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?

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

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

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)

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

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 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

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

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

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

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

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