S4926 Successful Multidisciplinary Treatment of Small Bowel Obstruction with Ileal Stricture Resulting in Bowel Perforation in the Setting of Multidrug-Resistant Gastrointestinal Tuberculosis: A Case Report

Introduction: We present the case of a patient with multidrug-resistant gastrointestinal tuberculosis (MDR GI TB) complicated by strictures of the ileum and jejunum, small bowel obstruction, and perforation successfully treated with bowel rest, total parenteral nutrition, intravenous antibiotics, and right hemicolectomy with creation of ileal-colon anastomosis. Case Description/Methods: A man in his 40s on BPAL-M regimen for MDR pulmonary TB presented to Emergency Department with abdominal pain, vomiting, and cessation of bowel movements. Computed tomography abdomen/pelvis showed small bowel obstruction with a terminal ileal stricture and focal jejunal narrowing consistent with a second stricture consistent with GI TB. Acute care surgery recommended bowel rest and decompression however declined nasogastric tube. A PICC line was placed and he was started on total parenteral nutrition for nutrition. His oral anti-TB regimen was held and he was started on intravenous linezolid, intravenous moxifloxacin, intravenous meropenem, and intravenous ampicillin-sulbactam. Stress dose corticosteroids were added alongside intravenous Bactrim for PJP prophylaxis. On day 18 of hospitalization he developed severe abdominal pain and computed tomography abdomen/pelvis showed pneumoperitoneum consistent with bowel perforation. He was taken emergently to the operating room for exploratory laparotomy. A perforation was found in the terminal ileum and a right hemicolectomy was done. On post-op day 2, he returned to the operating room for stapling of the ileocolic anastomosis and fascial closure. He tolerated the initiation of diet and resumption of oral anti-TB regimen and was discharged home after a 23-day hospitalization. Discussion: GI TB can be challenging to diagnose, in part due to non-specific symptoms that mimic other pathologies but also in that it could present without pulmonary involvement. GI TB can be especially challenging to cure due to impairment in the absorption of oral anti-tuberculosis medications. MDR-TB further complicates the therapeutic plan and is associated with higher mortality compared to drug-susceptible TB. Most of the agents in the BPAL-M regimen are not available in intravenous formulation. High-dose corticosteroids decrease the risk of strictures and obstruction, Complications of GI TB include strictures (most commonly in the ileocecal area of the small bowel), bowel obstruction, and perforation. These patients are poor surgical candidates due to often being severely malnourished and as such ensuring timely diagnosis and initiation of therapy is crucial to prevent progression to these severe complications. If emergent surgery is required such as in our case, resection anastomosis is preferred over primary closure due to better outcomes (see Figure 1).Figure 1.: (A) Small bowel obstruction from terminal ileal stricture near the ileocecal junction (white arrow), (B) pneumoperitoneum consistent with bowel perforation (white area pointing to free air in the abdomen).