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INTRODUCTION |
ITuberculosis
is known to involve any segment. of gastrointestinal tract, however
involvement distal to ileocaecal junction is rare. Isolated tubercular
perforation of ascending colon is rare. We report a rare case of isolated
ascending colonic tubercular perforation who was successfully treated
with primary suturing of colon. |
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CASE
REPORT |
A
19 years old male patient presented with acute pain in right lower quadrant
of abdomen since 2 days. He had history of fever since 3 to 4 days.
No history of loose motion or constipation or any other bowel complaints.
No history of abdominal trauma. No past history of Kochs or Kochs contact.
On clinical examination, patient had tachycardia of 110/min and blood
pressure of 110/70 mm Hg with total leucocytes count of 12000/cu mm
and ESR - 78 mm/hour. Plain radiograph of chest revealed gas under the
domes of diaphragm with no evidence of active or healed pulmonary Kochs.
Patient was subjected to emergency exploratory laparotomy which revealed
minimal contamination in the form of pus more in right side of abdomen
and pelvis. There was a 1 to 1.5 cm perforation in the anterior wall
of ascending colon about 5 cm from the hepatic flexure with no distal
stricture or growth. There were multiple mesenteric lymphnodes. Ileocaecal
junction, small and the rest of large intestine were normal. Biopsy
from the edge of perforated colonic ulcer was taken. In view of minimal
contamination, small, single perforation, primary suturing of the colon
was done. Mesenteric lymphnode biopsy was taken. Postoperative period
was uneventful. He was started on Antituberculous drugs and discharged
home. Patient had 1 kg of weight gain after 15 days of follow up. He
was totally asymptomatic at 6 months of regular followup. |
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DISCUSSION |
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Colonic
tuberculosis is an uncommon condition and further rarity is its
presentation as perforation.1 About 3% of patients with abdominal
tuberculosis have isolated colonic tuberculosis.2 The ileocaecal
area is reported to be the area most commonly involved in colonic
tuberculosis.3-6 The apparent affinity of the tubercle bacillus
for lymphoid tissue and areas of physiologic stasis facilitating
prolonged contact between the bacilli and the mucosa may be the
reason for the ileum and caecum being the most common sites of
the disease. Other areas of the colon besides the ileocaecal area
represent the next more common site of tuberculous involvement
of the gastrointestinal tract, usually manifested as segmental
colitis involving the ascending and transverse colon.3 Colonic
tuberculosis may present as an |
inflammatory stricture,
hypertrophic lesions resembling polyps or tumours, segmental ulcers
and colitis or rarely, diffuse tuberculous colitis.6 The diagnosis can
be quite difficult since there are no specific clinical symptoms of
large bowel tuberculosis and only a quarter of patients have chest radiographs
showing evidence of active or healed pulmonary kochs.1 Our patient had
presented with right lower quadrant pain and fever. His chest radiograph
showed no evidence of kochs, but gas under diaphragm was present suggestive
of bowel perforation. As our patient had presented with perforative
peritonitis, so emergency exploratory laparotomy was done.
Our patient did not have any stricture or distal obstruction with minimal
contamination and had perforation of the ascending colon. In colonic
perforation following trauma routinely colon stomas are preferred as
compared to colonic resection and anastomosis. However Shanon et al
have laid guidelines on colon injury severity and management of colon
perforation and suggested primary colon suturing if the perforation
is small, with minimal contamination, with good vascularity and if patient
is haemodynamically stable.7 Matolo et al also reported decreased morbidity
and mortality following primary colonic repair in colonic trauma.8 Our
patient satisfied the criteria of having small, single ascending colon
perforation, with minimal contamination with good vascularity and patient
was haemodynamically stable. Hence primary suturing of colon was done.
Histopathology of perforated colonic wall biopsy and mesenteric lymphnode
revealed tuberculosis
.
Due to Nonspecific clinical manifestation and radiological features
of colonic tuberculosis, Laparotomy with biopsy is often needed to diagnose
the disease.
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CONCLUSION |
Isolated
colonic tuberculosis perforation being the rarest form of intestinal
tuberculosis poses great difficulty in diagnosis. High index of suspicion,
supported by radiological investigation, exploratory laparotomy and
histopathological examination of tissue biopsy can only lead to a definitive
diagnosis of this rare condition. Surgical treatment involves either
primary suturing or stomas followed by Antituberculosis Chemotherapy. |
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Kashid
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| 2. |
Palmer KB, Patil DH, Basran GS, Riordion JF, Silk DB. Abdominal
tuberculosis in urban Britain. A common disease. Gut 1985; 26
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Singh V, Kumar P, Kamal J, et al. Clinicocolonoscopic profile
of colonic tuberculosis. Am J Gastroenterology 1996; 91 : 565-68. |
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Chen WS, Leu SU, Hsu, et al. Trend of large bowel tuberculosis
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Guth A, Kim U. The reappearance of abdominal tuberculois. Surg
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Marshall
JB. Tuberculosis of the gastrointestinal tract and peritoneum.
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Shannon FL, Moore EE. Primary repair of the colon : When is it
a safe alternative? Surgery 1985; 98 : 851-57. |
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Matolo
NM, Wolfman ER. Primary repair of colonic injuries. A clinical
evaluation. J Trauma 1997; 17 : 554-56.Piraccini BM, Parente GL,
Varotti E, Tosti A. Congenital hypertrophy of the lateral nail
folds of the hallux: clinical features. Pediatr Dermatol 2000;17(5):348-51. |
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TB
SCREENING IN HIV
In countries with a high prevalence of tuberculosis (TB),
people with HIV are recommended to take 6 months of isoniazid
to prevent TB. However, before such treatment can be started,
presence of TB needs to be excluded. UNAIDS/WHO thus recommends
that every patient being assessed for isoniazid preventive
treatment has a chest radiograph. But, in some countries,
chest radiographs are costly and difficult to access.
Lancet Neurol 2003; 2 : 1516,1551
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