Presentation
On treatment for cerebral and pulmonary tuberculosis. Abdominal pain and distension.
Patient Data
Acute high-grade small bowel obstruction secondary to stricturing of the terminal ileum. The terminal ileum is thickened and hyperenhancing over a length of 5 cm. The cecum is collapsed and not thickened, and is in a normal position. Two other foci of small bowel thickening and luminal narrowing are present upstream, each approximately 1 cm in length, although this may represent spasm. No other segments of bowel are similarly affected. A few small mesenteric lymph nodes are present but no bulky or necrotic nodes. A small volume of free fluid is present in the pelvis. Extensive nodularity is seen at the lung bases.
HISTOPATHOLOGY REPORT
Sections from the 3 small bowel strictures, and also from the ileocecal valve stricture, show similar features with obvious granulomatous inflammation characterized by well-formed granulomas present throughout the full thickness of the bowel wall. There is associated chronic inflammation, and patchy mucosal ulceration is noted. The background small and large bowel are unremarkable.
COMMENT: The appearances are of granulomatous inflammation, causing strictures in the small bowel and at the ileocecal valve and fit with the clinical impression of TB.
Case Discussion
The differential for the multifocal small bowel strictures causing obstruction is Crohn's disease and tuberculosis. The presence of cecal retraction and necrotic lymphadenopathy can help steer the diagnosis towards TB but these features were absent in this case. The history of TB in the brain and lungs does help though. Ultimately, the diagnosis must be made using tissue from a biopsy with microbiological and pathological analysis.
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