Intestinal Tuberculosis Associated with Short Bowel Syndrome. Case report. National Hospital Guillermo Almenara, Lima, Peru

Abstract

Introduction: In Peru, intestinal tuberculosis (TB) represents 1.4% and the main complications are obstruction (15%) and intestinal perforation (15%); requiring surgical treatment that can lead to short-bowel syndrome (SBS) and malabsorption for anti-TB treatment. For the management of SBS, the specialized units have improved survival, however, to explain the effect of SBS on the absorption of anti-TB drugs, there is little information. We present a case of SBS after an intestinal resection due to complicated intestinal TB. Clinical Case: A 26-year-old woman, a history of untreated pulmonary TB, entered emergency with Acute Abdomen and Organic Dysfunction. Laparotomy, intestinal resection and jejunostomy are performed at 120 cm from the Treitz ligament for perforated intestinal TB and peritonitis. In the postoperative period, she developed SBS due to intestinal TB and high-flow jejunostomy. The patient did not tolerate intestinal rehabilitation or anti-TB treatment. The Intestinal Failure Unit (IFU) was convened, installing an individualized intravenous anti-TB treatment with second and third line drugs (Meropenen, Ampicillin/Sulbactam, Amikacin, Ciprofloxacin). The patient presented central venous catheter (CVC) sepsis receiving treatment. All this allowed to take the patient to a definitive surgery of restitution of the intestinal transit and to continue the treatment anti-TB orally. Discussion: After controlling the infection, two problems remained: SBS and TB. The intestinal failure [ZERO WIDTH SPACE][ZERO WIDTH SPACE]has standardized management and TB as well. However, when coexisting in our patient, these treatments failed and the intervention of the IFU was necessary. I apply an individualized intravenous anti-TB therapy. This therapy is indicated for cases of resistant TB. We use it with the purpose of not increase the osmotic load of the functioning intestine. This allowed compliance with anti-TB therapy and improved nutritional status with enteral nutrition. The intestine was very difficult to rehabilitate because it increased its losses by jejunostomy when an infection coexisted; as happened in CVC sepsis. When these were resolved, it led to the benefit of becoming independent of the parenteral nutrition and continuing enteral intestinal rehabilitation until surgical rehabilitation. Conclusion: The management of the SBS must be by the IFU and we recommend starting individualized treatment for TB in case of Residual Intestinal less than 150 cm.