sediment of the specimen
Disease (NRITLD); in Tehran, Iran from January 2008 to for Ziehl-Neelsen (ZN) acid-fast microscopy. For all
December 2008. Those patients, suspected for TB with patients with positive culture (n=48), drug susceptibility test
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clinical and radiological findings, were included in this (DST) was done. DST for isoniazid (INH), rifampin (RMP),
study who met the following criteria: (1) being above 15 streptomycin, and ethambutol (EMB) was performed by the
years of age; (2) having no history of receiving previous or proportion method on LJ media at concentrations of 0.2,
current anti-TB medication; (3) being unable to expectorate 40, 4.0, and 2.0 mg/ml, respectively. Resistance was labeled
sputum samples; and (4) having no immunodeficiency or if number of the colonies on the drug-containing medium
HIV infection. GL was done once for any patient. All GL was more than 1% number of the colonies on drug-free
specimens were sent for AFB smear and culture. In the medium. Susceptibility to pyrazinamide (PZA; 900 and
case of negative smear results, BAL was undertaken in 1200 mg/ml) was tested using a 2-phase medium where
order to obtain a conclusive diagnosis. Anti-TB treatment the strain was reported to be resistant to PZA if, on day 21,
was initiated for patients whose smears turned positive for the proportion of drug resistant colonies was higher than
Mycobacterium tuberculosis (MTB). the defined critical proportion. The method of DST was
described in previous publications in the fullest detail.[11,12]
Gastric lavage The positive smears and cultures were gathered and analyzed
for sensitivity. Statistical analysis was performed using
An appropriate-sized nasogastric (NG) tube was placed SPSS V.13 software. The scientific and ethics committee
transesophageally in the stomach of a fasting patient early of NRITLD approved the study protocol.
in the morning before getting out of the bed. The stomach
was washed with 50 ml of normal saline pushed via NG RESULTS
tube, and then the gastric content was aspirated. The sample
was collected in a sterile plate, placed on ice and delivered Eighty-five patients were included in the study. The
to the mycobacteriology laboratory immediately. majority of the patients were women (80; 94%). Most
patients (72; 84.7%) were Iranian and the remainder came
Bronchoalveolar lavage (15.3%) from the neighboring country Afghanistan. The
mean age of the patients was 61.9+18.9. Diagnosis of TB
Fiber-optic bronchoscopy was performed on fasting patients was confirmed in 56 patients with isolating MTB from their
whose GL smear results were negative. Bronchoalveolar specimens. Out of confirmed 56 cases, 37 (66.07%; 95%CI:
lavage (BAL) samples were collected from affected lung 53-77%) were revealed MTB in the smear of the specimens
lobes. Approximately, 20-30 ml aliquots of sterile saline taken via GL. Sensitivity and specificity of GL smear were
solution up to a total of 100 ml were aspirated of the 66.07% (37/56) and 100% (29/29), respectively [Figure 1].
affected segments and then about 10-15 ml aspiration
samples were collected and placed on ice and delivered to As well, GL specimens’ culture for MTB became positive
the Mycobacteriology Laboratory immediately. in 48 (85.7%; 95% CI: 74.2-99.2%) patients. Sensitivity and
specificity of GL culture were 85.7% (48/56) and 100%
Clinical specimens (37/37) respectively.
In the laboratory, the GL fluid samples were immediately Overall, a total of 48 (85.7%; 95% CI: 74.2-99.2%) patients
adjusted to neutral pH using 100 mg sodium carbonate. had both smear and culture positive results for MTB in
Then, the specimens were cultured on Löwenstein-Jensen their GL specimens.
(LJ) slants. Briefly, for culture, the samples were digested
and decontaminated, using the Petroff method, with In 11 patients with negative GL smears, the culture of
sodium hydroxide at a 2% final concentration. After 15 GL rendered positive results. DST was performed for
minutes of digestion, the samples were centrifuged at the 46 patients with positive culture. The DST was not
340 Journal of Global Infectious Diseases / Oct-Dec 2011 / Vol-3 / Issue-4
 Baghaei, et al.: Diagnosis of tuberculosis

Suspicious TB
n=809

Sputum Gastric Lavage

n=724 n=85
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Positive for AFB Negative for AFB Negative for AFB Positive Smear
n=434 n=290 n=48 for AFB (n=37)
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Imaging compatible Imaging compatible Positive culture

with TB with TB n=11

BAL Other diagnosis BAL

n=20 n=306 n=21

Positive for AFB Negative for AFB Negative for AFB Positive for AFB
n=5 n=15 n=5 n=16

Treatment of TB Treatment of TB*

n=495 n=56

Figure 1: The algorithm of diagnosis of tuberculosis in suspicious patients, AFB: acid fast bacilli, BAL: broncho-alveolar lavage, *8 patients
with BAL smear positive were GL culture positive so the total of TB patients was 56

done for two culture positive patients because technical specimen and the risk of nosocomial transmission is lower
problems happened in the Mycobacteriology Labor. MTB in children than in adults.[14] But SI should be done in a
was sensitive to all drugs in 40 cases (87%), was resistant room with adequate ventilation and personal respiratory
to one drug in five cases (10.9%), and the pathogen protection.[15] On the other hand, bronchoscopy causes
was multidrug-resistant (MDR) in one case (2.2%). We coughing and leads to an increased risk of respiratory
performed polymerase chain reaction (PCR) to confirm the dissemination of TB.[16] The GL method is found to be
presence of MTB in the suspected MDR case which had an efficient and beneficial which does not require specific
ultimately a positive PCR. There were no adverse effects facilities. This method is commonly used among children;
reported during or after GL in the study. however, its utility and results have varied among adults. [6,7,9,10]
In our study, there were no complications after GL.
DISCUSSION The main drawback with the previous studies was observing
low numbers of positive GL cultures in comparison to
Even though clinical and radiological findings can provide
their corresponding positive GL smears results obtained
to some extent, useful information on diagnosis of TB,
in the patients.[3,10,13,17] For instance, in Rizvi et al   ’s study
isolating MTB from the patients’ specimens is crucial. In the sensitivity of GL smear was determined approximately
addition, the separation of the mycobacterium is needed to be 90%, whereas positive cultures were present in only
in order to perform DST.[1,13] Meanwhile, microbiological 40% of the cases. In our study, these values were found
confirmation of TB in patients who are unable to produce to be 66.07% and 85.7%, respectively. A summary of our
sputum is problematic.[2] In this regard, a number of results compared to other studies is depicted in Table 1.
methods including GL, BAL, and sputum induction (SI)
exist to facilitate the sample collection. Heather et al stated There were possibly two reasons for low rates of positive
SI is better than GL in children because three GL were GL culture despite high rates of concomitant positive
necessary to obtain the same yield as one induced sputum smears in the previous studies.
Journal of Global Infectious Diseases / Oct-Dec 2011 / Vol-3 / Issue-4 341
 Baghaei, et al.: Diagnosis of tuberculosis

Table 1: The used procedures in the literature and their results compared to our findings
Studies Patients The used procedures in studies
GLs† positive GLc‡ positive BALc†† SIc‡‡ positive Sc¶ positive All procedures*
Norrman et al[9] 63 adults - 7 (12) 13 (21) - - -
Rizvi et al[10] 20 adults 16 (80) 6 (30) 14 (70) - - -
Okutan et al[13] 107 adults 30 (61) 15 (31) 47 (81) - - -
Zar et al[14] 250 children 17 (7) 38 (15) - 51 (20) - -
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Uskul et al[16] 38 adults - 17 (49) 18 (55) - 23 (66) 36 (95)

Singh et al[20] 58 children - 10 (17) 12 (21) - - 20 (34)
Jones et al[23] 155 adults - 59 (30) - 176 (51) - 176 (51)
Our study 85 adults 37 (66) 48 (86) - - - -
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†
GLs: gastric lavage smear; ‡GLc: gastric lavage culture; ††BALc: broncho-alveolar lavage culture; ‡‡SIc: sputum induction culture; ¶Sc: sputum culture, *When the procedures
are used together, these procedures complement each other and increase positive culture and double the diagnosis yield; Figures in parenthesis are in percentage

1. Effect of not neutralizing samples and the collection As well, in one suspected MDR case, we confirmed the
of the specimens for the period of 1-2 weeks, that presence of the MTB, rather than NTM, by PCR. This
makes some microorganisms die in the presence of demonstrates that GL is efficient for the microbiological
the gastric acid (low pH). confirmation of TB and high rates of culture positive cases
2. Inappropriate decontamination: Which may cause the yield the possibility to perform DST.[10] Another noteworthy
mycobacterium to be trapped in the mucus and make factor was the absence of complications due to GL during
its growth in culture media improper.[10] our study. Notably, it can be compared to major adverse
events of bronchoscopy in a study by Dang et al that
In this study, our samples were immediately transferred they stated this technique is safe and they had less major
to the laboratory following having been collected, and complications like pneumothorax just in three patients
the neutralization and decontamination were done as occurred within 4 hours of bronchoscopy. [22] However the
described earlier. Therefore, this may be the likely cause aim of this study was not to evaluate the efficacy of BAL
that we have observed higher rates of positive GL procedure, there were no major complication of BAL in
culture in comparison to other studies. Interestingly, this 21 patients.
rate of positive GL culture (with GL sampling once) is
comparable to the results obtained by BAL sampling Another issue was that the most patients unable to give
in other studies.[10,18] Against GL without any inhibitor, sputum specimens were female whose rationalization is
using topical anesthetics such as tetracaine and lidocaine not addressed here.
during bronchoscopy inhibit the growth of MTB and
other bacteria.[19] In a study by Singh et al is shown that The hypothesis that performing GL for several times
there are no differences in mycobacterial isolation rates would increase its sensitivity is not investigated in most of
from GL and BAL.[20] previous studies.[10,17] So, this indicates the need for further
studies on the subject to reveal much more features and
In previous studies, some authors have proposed that capacity of this diagnostic method.
disproportionate GL smear and culture results can
be presumed as the consequence of nontuberculous Our study also carried some limitations. The study is
mycobacteria (NTM). [10,13] Since the patients under undertaken in the national referral. So, at least in part, the
our study had clinical and radiological manifestations findings may not be the exact representation of the general
suggestive for TB, it is most likely that the AFB observed population. As well, we did not perform BAL for all patients,
in the smear was MTB.[13] On the other hand, in GL a factor that may affect the findings in different ways.
positive cultures, the characteristics of MTB in culture
plate (slow grower, nonpigmented, nonchromogen, CONCLUSION
rough, waxy, dry, Niacin and NO3 reduction test positive)
were detected and the DST demonstrated that in most In summary, MTB can be isolated for smear and culture
of the cases MTB was sensitive to the first-line drugs. using a simple, rapid, and economic procedure; GL. In
Therefore, considering the fact that most NTM are this study MTB was detected in 85.7% of cases suspected
resistant to the first-line drugs, our finding confirmed for TB who could not efficiently expectorate to give
that isolates obtained from the GL positive cases in our sputum samples. Additionally, a substantially high rate of
study were in fact MTB.[21] positive cultures obtained in our study is of note. Thus,
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 Baghaei, et al.: Diagnosis of tuberculosis

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