Postgrad Med J: first published as 10.1136/pgmj.61.713.251 on 1 March 1985. Downloaded from Postgraduate Medical Journal (1985) 61, 251-252

Tuberculous perforation ofthe small bowel

N.O. Aston and A.M. de Costa Dudley RoadHospital, Birmingham, UK.

Summary: Small bowel perforation occurs in up to 2 percent ofpatients with abdominal tuberculous. Patients present with an acute abdomen. Resection ofthe diseased segment and 18 months treatment with anti-tuberculosis drugs is recommended.

Introduction The overall incidence of free intestinal perforation in Case 3 patients with abdominal tuberculosis is close to that of 2% recorded in one of the largest series from India A 77 year old white man was found to have a rigid (Mukerjee & Singal, 1979). In Britain this complica- abdomen and absent bowel sounds. The perforated tion is rare. Only one case has been reported in series ileal stricture found at was resected and published over the last two decades (Mandal & the appendix removed. He died ofbronchopneumonia Schofield, 1976). We report 3 cases diagnosed at on the tenth post-operative day. laparotomy. All patients presented acutely with

abdominal pain and vomiting of less than 24 h dura- Histological examination showed caseation, the copyright. tion. None gave a history of previous tuberculosis. presence of acid-fast bacilli or both in all cases. The two survivors were treated with anti-tuberculous drugs. Both remain well after 2 years follow-up. Case reports Case I Discussion A 30 year old Asian woman had signs of generalized Patients with abdominal tuberculosis are usually peritonitis. Free peritoneal gas was seen on a plain young Asians. Only a minority have a history of http://pmj.bmj.com/ abdominal radiograph. At operation a perforated ileal previous pulmonary tuberculosis or an abnormal stricture and multiple peritoneal tubercles were found. chest radiograph. Over 50% of patients have chronic The involved segment was resected. She developed a abdominal symptoms which are often mild and non- wound haematoma that required evacuation under specific (Bhansali et al., 1968). These include pain, anaesthesia on the sixth post operative day. No further weight loss, nausea, diarrhoea and constipation. complication occurred. Those who perforate present with acute abdominal

pain and signs of generalized or localized peritonitis. on September 27, 2021 by guest. Protected Case 2 Occasionally perforation leads to abscess formation (Mandal & Schofield, 1976). Although any part ofthe A sixteen year old Asian girl had signs of acute small bowel or colon may perforate, the most frequent appendicitis. A localized perforation of the distal site is the distal ileum. A diagnosis of acute appen- ileum was found; the appendix was normal. Small dicitis will often be made ifthe signs are localized to the and appendicectomy were performed. right iliac fossa. Radiographic evidence of free She made an uneventful recovery. peritoneal gas is found in only 25% ofcases (Bhansali et al., 1968). A single perforation is present in 90% of cases. Perforation occurs within or proximal to an area of N.O. Aston, F.R.C.S.; A. M. de Costa, F.R.C.S., F.R.C.S.I. stricture formation. An element of obstruction is Correspondence, and present address: N.O. Aston, Kent and frequently present and fluid levels seen on the plain Canterbury Hospital, Canterbury, Kent CTI 3NG abdominal radiograph add to the difficulties of diag- Accepted: 15 March 1984 nosis (Bhansali et al., 1968). In few reported cases has D The Fellowship of Postgraduate Medicine, 1985 Postgrad Med J: first published as 10.1136/pgmj.61.713.251 on 1 March 1985. Downloaded from 252 CLINICAL REPORTS the diagnosis of tuberculous perforation been made erjee & Singal, 1979). Removing the appendix is a safe prior to laparotomy. procedure even ifmicroscopic evidence oftuberculosis Perforation may occur during treatment ofpulmon- is present (Abrams & Holden, 1964). The overall ary tuberculosis (Sweetman & Wise, 1959). Iatrogenic mortality ofperforation is 30% but may be considera- perforation may be caused by Cope needle peritoneal bly higher in the elderly and in those who have already biopsy for suspected tuberculosis in patients with become cachectic from the underlying disease (Man- ascites (Sherman et al., 1980). dal & Schofield, 1976). The most effective treatment is resection of the The excised specimen should be sent for histological diseased segment with an end to end anastomosis. examination and a segment ofdiseased tissue or lymph Because tuberculous strictures are short, unlike those node cultured for mycobacteria. This is particularly of Crohn's disease, an alternative and quicker treat- important in the elderly, in whom peritoneal tubercles ment for those who are critically ill is oval excision of may be diagnosed as disseminated malignant disease. the perforated area with a transverse anastomosis The standard post-operative treatment is triple reinforced by an omental patch (Pujari, 1979). The therapy with rifampicin, isoniazid and ethambutol. results of oversewing alone are poor (Bhansali et al., An 18 month course is probably necessary. Corticos- 1968). Even when a bypass is added, fistula formation teroids are frequently added empirically to this re- frequently occurs (Ahmad, 1962). Although strictures gimen for 2 months to reduce the degree of cicatrisa- are multiple in over 50% of cases strictureplasty or tion that may occur with healing (Findlay, 1982). resection ofthose remaining is rarely necessary (Muk-

References ABRAMS, J.S. & HOLDEN, W.D. (1964). Tuberculosis of the MUKERJEE, P. & SINGAL, A.K. (1979). Intestinal tuber- . Archives ofSurgery, 89, 282. culosis: 500 operated cases. Proceedings ofthe Association AHMAD, M. (1962). Acute tuberculous perforation of the ofSurgeons ofEast Africa, 2, 70. . Journal ofthe Indian Medical Association, PUJARI, B.D. (1979). Modified surgical procedures in intes- 38, 317. tinal tuberculosis. British Journal of , 66, 180. copyright. BHANSALI, S.K., DESAI, A.N. & DHABOOWALA, C.B. (1968). SHERMAN, S., ROHWEDDER, J.J., RAVIKRISHNAN, K.P. & Tuberculous perforation of the small intestine. Journal of WEG, J.G. (1980). Tuberculous enteritis and peritonitis. the Association of Physicians ofIndia, 16, 351. Archives ofInternal Medicine, 140, 506. FINDLAY, J.M. (1982). Medical management of gastrointes- SWEETMAN, W.R. & WISE, R.A. (1959). Acute perforated tinal tuberculosis. Journalofthe RoyalSociety ofMedicine, tuberculous enteritis: surgical treatment. Annals of Sur- 75, 583. gery, 149, 143. MANDAL, B.K. & SCHOFIELD, P.F. (1976). Abdominal tuberculosis in Britain. Practitioner, 216, 683. http://pmj.bmj.com/ on September 27, 2021 by guest. Protected