S3002 Mycobacterial Ileitis Resulting in Small Bowel Obstruction

Abstract

Introduction: Tuberculosis (TB) is known to cause significant pulmonary disease but can rarely affect the abdomen. Here we describe a case of TB involving the terminal ileum, resulting in small bowel obstruction (SBO). Case Description/Methods: A 64-year-old male with gastroesophageal reflux disease and peptic ulcer disease presented with a 2-month history of diffuse abdominal pain. Along with this, he had an associated 40-pound weight loss, night sweats, and fatigue over the previous six months. On exam, the right lower quadrant was exquisitely tender to palpation, with voluntary guarding but without rebound. Laboratory findings were unremarkable. Abdominal computed tomography (CT) showed a mass-like thickening with mucosal enhancement of the terminal ileum. Colonoscopy revealed a circumferential friable mass involving the terminal ileum (TI), with pathology showing mycobacterial ileitis with necrotizing granulomatous inflammation (Figure 1). The patient was subsequently started on rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) therapy and discharged home. He was then readmitted one month later for a 5-day history of worsening abdominal pain, post-prandial emesis, and decreased bowel movements. Repeat abdominal CT revealed a SBO at the ileocecal junction. Surgery was consulted, and the patient underwent an ileocolectomy with complete removal of the TI mass. The patient has since completed TB treatment with resolution of his gastrointestinal symptoms. Discussion: Tuberculosis can involve sites other than the lungs, with the abdomen being affected in 11-16% of extrapulmonary cases. Intestinal TB can present similarly to other diseases that affect the GI tract including malignancies, infection, and inflammatory bowel disease. Obstructions can develop as a result of strictures, adhesions, or mass effect from the infection. Although rarely seen in the United States, SBO secondary to abdominal TB has been reported in developing countries with higher disease prevalence. Treatment typically involves surgical resection and RIPE therapy. Our case demonstrates that TB should be considered in the differential diagnosis of patients presenting with SBO due to a terminal ileum mass.Figure 1.: Mycobacteria visualized in ileal mass cytology specimen, Acid Fast Bacteria stain, 100x magnification under immersion oil.