Multiple Tubercular Intestinal Perforations: A Case Report

Abstract

Intestinal tuberculosis (TB) is a frequently encountered pathology by surgeons all over India. There exists a vast body of knowledge about this disease; however, a detailed understanding of its presentation as well as surgical management is essential for every Indian surgeon, given its rampant nature. This report discusses the case of a 28-year-old female presenting with severe left upper abdominal pain, non-bilious vomiting, and fever, who was ultimately diagnosed with small bowel TB leading to perforations. Despite a history of pulmonary TB treated a year prior, the patient exhibited significant clinical and imaging findings, including pneumoperitoneum and peritonitis. Exploratory laparotomy revealed multiple tubercular perforations in the mid-jejunum and a stricture causing proximal jejunal dilatation. Surgical intervention involved resection of the affected segment and end-to-end anastomosis. Histopathological analysis confirmed TB as the cause. This case underscores the importance of considering TB in the differential diagnosis of small bowel perforations and highlights the critical role of timely surgical intervention and comprehensive management in improving patient outcomes.

Keywords: abdominal pain; non-bilious vomiting; pneumoperitoneum; small bowel perforation; tuberculosis.

Figure 1. Chest X-ray (preoperative)

Chest X-ray showing free air under the right dome of the diaphragm (white arrow)

Figure 2. Intraoperative image

Multiple perforations in the mid-jejunum over a segment of 10 cm and dilation of the jejunum proximal to the stricture up to 6 cm (wall-to-wall diameter)

Figure 3. Intraoperative photograph showing intestinal perforation

Resection and anastomosis being performed (jejunoileal end-to-end anastomosis in four layers)

Figure 4. Histopathology image of intestinal mucosa from the perforation margin

The image shows caseating granuloma (black arrow) with lymphocytic proliferation