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HPI
Timeline
Signs and Symptoms
2 years, 3.5 mo PTC
(Mar 2008)
chronic cough
loss of appetite
weight loss
afternoon fever
body malaise
local HC in Cainta: CXR,
sputum exam
1 year, 8.5 mo PTC
Implication





TB
TB
TB
TB
TB
 TB
repeat CXR, claimed cleared,
 Resolution of TB?
no records available
HPI
Timeline
8 months PTC (Feb
2010)
Signs and Symptoms
Implication
tolerable colicky abdominal  Involvement of a hollow
pain
organ
 Involvement of more
bloatedness
distal segments of
intestines
 Hallmark of intestinal
obstruction;
abdominal distention
 Involvement of more
distal segments of
intestines
relieved by passage of flatus  Not obstipated, partial
or stool
obstruction
HPI
Timeline
Signs and Symptoms
vomiting of ingested food
~1-2x/week
increased frequency and
severity of abdominal
distention
4 weeks PTC
Implication
 Obstruction
 Progressive cause of
obstruction
 Possible locations
colicky pain localized @ RLQ  Chronicity rules out
appendicitis
 Malabsorption,
anorexia
malnutrition
 Malabsorption,
lost 20-30% weight
malnutrition
HPI
Timeline
18 days PTC
Signs and Symptoms
Implication
menses
 Rules out pregnancy as cause of
vomiting, colicky pain
 (Ruptured ectopic pregnancy
can present as intestinal
obstruction)
HPI
Timeline
Signs and Symptoms

stable vitals
On admission

Implication
BP, HR and RR important
indicators of compensatory
responses to a hypovolemic
status.
37.8 degrees Celsius is the
cut-off point for normal
expected temperature in
cases of obstruction
ambulatory
evidence of muscle wasting
hyposthenia
minimally worked up and
diagnosed but cannot be
cleared for intervention due to
pulmonary complications


Malabsorption,
malnutrition
Malabsorption,
malnutrition
Primary Impression: GI Tuberculosis
• History of pulmonary tuberculosis with
undocumented resolution
• Abdominal pain localized at the right lower
quadrant
• Signs and symptoms of obstruction
– Bloatedness
– Abdominal disentention relieved by passage of flatus
or stool
– Vomiting
– Anorexia
– Progressive
Gastrointestinal Tuberculosis
• Gastrointestinal Tuberculosis is the 6th most common
extrapulmonary manifestation of tuberculosis (Chong
and Lim 2009)
• Any site of the GI tract may be involved although
studies show a predilection to the ileocecal segments
(Fauci et al, 2008).
–
–
–
–
increased density of lymphoid tissue
increased stasis
neutral luminal pH
absorptive transport mechanisms
• route of infection
– penetration of the bowel wall
– hematogenous dissemination
Gastrointestinal Tuberculosis and its
Correlation with Pulmonary Tuberculosis
• 25% of gastrointestinal TB cases have evidence of
pulmonary TB
• there is a direct correlation between the severity
of pulmonary infection with the presence of GI
infection
– With minimally advanced pulmonary disease, 1% of
patients have a concomitant GI infection
– moderately advanced cases of pulmonary TB, 4.5%
have evidence of GI TB
– 25% of patients with severely advanced PTB cases
have concomitant GI TB while
– 55% to 90% of fatal cases have GI involvement.
Hamer et al 1998
Gastrointestinal Tuberculosis
Manifestations
• Ulcerative form
– major form associated with increased pathogenicity and mortality
– appears as superficial ulcerative lesions on the epithelial surface.
• Hypertrophic form
– scarring, fibrosis and mass formation resembling carcinomatous lesions.
• Ulcerohypertrophic form
– combination of the first two with both ulcerations and scar formation
• The host’s immune system plays a major role in determining the
presentation.
– Those with depressed immune responses are likely to develop the
ulcerative form while those with competent immunologic responses
would present with a hypertrophic form of the disease (Chong and Lim.
2009).
Hamer et al 1998
Pathophysiology of the Disease
Imaging Studies
Differential Diagnoses
• Mechanical causes of obstruction
– herniations, volvulus and intussusceptions are
ruled out on physical exam and barium studies
performed on the patient
– adhesions secondary to previous surgery are
unlikely as there is no mention of it in the
patient’s history
– Adynamic ileus and colonic pseudo-obstruction
are ruled out as colicky pain is absent in both
conditions
Fauci 2008
Differential Diagnoses
• Causes of RLQ pain
– Appendicitis, ruled out by the duration of illness.
– Right-sided diverticulitis
• less prevalent form of diverticulitis.
• clinical manifestation includes abdominal tenderness,
nausea, emesis, anorexia and GI bleeding (Nirula and
Greaney, 1997)
• Obstruction secondary to scarring from an infectious process
can be a complication of this disease
• Examinations for ruling out this disease include a complete
blood cell count, urinalysis, and flat and upright abdominal
radiography.
• Further examinations include CT imaging studies, abdominal
radiography with contrast and endoscopy (Roberts et al
1995).
Differential Diagnoses
• Causes of RLQ pain
– Gastroenteritis and inflammatory bowel disease
• both do not present with obstructive symptoms
• lack of diarrhea in the patient
• lack of cobblestoning on radiographic studies rules out
inflammatory bowel disease, particularly Crohn’s
disease.
Differential Diagnoses
• Causes of RLQ pain
– Gynecologic causes of right lower quadrant pain
such as ovarian tumor or torsion, and pelvic
inflammatory disease as well as
– Renal causes such as pyelonephritis,
perinephritic abscess and nephrolithiasis are
ruled out as they do not present with obstructive
symptoms.
Differential Diagnoses
• TB peritonitis
– uncommon extrapulmonary manifestation
– a consideration in patients presenting with several
weeks of abdominal pain, fever, and weight loss.
– Ruled out because of the lack of ascites, a major
feature arising from the exudation of
proteinaceous fluid from the tubercles
• Ruptured tubal pregnancy presenting as
intestinal obstruction is unlikely as the patient
reports recent menstruation
Management
1. Alleviation of symptoms of distention via
nasogastric decompression
2. Correction of nutritional status
3. Resection of the involved tissue
4. Demonstration of organism via culture of
resected segment followed by sensitivity
testing
5. Anti-mycobacterial treatment using
appropriate medications
Management
1. Alleviation of symptoms of distention via
nasogastric decompression
2. Correction of nutritional status
• serves to prepare the patient for surgical
intervention
• monitoring of serum albumin
Management
3. Resection of the involved tissue
• obstruction is a leading indication for surgery
in intestinal tuberculosis
• other indications for surgery include
ulcerative complications such as free
perforation, perforation with abscess, or
massive
• Preoperative drug therapy is still
controversial
Townsend et al 2008
Sharma and Bhatia 2004
Management
3. Resection of the involved tissue
• right hemicolectomy with a 5 cm margin with
anastomosis
• an ileostomy and a mucous fistula with
subsequent anastomosis
Townsend et al 2008
Sharma and Bhatia 2004
Management
4. Demonstration of organism via culture of
resected segment followed by sensitivity
testing
• definitive diagnosis of mycobacterial
infection by acid-fast stain or culture
• PCR methods
• culture and sensitivity to determine which
drugs are still effective
Management
5. Anti-mycobacterial treatment using
appropriate
• HRZES
• RCT: standard 6 month course vs prolonged
courses of conventional TB medication shows
no significant difference in cure rates
Sharma and Bhatia 2004