October - LRS Institute of Tuberculosis & Respiratory Diseases

CaseNo. Chest X – ray Abdomen X-
ray
1 Fibrocalcific lesion Free air
(inactive)
2 Blunted costophrenic
Loculated air
angle
3 Pleural effusion
(fresh)
4 Activeparenchymal
lesion sputum
negative for AFB.
TUBERCULOUS PERFORATIONS OF THE SMALL INTESTINE 189
TABLE 2
Tuberculous Perforations of the Small Instestine (contd.)
Free air
Operative findigs Operative procedure* Hospital
stay
Ileal perforation, Resectin-anastomosis 15days
stricture.
Extensiveadhesions,
- 17days
perforation not
found
- 9days
- Extensiveadhesions,
perforation not
found
Ileal perforation,
stricture
5 Normal - Ileal perforation,
strictures.
6 Normal - Ileal perforation,
stricture
Closure of perforation
Resection-anastomosis
Closure of perforation
Resection-anastomosis
Resectionan-astomosis
30days;
Fecal fistula
11 days
11days
* Peritoneal toilet and drainage performed in all cases.
ileal strictures on barium meal follow through
and were receiving antitubercular treatment.
An increased incidence of perforation with antitubercular
treatment has been noted (Bahari,
1978). Chest X-ray showed evidence of tuberculosis—active
or healed in 4 (66%) cases.
Correct preoperative diagnosis of tuberculous
perforation of the small intestine is not possible
(Kakar et al 1983). We suggest that the diagnosis
of tuberculous perforation should be strongly
suspected in patients with peritonitis who have
previous history of subacute intestinal obstruction
and/or show evidence of tuberculosis on
chest X-ray. All our cases fulfilled one or
both of these criteria.
Surgical treatment of tuberculous perforation
is controversial. Closure of the perforation
with or without bypass has been reported to
give poor results (Bhansali et al, 1968).
Resection—anastomosis is therefore, recommended
(Aston and De Costa 1985). Irrespective
of the surgical procedure adopted, however,
the mortality is high 30% (Aston and De
Costa 1985; Bhansali et al 1968) to 45%
(Kakar et al 1983). Tuberculous perforations
are often associated with strictures—these must
be resected alongwith closure of the perforation
(as was done in cases 4 and 5). Perforations
adjacent to strictures shoud be included in
the resected segment of the intestine (cases
1 and 6). In the presence of extensive adhesions.
no attempt should be made to locate the
perforation (cases 2 and 3) as injury to the
adherent intestinal loops is likely and focal
fistula may result in the post-operative period.
Peritoneal toilet and drainage should always be
performed. We have successfully managed 6
cases with these guidelines of treatment and
advocate them for the managment of tuberculous
perforation of the small intestine.
REFERENCES
Aston N.O. and De Costa A.M. : Tuberculous perforation
of small bowel. Postgraduate Medical Journal;
1985, 61, 251-252.
Bhansali S.K. : Abdominal tuberculosis. Experiences
with 300 cases. American Journal of Gastroenterology;
1972, 67, 324-337.
Bhansali S.K., Desai A.N. and Dhaboowala C.B, :
Tuberculous perforation of the small intestine.
Journal of Association of Physicians of India; 1968,
16, 351-355.
Kakar A,, Aranya R.C., and Nair S.K. : Acute
perforation of small intestine due to tuberculosis.
Australia and New Zealand Journal of Surgery;
1983, 53, 381-383.
Lal M.M., Grover, S. and Singla S.N.: Acute tuberculous
perforation of the small intestine. Indian Journal
of Tuberculosis; 1984, 34, 130-132.
Mohd. Bahari H.M. : Perforation of tuberculous
enteritis. Medical Journal of Malaysia; 1978, 32,
282-284.