Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1997  |  Volume : 3  |  Issue : 2  |  Page : 96-98
Tuberculous enteritis with 21 intestinal perforations : A case report


1 Department of Surgery, University College Hospital, P.M.B. 5116, Ibadan, Nigeria
2 Department of Anesthesia, University College Hospital, P.M.B. 5116, Ibadan, Nigeria

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Date of Submission02-Oct-1996
Date of Acceptance18-Feb-1997
 

How to cite this article:
Ajao OG, Soyannwo OA, Adebamowo CA, Mathews O A, Solagberu B. Tuberculous enteritis with 21 intestinal perforations : A case report. Saudi J Gastroenterol 1997;3:96-8

How to cite this URL:
Ajao OG, Soyannwo OA, Adebamowo CA, Mathews O A, Solagberu B. Tuberculous enteritis with 21 intestinal perforations : A case report. Saudi J Gastroenterol [serial online] 1997 [cited 2019 Oct 23];3:96-8. Available from: http://www.saudijgastro.com/text.asp?1997/3/2/96/33934


Abdominal tuberculosis is not an uncommon condition in Ibadan and in many African countries [1],[2],[3],[4],[5] . However, they are not usually known to cause intestinal perforation. Actually when a patient presents with an intestinal perforation following a febrile illness in this environment it is usually regarded as a case of typhoid perforation until proven otherwise [6],[7] .

Of late, many cases of unusual presentations of tuberculosis have surfaced in the literature [8],[9],[10] even when the lungs are free of primary lesion. This reappearance of tuberculosis with a vengeance in many African countries, including Nigeria, is directly related to grinding poverty. We present here a case of abdominal tuberculosis resulting in 21 intestinal perforations to add to this growing list of unusual presentations of tuberculosis. This is probably the largest number of perforations, to our knowledge, ever recorded in the literature for abdominal tuberculosis.


   Case Report Top


A 15-year-old student, referred to the surgical team on call, presented with weight loss for six months, colicky abdominal pain, intermittent vomiting and fever for three months. He never sought medical treatment during the period because his parents could not afford hospital cost. Abdominal pain was initially located in the right lower quadrant, but became generalized two days prior to presentation. Bowel motions were normal, once daily. There was no history of chronic cough or contact with one.

He was emaciated, pale and pyrexic. Temperature on admission was 38.5 C. No significant peripheral lymphadenopathy was palpable. The chest was clinically clear. The abdomen was distended, with diffuse tenderness, guarding and hypoactive bowel sounds. Rectum was loaded with feces on digital examination.

Chest X-ray was normal but abdomen revealed pneumo-peritoneum. There were multiple air-fluid levels, and distended small bowel loops. A diagnosis of typhoid ileal perforation was made, with differential diagnoses of perforated appendicitis, and queried tuberculous peritonitis. He was resuscitated and commenced on intravenous chloramphenicol and metronidazole. Laparotomy revealed about one liter of sero-purulent peritoneal fluid, and peritoneal fecal contamination. There were eight transverse perforations on the antimesenteric border distributed from 15 cm distal to duodenojejunal junction to 5 cm proximal to the ileocecal junction. There was a generalized spread of nodules on the small intestines, and cecum. There were also multiple mesenteric and para-aortic lymphadenopathy. The cut surface of the nodes showed caseation necrosis. The diffuse spread of the perforated ulcers precluded a resection. The edges of all the eight perforations were therefore freshened and closed in two layers. Peritoneal lavage was done with three liters of normal saline, and mopped dry. A drain was left in the pelvis.

The patient did not do well postoperatively, and died on the first postoperative day.

Postmortem examination showed 13 more perforations which were probably missed at laparotomy making a total of 21 in the small intestines and cecum. There was pulmonary edema but the lungs were grossly free of tuberculous lesions. Histology showed caseation necrosis within granulomatous lesions and ZN stain was positive for acid fast bacilli.


   Discussion Top


When we think that we know all there is to know about tuberculosis, and when we think that we have now conquered tuberculosis, this disease seems to have undergone a clinical "metamorphosis" to make its detection difficult. This is being manifested in various unusual presentations.

It has been shown that late generalized tuberculosis is an often unrecognized cause of severe illness in the elderly, alcoholic or those with chronic illnesses [11] , who present usually with vague constitutional symptoms. Kemp [11] described three cases of generalized tuberculosis without a past history of tuberculosis but presented only with chronic debilitating illnesses.

Tuberculosis can affect any organ of the body, but in our environment it commonly affects the lungs and the abdomen. The previous classification of abdominal tuberculosis into three forms [12] is probably not necessary since this can be regarded as various stages of the same disease process which bears little relevance to the treatment.

Two conditions most commonly confused with tuberculous enteritis when Africans or people from the Third World countries are seen in Europe and North America are ulcerative colitis and Crohn's disease. These two conditions have never been reported in an African living in Africa [13],[14] . We have treated such cases diagnosed as Crohn's disease and ulcerative colitis successfully with antituberculous drugs even without tissue diagnosis as long as there is evidence of a granulomatous infection [8] . The use of Polymerase Chain Reaction Assay seems promising in diagnosing abdominal tuberculosis [15] .

It is difficult to differentiate intestinal tuberculosis from Crohn's disease. The yield of acid fast bacilli found in intestinal tuberculosis specimens was 44.4%, [15] but the use of Polymerase Chain Reaction Assay (PCR) identified 75% of mycobacteria tuberculosis DNA, but none in the 26 cases of Crohn's disease studied [15] .

When tuberculosis presents in the usual classical manner, the diagnosis is often not difficult. Tuberculosis seems to be undergoing, in some cases, a form of clinical "metamorphosis" to a disease quite different from what is known to be its clinical presentation. It is now known that stress, including psychological stress causes an impairment in the efficiency of the performance of the immune system [16],[17],[18] . This will seem to be a contributory factor in the subclinical or "silent" abdominal tuberculosis previously reported [8] .

The case presented here showed that the patient's immune system was markedly reduced, or the mycobacterium was very virulent, or both. This period coincided with the period of IMF structural adjustment program in Nigeria. As a result of this, the griding poverty experienced in some areas, made it impossible for many to have three square meals a day. Naturally, the children bore the brunt of this calamity. With poor nutrition comes reduction of immunity, and overwhelming infection, especially in an unsanitary environment.

Perforation in tuberculous enteritis is rare [19] and that is what makes this case rather unusual. When a pneumo-peritoneum occurs in an acute abdomen in this environment especially in the younger age group after a febrile illnesss, typhoid enteritis with ileal perforation is often considered first [6],[7] . Typhoid ileal perforations usually do not present with pneumoperitoneum. However, the presence of pneumoperitoneum in a typhoid perforation idicates that the ileal perforation must have occurred for a relatively long time and therefore denotes a very poor prognosis [6] .

This unusual case presented a management problem because of the number and the area of the intestines the perforations involved. It is not unlikely that the 13 additional perforations were missed at laparotomy which was performed as an emergency at night. The number of the intestinal perforations may be due to the virulence of the organism or the lowered resistance of the patient or both. The late stage at presentation of this case to the hospital typifies our experience with most cases.Usually the traditional doctors and the faith-healers offer a more attractive choice to patients than hospitals because of their low-budget treatment. What we always see are the failures of our competitors.


   Conclusion Top


Unusual presentations of tuberculosis seem to be now relatively common. As long as griding poverty persists in African countries, so will tuberculosis in various forms. The previously rare complication of tuberculous enteritis like intestinal perforation can, and does occur.

 
   References Top

1.Akande B, Ogunbiyi TAJ. Tuberculosis of the duodenum presenting as gastric outlet obstruction. Ghana Med J, 1977;16:57-9.  Back to cited text no. 1    
2.Francis TI. Abdominal tuberculosis in Nigeria. Trop & Geog Med 1972;24:232-2.  Back to cited text no. 2    
3.Johnson AOK, Aderele WJ. Abdominal tuberculosis in childhood. J Trop Med & Hyg 1979:82:47-52.  Back to cited text no. 3    
4.Lester FT, Tsega E. Tuberculous peritonitis in Ethiopian patients. Trop & Geog Med 1976;28:47-52.  Back to cited text no. 4    
5.Lewis EA, Kolawole TM. Tuberculosis ileo-colitis in Ibadan: Clinico-radiological review. Gut 1972;13:464-753.  Back to cited text no. 5    
6.Ajao OG. Typhoid perforations: Factors affecting mortality and morbidity. Internal Surg 1982;67:317-9.  Back to cited text no. 6    
7.Angorn JB, Pillay SP, Hegarty M, Baker LW. Typhoid perforations of the ileum: a therapeutic dilemma. S. Afr. Med J 1975;49:718-84.  Back to cited text no. 7    
8.Ajao OG, Ajao FA, Ladipo JK, Al-Saigh AA, Malatani T. Silent abdominal tuberculosis: a report of six cases. E. Afr. Med J 1993;70:606-8.  Back to cited text no. 8    
9.Ejigu A. Intracranial tuberculosis mimicking brain tumor: Case report. E. Aft. Med J 1993;70:659-60.  Back to cited text no. 9    
10.Odhiambo JA. Unusual presentation of tuberculosis (Editorial). E. Afr. Med J 1993;70:605.  Back to cited text no. 10    
11.Kemp Jr WE. Late generalized tuberculosis: Unusual features of an often overlooked disease. South Med J 1995;88:1221-5.  Back to cited text no. 11    
12.Addison NV. Abdominal tuberculosis a disease revived. Ann Roy Coll Surg Eng. 1983;65:105-11.  Back to cited text no. 12    
13.Ajao OG. Differences between surgical colorectal conditions seen in the temperate and tropical regions. Dis Colon Rect. 1982;25:795-7.  Back to cited text no. 13    
14.Ajao OG. An outline of differences between temperate and tropical presentations of some surgical upper gastrointestinal diseases. Brit J. Surg 1984;71:79-80.  Back to cited text no. 14    
15.Gan Huatian, et al. Value of polymerase chain reaction assay in diagnosis of intestinal tuberculosis and differentiation from Crohn's disease. Chin Med J. (Engl) 1995;108:215-20.  Back to cited text no. 15    
16.Dixon B. Stress and immune response. Brit Med J 1993;307:874.  Back to cited text no. 16    
17.Jabaaij L, Grosheidi AJ, Heijtink RA, Duivenvoordon HJ, Ballieux RE, Vingerhoets AJ. Influence of perceived psychological stress and distress on antibody response to low dose RDNA hepatitis B vaccine. J Psychosom Re. 1993;37:361-9  Back to cited text no. 17    
18.Findeisen DG. Stress and immune response. On appropriate stress management for prevention and treatment of disease. Z Art] Fostbild (Jena) 1992;86:1117-23 (Ger).  Back to cited text no. 18    
19.Kilawole TM, Lewis EA. A radiologic study of tuberculosis of the abdomen (Gastrointestinal tract). Am J Roent Rad Ther & Nuclear Med. 1975;123:348-58  Back to cited text no. 19    

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Correspondence Address:
Oluwole G Ajao
Department of Surgery, College of Medicine, King Saud University - Abha Branch, P.O. Box 641, Abha, Saudi Arabia

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