Intestinal Tuberculosis

Abstract

We here signify the return of an old offender that used to destroy the health of a great number of the population all over the world (Tuberculosis). This disease should be remembered when treating patients with vague abdominal pain because making a preoperative diagnosis may be difficult even with the use of the modern sophisticated means of investigations.

Full text

Current Research in Microbiology and Biotechnology
Vol. 5, No. 2 (2017): 992-996
Case Report
Open Access
I
IS
SS
SN
N:
:
2
23
32
20
0-
-2
22
24
46
6
Intestinal Tuberculosis
Riyadh Mohamad Hasan*
Consultant Surgeon, Al-Kindy College of Medicine, Baghdad University, Iraq.
* Corresponding author: Riyadh Mohamad Hasan; e-mail: riyadhmoh57@gmail.com
ABSTRACT
We here signify the return of an old offender that used to destroy the health of a great number of the population
all over the world (Tuberculosis). This disease should be remembered when treating patients with vague
abdominal pain because making a preoperative diagnosis may be difficult even with the use of the modern
sophisticated means of investigations.
Keywords: TB, Abdomen, Intestine.
INTRODUCTION
Tuberculosis is a disease of the poor deprived
communities, although the incidence is increasing in
the well developed countries with the increased
incidence of AIDS disease. Intestinal tuberculosis is one
of the extrapulmonary manifestations of the disease.
Diagnosis is usually difficult unless the disease is
always remembered as being a cause of vague
abdominal pain.
Case Report
A 50 years old female patient of middle socioeconomic
class presented with vague abdominal pain for 5 days,
accompanied by repeated vomiting and distension. She
had similar attacks during the last 2 years with
alternating constipation and diarrhea resolved by
medical measures. She had cholecystectomy 15 years
ago.
On examination the patient was looking ill, pale Bp
80/60-pulse rate 90/min regular temperature 38oC.
Chest examination normal. The abdomen was soft with
mild abdominal distension. Her investigations were as
follows:
Plain abdominal X-ray show few fluid levels. (figure 1),
Hb 11.2gm%, WBC 6400 N 60%, L 32%, M 7%, E 1%,
ESR 63.
FBS 117mg%, BU 30mg%, S creatinine was 1.5mg%,
TSB 0.6mg% and TSP 5 gm%.
U/S: cholecystectomy, distended loops of bowel in the
pelvic cavity with small amount of free fluid, features
suggesting gastroenteritis.
She was put on nothing by mouth intravenous fluids
and antibiotics she refused nasogastric suction. On the
next 2 days she had colicky abdominal pain with
constipation after which she passed a normal motion
with subsidence of the pain and was discharged home.
She remained well for 3 days after that returned to
hospital with the same symptoms but this time she had
nausea, vomiting and watery diarrhea and abdominal
distension. Her Bp was 130/70, the abdomen was soft
but distended. The same conservative regimen was
adopted and a colonoscopy was arranged for.
Colonoscopy was normal. Gynecological consultation
requestedfor her. They commented that the patient had
a small ovarian cyst needs not to worry about but she
has no gynecological problem.
A barium meal and follow through was done for her
(figure 2) and the report was that there is an ill defined
short segment of filling defect in the terminal part of
the small bowel associated with distortion of adjacent
mucosal pattern causing partial hold up of barium
(obstructive sign)? Bowel mass suggesting (TB, Crohn’s
Received: 02 February 2016 Accepted: 16 February 2017 Online: 01 March 2017
http://crmb.aizeonpublishers.net/content/2017/2/crmb992-996.pdf 992

993
Riyadh Mohamad Hasan / Curr Res Microbiol Biotechnol. 2017, 5(2): 992-996
http://crmb.aizeonpublishers.net/content/2017/2/crmb992-996.pdf
disease, lymphoma). A computerized tomography was
not available.
Conservative treatment continued but the patient’s
vomiting was almost daily with passage of loose stools
her distension was increasing. So a decision was made
to explore her abdomen. Laparotomy with a midline
incision revealed a mass in the terminal illeum about 2
feet from the illeocecal valve, wrapped with omentum.
On separation of the omentum the bowel showed an
area of obstruction consisting of a stricture of about 10-
cm in length with a proximal dilated segment and a
distal collapsed segment (figure 3 &4). The mass felt
firm and yellow in color with no lymph nodes in the
nearby mesentry. Resection and anastomosis of the
bowel was done. On laying open the strictured segment
it showed thickened bowel wall with destruction of the
mucosal pattern (figure 5). The rest of the bowel was
healthy apart from dilatation of the proximal bowel due
to obstruction.
Histopathology reported multiple caseating
granulomas with Langhan’s giant cells involving the full
thickness of bowel wall, a picture of tuberculous
enteritis no malignancy.

994
Riyadh Mohamad Hasan / Curr Res Microbiol Biotechnol. 2017, 5(2): 992-996
http://crmb.aizeonpublishers.net/content/2017/2/crmb992-996.pdf

995
Riyadh Mohamad Hasan / Curr Res Microbiol Biotechnol. 2017, 5(2): 992-996
http://crmb.aizeonpublishers.net/content/2017/2/crmb992-996.pdf
Discussion:
TB is associated with poverty, deprivation, and human
immune deficiency virus infection [1]. It continues to be
a problem in the under developed countries and began
now to be a problem in the developed world with the
increased prevalence of HIV disease. There are case
reports that stress the fact that illeal tuberculosis still
exist today and that it doesn’t exclusively affect “high
risk” patients [2]. A retrospective review of patients
diagnosed with Tuberculosis from 1993-1995 in 2
hospitals 7 patients were diagnosed as abdominal TB, 2
of them were HIV positive [3]. A study at Melbourne
teaching hospital noted an increased incidence of
abdominal TB in immigrants and AIDS patients [4].
Tuberculous infection of the intestine is either primary
caused by ingestion of bovine strain of M tuberculosis
[5]or secondary to swallowing of the human strain.
Primary tuberculous infection of the intestine is rare in
USA and about 1% of patients with pulmonary TB have
intestinal involvement [6]. Regrettably we don’t have
exact figures in our country of the same condition.
Pathologic reaction of Intestinal TB has three forms
ulcerative, hypertrophic or ulcerohypertrophic and
fibrous structuring [7]. The distal illeum is the most
common site of disease [5], accounting for about 85%
of cases of tuberculous enteritis.[8].Infection
establishes itself in the lymphoid follicle and resulting
chronic inflammation causes thickening of the
intestinal wall and narrowing of the lumen [9].
It may cause diffuse ulceration, severe hemorrhage and
even perforation in patients with advanced TB (10].
Narrowing of the lumen may lead to stricture formation
which may be single or multiple. Concentric strictures
are most commonly situated in the terminal illeum but
may affect the more proximal bowel (10]. In a study
60% of the strictures were solitary and 40% multiple
[11], and the bowel between strictures is normal in
appearance in contrast to Crohn’s disease in addition to
that the characteristic mesenteric lesion of Crohn’s
disease are not seen [10].
The disease is considered when abdominal pain,
anemia and fever weight loss and abdominal lymph
node enlargement are present [12]; attacks of
abdominal pain with intermittent diarrhea are the
usual symptoms [9]. In the case of the fibrous
stricturing disease Sooner or later subacute intestinal
obstruction will supervene often with impaction of
enterolith in the narrowed lumen [9].
Diagnosis is difficult and delayed diagnosis is common
resulting in high mortality [1]. The protean clinical
manifestations and the varied complications of
abdominal tuberculosis continue to challenge the
diagnostic acumen and therapeutic skills of all
physicians[13]. In a recent study less than half patients
had an abnormality on CXR and none had positive
sputum [6].
Bacteriology of body fluids, abdominal ultrasound and
CT combined with guided needle aspiration biopsy,
barium examination colonoscopy and laparoscopy can
not only elucidate the diagnosis but also be helpful in
assessing an appropriate management [12]. With the
introduction of laparoscopy it should replace
laparotomy as the definitive diagnostic tool [4]. Barium
follow through is useful and it shows thickened folds
spasticity and shallow ulcers, single or multiple short
strictures while CT scan show preferential thickening
of illeocecal valve and medial wall of the cecum and few
small regional nodes[6]. Unfortunately, MRI was not
done which may be useful in the evaluation of small-
bowel TB [14].
Assay of ascitic fluid adenosindeaminase activity is a
valuable simple method of diagnosis that may reduce
the need for laparoscopic biopsy [1]. A peritoneal fluid
adenosindeaminase value of over 30 IU/l has been
reported to have a sensitivity of 93%, a specificity of
96% and positive predictive values have been noted in

996
Riyadh Mohamad Hasan / Curr Res Microbiol Biotechnol. 2017, 5(2): 992-996
http://crmb.aizeonpublishers.net/content/2017/2/crmb992-996.pdf
© 2017; AIZEON Publishers; All Rights Reserved
This is an Open Access article distributed under the terms of
the Creative Commons Attribution License which permits
unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.
malignant ascites and collagen diseases. It was found
significantly high in 3 out of 4 patients in a pediatric
study [15]. We couldn’t measure adenosindeaminase in
our patient.
The most important differential diagnostic problem in
intestinal tuberculosis is from Crohn’s disease but in
Crohn’s disease there is lesser thickening of bowel wall
on barium follow through, mural stratification and
vascular jejunisation or the comb’s sign and mesentric
fatty proliferation [7], in addition the bowel between
strictures is not healthy [10].
Treatment is medical in the form of
antituberculousdrugs ; surgery is reserved to diagnosis
in peritoneal TB and to treat complications[13] like
stricture or perforation of the intestine [16]. But due to
the fact that diagnosis is delayed due to non specific
presentation [3] these patients usually need surgical
intervention, and in fact some surgeons recommend
early operation because medical treatment “in their
opinion” result in healing by fibrosis [6].
Resection is the preferred surgical procedure, bypass is
done only if abscess or fistula are present [6,9], or
extensive disease [8].
A recent report suggest that a stricturoplasy of Heinki-
Mikulikz’s type is safe simple and easy procedure
particularly suitable at poorly equipped and under
staffed district hospitals [11]. Research work found that
there is no significant difference between the 2
procedures (resection and stricturoplasty) while
stricturoplasty is superior in multiple strictures
[17,18]. Steroids don’t decrease the incidence or the
degree of fibrosis in intestinal TB [13].
Conflict of interest: none
Funding: none
REFERENCES
1. AstonN. Abdominal tuberculosis. World-J-Surg
1997;21(5):492-9.
2. Jouan MH, Ledaguenel P, Callet D, Perissat J. Illeocaecal
tuberculosis. A propos of a case. Ann Chir 1997;51(9):1023-
31.
3. Ko-CY,Schmit PJ, Petrie B, Thompson JE. Abdominal
tuberculosis : the surgical perspective. Am-surg
1996;62(10):865-8.
4. McLaughlin S, Jones T, Pitcher M, Evans P. Laparoscopic
diagnosis of abdominal tuberculosis. Aust-N-Z –J-Surg
1998;68(8):599-601.
5. Saidu AS, Okolocha EC, Gamawa AA, Babashani M, Bakari NA.
Occurrence and Distribution of bovine tuberculosis
(Mycobacterium bovis) in Slaughtered cattle in the abattoirs
of Bauchi State, Nigeria.Vet World.2015 ;8:432-7.
6. Andrew A Shelton, Theodor R Schrock, Mark Lane Weltone.
Small intestine. In Laurrence W Way, Gerard M Doherty
eds.Current surgical diagnosis and treatment New York:
Lange Medical books /Mc Grew Hill, 2003; 694-5.
7. Engin G, Balk E. imaging findings of intestinal
tuberculosis.JComput Assist Tomogr. 2005 ;29(1):37-41.
8. Courtney M. , Townsend Jr and James C. Thompson.Small
intestine. In:Seymour I. Schwartz, G Tom Shire, Frank C.
Spencer. Principles and Practice of surgery. Singapore:
McGraw Hill Book comp ,1988;1202-03.
9. J Mc C Neil, Mortensen and Oliver John. Small and Large
intestine. In: RCG Russell, Norman S Williams , Christopher JK
Bulstrode eds. Bailey &Love’s Short practice of surgery.
London: Arnold, 2004; 1173-74.
10. Alan White, IB Angorn, H.M. Al Hashimi, John Wong. Acute
surgical problems in non temperate zones. In: Hugh AF
Dudley eds. Hamilton Bailey’s emergency surgery. Bristol:
John Wright and sons Ltd, 1986;697-98.
11. Akbar M. Sticturoplasty in tuberculous small bowel
strictures. J Ayub Med CollAbbottabad 2003;15(2):37-40.
12. Schanaider A, Madi K. Intra abdominal tuberculosis in
acquired immunodeficiency syndrome. Diagnosis and
management. IntSurg 1995;80(2):147-51.
13. VeeragandhamRS,LynchFP,Canty TG, Collins DL, Danker WM.
Abdominal tuberculosis in childeren :review of 26
cases.JPediatrSurg 1996;31(1):170-5.
14. Krishna S, Kalra N, Singh P, Kochhar R, Gupta R, Singh R,
Khandelwal N. Small-Bowel Tuberculosis: A Comparative
Study of MR Enterography and Small-Bowel Follow-
Through.AJR Am J Roentgenol.2016 ;207:571-7.
15. Sothar MA, Simjee AE, Coovasdia YM, Soni PN, Moola SA,
Insam B, et al.Ascitic fluid gamma interferon concentration
and adenosindeaminase activity in
tuberculousperitonitis.Gut 1995;36:419-421.
16. Saitou m, suzuki t, niitsuma k. pulmonary and intestinal
tuberculosis developing acute tuberculous perforation of the
intestine during antituberculosis therapy.kekkaku.2015
;90:631-4.
17. Zafar A, Qureshi AM, Iqbal M. comparison between
stricturoplasty and resection anastomosis in tuberculous
intestinal strictures . J Coll Physicians Surg Pak
2003;13(5):277-9.
18. Katariya RN, Sood S, Rao PG, Rao PL. stricture-plasty for
tubercular strictures of the gastro-intestinal tract. Br J Surg
1977;64(7):496-8.
*****