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| Year : 2002 | Volume
: 8
| Issue : 2 | Page : 64-66 |
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| Acute ileal tuberculosis perforation : A case report |
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Saleh M Al Salamah, Hayan Bismar
Department of Surgery, College of Medicine and King Khalid University Hospital, Department of Surgery University Unit, Riyadh Medical Complex, Riyadh, Saudi Arabia
Click here for correspondence address and email
| Date of Submission | 03-Jun-2001 |
| Date of Acceptance | 19-Dec-2001 |
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How to cite this article:
Al Salamah SM, Bismar H. Acute ileal tuberculosis perforation : A case report. Saudi J Gastroenterol 2002;8:64-6 |
In the past, abdominal tuberculosis caused by ingestion of milk contaminated by mycobacterium bovis  frequently complicated extensive pulmonary tuberculosis, but the rate of intestinal tuberculosis in the absence of recognizable pulmonary disease has increased [1] . The incidence of intestinal tuberculosis is increasing in the west due to immigration from third world countries, aging population and increasing incidence of human immune deficiency (HIV) infection [2] .
The complications of intestinal tuberculosis are bowel obstruction (31.7%), intestinal perforation (4.9%), enterocutaneous fistula (2.4%) and small bowel volvolus due to mesenteric lymphadenitis (2.4%) [1] . Free intestinal perforation is an uncommon complication of intestinal tuberculosis because of reactive thickening of the peritoneum and formation of adhesion with surrounding tissues [3] . It account 1-10% of abdominal tuberculosis cases and it has a poor prognosis with mortality rate higher than 30% [4],[5] .
Small bowel perforation due to tuberculosis is rare in Saudi Arabia [14] , therefore, we report a case of free tuberculosis small bowel perforation in a 45-year Bangladeshian male.
 Case Report | |  |
A 45-year old Bangladeshi male presented with one-day history of acute abdominal pain, central and vague in nature. There were no associated symptoms. The past medical and surgical histories were irrelevant.
On physical exam; the patient looked ill, he was haemodynamically stable, febrile (temperature 38° C). Abdominal examination showed evidence of peritonitis (tenderness and guarding all over the abdomen), bowel sounds were sluggish, his blood profile showed haemoglobin (12.2 g/dL), leukocyte count (8.1 x 10 3 /ul), liver function tests and electrolytes were normal. Abdomen and chest radiography showed free air under diaphragm [Figure - 1], the patient was admitted with a provisional diagnosis of perforated viscus.
The patient was started on intravenous fluids and intravenous antibiotics (Cefuroxime 750 mg l.V 8 hourly + Metronidazol 500mg IN 8 hourly). Nasogastric tube and Foley catheter were inserted. Exploratory laparotomy showed a thickened wall of an ileal segment with 0.6cm free perforation, and multiple enlarged lymph nodes. The operative findings were consistent with small bowel tuberculosis. A segmental small bowel resection was done with primary anastomosis. Postoperatively the patient had uneventful recovery. Tuberculine test done at 6"' post operative day (5 units of PPD injected intradermally) and was positive (induration >10 mm after 72 hrs). Microscopic examination revealed transmural perforation with caseating granulomatous inflammation, consistent with small bowel tuberculosis, mesenteric lymph nodes showed granulomatous inflammation as well [Figure - 2]. The patient was started on anti tuberculosis treatment (isoniazid, ethambutol, rifampicin). He was seen in out patient clinic one-month post operatively and he was symptoms free.
| Discussion | | |
Tuberculous enterocolitis is a disease of young adult (third decade), the most frequently involved segments of bowel are ileocaecal region, the ileum and the colon [7] . The complication of intestinal tuberculosis include intestinal obstruction, perforation, fistulae and bleeding [8] .
The intestinal tuberculosis continues to be a frequent problem in many developing countries [1],[9]. S. Talwar et al have found 19% of non-traumatic small bowel perforation in 308 patients were due to intestinal tuberculosis [9] . Badoui et al in Switzerland, also reported eleven cases of intestinal tuberculosis perforation, ten of them were immigrants from countries endemic for tuberculosis [10] .
Intestinal perforation due to tuberculosis appears to be uncommon in Saudi Arabia. Intestinal tuberculosis was reported in four of 65 patients with abdominal tuberculosis by Al Quorain et al in the Eastern Region [16] In the Central Region, Al Karawi et al have found 84 patients with intestinal involvement in their series of 130 patients with abdominal tuberculosis [17] . Both studies have not reported intestinal perforation despite the large number of patients with intestinal tuberculosis in the later series. Also Makanjoula has not reported intestinal perforation among 13 complications in 21 patients [14] .
Free perforation in intestinal tuberculosis usually occurs in the terminal ileum [7] and it can occur in patient during anti tuberculosis therapy [11] . Specific diagnostic investigations are not available. Plain xray has shown free air in only 25-50%. Fifty percent of the extra pulmonary tuberculosis patients have normal chest radiography [3],[14],[12] . Peritonitis, occurring in a patient with chest radiography indicative of tuberculosis should lead one to suspect a perforated tuberculosis ulcer [6] . In patients with intestinal tuberculosis who presented with generalized peritonitis should have exploratory laparotomy. However, in equivoval cases computed tomography helps in identifying the perforation. Makanguola has shown that computed tomography can provide a diagnosis of intestinal tuberculosis in 81% ofthe cases [15] .
In 90% of the cases, perforation is solitary, but multiple perforations occur in 10-40% of patients [13] and are associated with a poor prognosis, therefore immediate operative intervention is needed to be undertaken [6] . Resection of the affected small bowel segment and end to end anastomosis proved to be the best method of treatment [4],[9],[12] . Simple repair of the perforation is not recommended because of the high incidence of leak and fistula formation [13] . High mortality and morbidity reported more than (29.3%) but the rate was significantly less in patients operated within 36 hours of perforation [9] .
| Conclusion | | |
Diagnosis of acute ileal tuberculous perforation is difficult because of the rarity of such case in Saudi Arabia and consequent tendency to concentrate on other causes of viscus perforation as perforated duodenal ulcer. Therefore, the abdominal tuberculosis must be considered as a possible diagnosis in endemic areas in patients presenting with acute or chronic abdominal pain [6] .
| Acknowledgement | | |
The authors would like to thank Prof. I. Al Mofleh for his kind assistance and Ms. Rani Mary George for her excellent assistance during typing of this manuscript.
| References | | |
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| 14. | Makanjuola D, Al Grainy -I, Al Rashid-R, Murshid K. Radiological evaluation of complications of intestinal Tuberculosis. Eur-J-Radiol 1998, 261-8. |
| 15. | Makanjuola D, Is it Crohn's disease or intestinal T.B? CT analysis. Eur-J-Radiol. 1998,28(1): 55-61. |
| 16. | Al Quorain, Satti M B, Al Freihi H M, Al Giudau Y M, Al Awa D N. Abdominal T.B in Saudi Arabia: A clinicopahtological study of 65 cases AMJ Gastroenterol, 1993;88:75-9. |
| 17. | M A Al Karawi et al. Protean Manifestation of Gastroitestinal Tuberculosis: Report on 130 Patients. .I Gastroenterol 1995; 20: 255-32. |
Correspondence Address:
Saleh M Al Salamah
Department of Surgery, University Unit, Riyadh Medical Complex, P. 0. Box 31168, Riyadh 11497
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
PMID: 19861794 
[Figure - 1], [Figure - 2] |
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