Syed Inamullah Shah, Ikram Khan, Aurangzeb Khan.
Skip Lesions in Intestinal Tuberculosis.
J Coll Physicians Surg Pak Jan ;13(4):233-4.

A young lady of 20 years presented with profuse vomiting and absolute constipation of three days duration. She had history of recurrent abdominal pain with vomiting associated with intermittent constipation, abdominal distension and weight loss for the last one year. Conservative management led to no improvement. There was no past history of diarrhea, bleeding per rectum, cough or hemoptysis. General physical examination showed her to be emaciated, afebrile and moderately dehydrated. Her weight was 38 kg. Abdomen was grossly distended with tinkling bowel sounds. No other general or specific physical abnormality was found. Her ESR was 25 mm at the end of 1st hour (Westergren method); hemoglobin was 9.3 gm% with a hematocrit of 30%; TLC was 8500/cm with 25% lymphocytes and the plain x-ray abdomen showed multiple air-fluid levels in small intestine confirming the diagnosis of intestinal obstruction. She was prepared for emergency surgery, which revealed seven tight strictures in the jejunum and ileum starting at 6 inches from the duodenojejunal flexure and ending 4 inches from the ileocaecal junction. Although the proximal jejunum was dilated, the intervening segments of intestine between strictures were absolutely normal in shape and thickness of wall, colour and texture varying in length from 7 to 18 inches. Gross examination of the mucosa showed transversely placed fibrous strictures causing stenosis without adjacent ulceration, edema or congestion. Mesenteric lymph nodes were enlarged. The rest of the gut was normal. All strictures were managed by stricturoplasties. A piece of the involved gut and an enlarged lymph node from the mesentery was taken as biopsy. Postoperative recovery was smooth. Considering the history and the gross appearance of the intestinal mucosa, anti-tuberculous (TB) chemotherapy was started. Histopathology revealed caseation and Langhan`s type of multinucleate giant cells in both the specimens. Ziehl Nielson (ZN) staining of the intestinal biopsy showed acid-fast bacilli, confirming the clinical diagnosis of tuberculosis. Anti-TB drugs were continued for 9 months. During this period her weight increased to 60 kg and abdominal symptoms disappeared. She was asymptomatic 6 months after cessation of drugs.

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