1. HPI Timeline Signs and Symptoms Implication
2 years, 3.5 mo PTC (Mar 2008)
chronic cough TB
loss of appetite
weight loss
afternoon fever
body malaise
local HC in Cainta: CXR, sputum exam
1 year, 8.5 mo PTC
repeat CXR, claimed cleared, no records available
Resolution of TB?

2. HPI Timeline Signs and Symptoms Implication 8 months PTC (Feb 2010)
tolerable colicky abdominal pain
Involvement of a hollow organ
bloatedness
Involvement of more distal segments of intestines
abdominal distention
Hallmark of intestinal obstruction;
relieved by passage of flatus or stool
Not obstipated, partial obstruction

3. HPI Timeline Signs and Symptoms Implication 4 weeks PTC
vomiting of ingested food ~1-2x/week
Obstruction
increased frequency and
severity of abdominal distention
Progressive cause of obstruction
colicky pain localized @ RLQ
Possible locations
Chronicity rules out appendicitis
anorexia
Malabsorption, malnutrition
lost 20-30% weight

4. HPI Timeline Signs and Symptoms Implication 18 days PTC menses
Rules out pregnancy as cause of vomiting, colicky pain
(Ruptured ectopic pregnancy can present as intestinal obstruction)

5. HPI Timeline Signs and Symptoms Implication On admission stable vitals
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
Malabsorption, malnutrition
hyposthenia
minimally worked up and diagnosed but cannot be cleared for intervention due to pulmonary complications

6. 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

7. 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

8. 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

9. 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

10. Pathophysiology of the Disease

11. Imaging Studies

12. 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

13. 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).

14. 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.

15. 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.

16. 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

17. Management
Alleviation of symptoms of distention via nasogastric decompression
Correction of nutritional status
Resection of the involved tissue
Demonstration of organism via culture of resected segment followed by sensitivity testing
Anti-mycobacterial treatment using appropriate medications

18. Management
Alleviation of symptoms of distention via nasogastric decompression
Correction of nutritional status
serves to prepare the patient for surgical intervention
monitoring of serum albumin

19. Management 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

20. Management 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

21. Management
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

22. Management 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