Urgent Exploratory Laparotomy Research Articles

Bowel perforation and peritonitis caused by a jejunal leiomyoma. A rare complication of jejunal leiomyoma

Small-bowel leiomyomas are rare, usually indolent, benign neoplasms, sporadically associated with complications, mainly including bleeding and obstruction. Herein we report a case of a 78-year-old female patient under high-dose corticosteroid treatment for systemic disease, presenting with clinical signs suggestive of peritonitis. Urgent exploratory laparotomy revealed an intraluminal jejunal mass complicated by bowel perforation and multiple enlarged mesenteric lymph nodes. Microscopic examination of the surgical specimen suggested the presence of a jejunal leiomyoma as the cause of perforation and lymph nodes’ infiltration by Hodgkin lymphoma. The patient died on the 15th post-operative day due to pulmonary complications. To our knowledge, this is the first reported case of a jejunal leiomyoma complicated by bowel perforation and peritonitis. A high index of suspicion for the presence of underlying neoplastic disease should be maintained in cases of non-traumatic small-bowel perforation. Additionally, the potentially detrimental effect of comorbidities on a patient’s outcome should be considered even in the context of successful management of primary disease.

Spontaneous Heterotopic Pregnancy: As One of the Most Challenging Emergency Cases in Obstetrics

Spontaneous Heterotopic Pregnancy “SHP”: is defined as the presence of multiple gestations, in which, intrauterine and extrauterine pregnancy occur simultaneously, it is a life-threatening condition that requires immediate and accurate diagnosis and treatment. Here, we present a case of a 38-year-old pregnant female who conceived spontaneously, at her sixth week of gestation, was presented to the emergency department with acute pain in lower abdomen and minimal vaginal bleeding, she underwent previous falsely reassuring ultrasound imaging for two times and her symptoms were ignored until the diagnosis was finally made by us. Pelvic ultrasound showed evidence of an IUP and a left adnexal mass, raising suspicion for a heterotopic pregnancy. An urgent exploratory laparotomy and a left salpingectomy were performed, postoperative, the patient recovered well but she had an early pregnancy loss at 8 weeks of gestation. Clinicians should keep in mind that confirmation of an Intrauterine Pregnancy (IUP) should not preclude the existence of a heterotopic pregnancy.

The importance of early diagnosis and surveillance in Peutz-Jeghers Syndrome: A case report

Abstract Introduction: Peutz-Jeghers syndrome is a rare autosomal dominant inherited disorder characterized by hamartomatous intestinal polyps and mucocutaneous pigmentation. Most cases appear to be linked to the mutation of the STK11 gene. Patients are at a lifetime risk of gastrointestinal and non-gastrointestinal cancers. Case Presentation: The present study offers the case of this rare disorder in a young woman revealed by jejunal obstruction caused by intussusception. A 32-year-old woman was referred to the surgical department with symptoms suggestive of an obstructive syndrome. On examination, there were multiple perioral pigmented lesions. An urgent exploratory laparotomy revealed bowel obstruction caused by an intussusception with a large polyp. The patient suffered another similar episode 4 years before leading to the diagnosis of Peutz-Jeghers Syndrome, however she was under no surveillance. Patients with pigmented lesions and a family member suffering from the mentioned syndrome should perform endoscopy and genetic tests to diagnose early and avoid complications. Conclusion: Peutz-Jeghers Syndrome is difficult to treat due to its nonspecific symptomatology and late diagnosis. Life-threatening complications such as intussusception and various types of cancer are unanticipated. It is vital to diagnose and perform routine screening, which will make it possible to prolong the survival of many patients.

Repair of Bowel Perforation: Endoscopic State of the Art

Background: Intestinal damage from various etiologies can result in the potentially dangerous complication of bowel perforation. Emergent treatment of small bowel perforation includes surgical repair with or without small bowel resection. As the number of therapeutic and diagnostic endoscopic procedures increase, more studies may be required to properly evaluate and report incidences of bowel perforation. Given the advantages of interventional procedures, novel endoscopic technologies which may prove beneficial in bowel perforation repair are continuously undergoing development. Bowel perforation can lead to peritonitis and sepsis – a medical emergency requiring immediate attention. Following diagnosis, hemodynamically stable patients may be treated conservatively whereas unstable patients undergo more intensive surgical procedures. Endoscopic procedures for bowel perforation repair also exist and recent advances in technology are furthering the scope of such closure methods. Methods and Findings: Endoscopic suturing technologies, while capable, require extensive training and entail prolonged activation processes. Wound vacuum sponge closure via endoscopy provides convergence of wound defects but may not be efficacious in defects larger than 5 cm. Furthermore, this method may be limited by inadequate seal and placement in the intestine. Endoscopic clipping is another modality beneficial for smaller perforations only. T-tag suturing has shown promising results in ex-vivo studies but entails blind placement of T-tags for perforation closure. Stents can be inserted endoscopically under fluoroscopic visual guidance. This technique, however, may result in stent migration, perforations and potential occlusions. Sealants can be injected for perforation closure but have not demonstrated clear efficacy. Robotic flexible endoscopy provides several novel features yet may require advanced training and sometimes more than one operator. As interventional procedures continue to gain popularity, a better understanding of endoscopic modalities is helpful for furthering their development. Regarding bowel perforation, this review aids in an overall understanding of the technologies which exist and are advancing further into more standard modalities for practical medical applications. Conclusion: There are currently various methods to repair perforation of the gastrointestinal wall and except for urgent exploratory laparotomy when indicated, there is likely no single method that is superior to others. It may be beneficial for the physician to consider all options for repair when evaluating a potential bowel perforation, considering physician preference and individual success or difficulty with a given modality. In more recent years as the focus has narrowed on minimally invasive procedures, future modalities will likely include increased automation and ease of use with the help of robotics, which will hopefully lead to decreased time to diagnosis, faster recovery and reduced morbidity and mortality.

Emphysematous gastritis in a patient with neutropenic sepsis: A case report and literature review with comment on management.

Emphysematous gastritis is a severe form of gastritis caused by gas-forming infectious organisms and is most frequently encountered in critically unwell patients. Diagnosis rests on the radiographic appearances of air within the gastric wall, which may extend into the portal venous system. Not previously described in the context of neutropenic sepsis, our case involves a 77-year-old patient with emphysematous gastritis who was admitted to the intensive care unit with a neutrophil count of 0.1 × 109/L and managed successfully with conservative treatment. Presenting complaints usually include abdominal pain, nausea, vomiting and occasionally haematemesis, in the context of systemic upset. Predisposing factors may include diabetes and immunosuppression, ingestion of corrosive substances, alcohol abuse, and abdominal surgery. The historical approach to management which previously involved urgent exploratory laparotomy with gastrectomy, has largely been replaced with conservative therapy, including broad-spectrum antimicrobials, gut rest and parenteral nutrition, with improved outcomes. Previously considered a commonly terminal diagnosis with mortality rates as high as 60%, this recent shift in approach to management has contributed to mortality rates being halved. The role of oesophago-gastro-duodenoscopy has not been established and is unlikely to be indicated in every case. Longterm complications may be of concern and include fibrosis and gastric contractures.

Vesical Explosion during Transurethral Resection of Prostate: A dreadful Complication associated with Common Endoscopic Procedure

Vesical explosion during transurethral resection of the prostate (TURP) is an extremely rare, serious and dreadful complication, which should be considered as a blast injury requiring urgent exploratory laparotomy and repair. Until 2019, only 38 cases have been reported in the International English literature. The underlying mechanism for this rare intravesical explosion is the generation and trapping of explosive gases under the dome of the bladder, which eventually detonates by sparks from the cutting electrode during TURP. Herein, we report a case of a 67- years- old man where an explosion occurred during TURP, resulting in a large intraperitoneal rupture of the urinary bladder. After confirmation of the diagnosis clinically, endoscopic ally and radio logically the patient underwent a successful emergency laparotomy to repair the bladder tear. He had uneventful postoperative recovery and he is symptoms free at 6months and one year of follow-up. Although uncommon, vesical explosion during TURP may occur and some preventive measures, discussed here, can be carried out to avoid this dreadful complication. In addition to the discussion of its mechanism, we will discuss the preventive measures of this dreadful event. To the best of our knowledge, this is the first case of a Vesical explosion reported in our department.

A rare case of duplication of the descending colon in a pregnant woman: case report and literature review.

Gastrointestinal duplications are uncommon congenital abnormalities that can occur anywhere throughout the intestinal tract. The small bowel is more interested than the large one. Duplications are schematically classified as spherical and tubular, respectively representing 80% and 20% of cases, with different relationships and communications with the native intestinal wall. Although typically diagnosed during infancy and early childhood, tubular colonic sub-type stays frequently hidden for several years until a complication occurs. we report the case of a T-shaped tubular duplication in a 20-year-old woman at the 30th week of gestation, who underwent an urgent exploratory laparotomy for intestinal occlusion, treated with the resection of the aberrant large bowel. The patient was notable for a long history of constipation and chronic pain. Diagnostic possibilities were limited by the on-going pregnancy. Intestinal duplications are uncommon malformations, and, of these, the T-shaped subtype of the colon is among the rarest ones. In the adulthood, diagnosis is usually established in the operating room during urgent or even emergency surgery performed for abdominal complications. A duplication of the descending colon is extremely rare, and this is, to our knowledge, the only article describing a case found in advanced state of pregnancy.

A comparative study between the outcomes of various surgical procedure in management of ileal perforation of tertiary care in central India

Background: This study was done to establish the outcomes of surgical procedure in management of ileal perforation. Methods: This study included 70 patients admitted to surgical emergency with acute abdomen. These patients were divided into 3 groups group A, group B, group C. The surgical management was done as primary repair (group A) and resection and anastomosis (group B) and primary repair with ileostomy (group C); Comparative study was done between all procedure. Study centre was L. N. medical college and hospital and research centre, Bhopal, Madhya Pradesh. Study duration was from March 2021 to September 2022. Results: This study highlights the life-saving role of loop ileostomy for postoperative intestinal leakage in cases of primary repair of perforation. It is recommended that whenever intestinal leakage is suspected in the postoperative period, urgent exploratory laparotomy must be undertaken and the continuing peritoneal contamination should be controlled by exteriorizing the site of intestinal leak as loop ileostomy. Conclusions: In our study we have found that, for a single perforation, primary repair is the procedure of choice and for multiple perforation with good systemic support, resection anastomosis is procedure of choice. For patient with poor systemic support, loop ileostomy is preferred procedure as it decreases the mortality.

Ileal metastasis from Phyllodes breast tumor.

We present the case of a 72-year-old woman with a history of right radical mastectomy due to the Phyllodes Tumor. Two months later, she went to the emergency room for intestinal occlusion. Analytically, she had anemia and thrombocytopenia. The abdominal tomography noticed signs of occlusion of the small bowell and injury of 5cm at the pericaecal level. Urgent exploratory laparotomy was performed and objectified distal ileum attached to the cecum with signs of irreversible ischemia, so an ileocaecal resection was performed with ileo-colonic anastomosis. In the postoperative period she presented paralytic ileus and paraneoplastic syndrome with bicytopenia refractory to corticosteroid treatment. To rule out abdominal complications, abdominal tomography was performed on the 5th day post-op that confirmed the integrity of the anastomosis and absence of signs of mechanical occlusion. The patient's evolution was unfavorable, went on to exitus on the 14th day. The anatomopathological study diagnosed metastasis of malignant Phyllodes Tumor at the ileal level.

S3489 The Uncommon Acute Abdomen: Enteropathy-Associated T-Cell Lymphoma Revealed by Jejunal Perforation

Introduction: Long-standing Celiac disease that is untreated or refractory to gluten-free diet can have dire consequences. Among these, Enteropathy-associated T-cell Lymphoma (EATL) is a rare form of non-Hodgkin’s intestinal lymphoma that carries a poor prognosis with high mortality. This neoplasm can manifest as complicated small bowel disease such as obstruction or perforation. We present a patient with Celiac Disease presenting with an acute abdomen found to have jejunal perforation due to EATL. Case Description/Methods: A 51-year-old male with history of biopsy-confirmed Celiac Disease (CD) presented for severe abdominal pain. Vital signs were stable and laboratory findings showed leukocytosis and lactic acidosis. Abdominal CT revealed closed loop obstruction and pneumatosis with hollow viscus perforation. He was taken to the OR for urgent exploratory laparotomy where purulent fluid and a perforation in the mid-jejunum was discovered. Subsequent jejunal resection with primary anastomosis was performed. Post-operative course was complicated by ileus and urinary retention but ultimately made full recovery. Biopsy of the resected jejunum revealed malignant lymphoid infiltrate in a background of mild villous blunting, increased intraepithelial lymphocytes, ulceration, perforation, and acute serositis consistent with EATL. Follow-up endoscopy was consistent with known CD, but otherwise unremarkable. T-cell receptor rearrangement study and bone marrow biopsy were negative. He was initiated on BV-CHP chemotherapy and achieved complete remission after 6 cycles. After induction, he opted for consolidation (BEAM) chemotherapy followed by autologous bone marrow transplant. Unfortunately, this treatment course was complicated by septic shock with multi-organ failure and ultimately decision was made for comfort care. (Figure) Discussion: Strict gluten-free diet (GFD) is the primary prevention of EATL in CD. Non-compliance to GFD has been shown to significantly increase risk of developing EATL. Small bowel perforation is a rare, but well-documented complication of EATL that must be recognized in CD patients presenting with acute abdomen. Current treatment of EATL with chemotherapy and autologous bone marrow transplant has shown promising improvement in survival rates and reduced mortality rate. For CD patients, strict adherence to GFD with close clinical monitoring is of utmost importance to improve quality of life, minimize progression of EATL, and prevent necessity of risky advanced interventions as highlighted in our case.Figure 1.: Axial view of Abdominal CT showing perforation of small bowel.

Intussusception in Five Months Old Infant, A Rare Cause Colocolica without Pathologic Lead Point: A Case Report

Intussusception is a common cause in gastrointestinal obstruction and one of condition in which early treatment is critical. Given the risk of acute bowel ischemia, intussusception represents an abdominal emergency in the pediatric population. The symptoms are generally related to intestinal obstruction, as intussusception accounts for up to 50% of pediatric small bowel obstructions in some series. Colocolica intussusception is an uncommon type of intussusception in children that is usually associated with a pathological lead point. This report depicts a five-months-old female baby with a chief complaint of bloody stool 7 hours before admission, accompanied with non-bilious vomit. Patient exhibited the classic triad of intussusception and upon the radiologic examination, a colocolica was noted. Patient then underwent urgent exploratory laparotomy, and the colocolica was reduced through manual reduction (milking technique).

A Trapped Colon

A Trapped Colon

Photo Quiz: Gram-Variable Staining in Anaerobic Bacteremia.

A 62-year-old male patient was admitted to the surgical intensive care unit (ICU) for secondary peritonitis and septic shock. His medical history included laryngeal cancer, adrenal insufficiency, and a recent total colectomy for acute mesenteric ischemia. An urgent exploratory laparotomy revealed an anastomotic leak secondary to the colectomy. Anastomotic takedown and peritoneal lavage were performed, with a Gram stain of the peritoneal fluid showing a polymicrobial flora. Antimicrobial therapy with piperacillin-tazobactam, amikacin, and caspofungin was initiated.

Right Anterior Sectionectomy for a Subcapsular Hepatic Hematoma Causing Disseminated Intravascular Coagulation Following an Endoscopic Retrograde Cholangiopancreatography

A 29-year-old female diagnosed with an acute cholecystitis and choledocholithiasis in a different medical center, was treated by an ERCP with sphincterotomy, being discharged 4 days later due to pain in the right hypochondrium radiated to the right cervical region and the diagnosis of hospital acquired pneumonia. 11 days after the initial procedure she came to our Emergency Department due to persistent pain in the right hypochondrium. She was hemodynamically stable with 99/62 blood pressure, heart rate of 70 bpm and a temperature of 36 C. The computed tomography scan on admission showed a liver dependent heterogeneous collection, predominantly hypodense with hyperdense material that formed a liquid - liquid level, measuring 157 x 188 x 96 mm with a volume of 1,481 cc that created a mass effect on liver parenchyma, compatible with subcapsular hematoma. A conservative management was proposed but in the fourth day of inpatient stay the hemoglobin levels dropped from 8.6 g/dL to 8.0 g/dL and the platelets dropped from 397 K/mL to 44.4 K/mL in the daily controls. A diagnosis of Disseminated Intravascular Coagulation was made and an urgent exploratory laparotomy was proposed. A big subcapsular hematoma involving segments V – VIII with 1,500 cc of clotted material was found. Drainage and rinsing of the hematoma were made and a right anterior sectionectomy was performed. On postoperative, patient showed no signs of complications. A control CT scan showed a small subphrenic collection with a well-placed drain. The patient was discharged after 7 days with no further complications.

Intestinal pseudo-obstruction in a patient with Kleefstra syndrome

Aim: To present a case of intestinal pseudo-obstruction in a paediatric patient with Kleefstra syndrome type 1 as a new clinical feature of this rare genetic disorder. Case report: A seven-year-old patient was admitted to the emergency department for nausea and vomiting. Clinical examination showed distended, meteoristic abdomen without detectable peristaltic sound. Abdominal X-ray revealed air-fluid levels and possible right subdiaphragmatic air collection. An urgent exploratory laparotomy was indicated. Intraoperatively, extremely dilated loops of small and large intestine up to the distal sigmoid colon were noted. No anatomical or mechanical causes of obstruction were found. The postoperative course was complicated by dysfunctional intestinal motility and urinary catheter-related infection which required prokinetics and intravenous antibiotic therapy. The patient was transferred to a paediatric centre specialized in intestinal motility disorders for further treatment. Conclusion: This is the first case of intestinal pseudo-obstruction described as a part of clinical presentation of Kleefstra syndrome type 1. Further research and re-evaluation of patients with KS1 is needed to determine if intestinal pseudo-obstruction is a new clinical manifestation depending on the size of the deletion or a repercussion of hypotonia sequential to an underlying syndrome.

750 An Unusual Presentation of a Rare Clinical Entity – A Case Report of Spontaneous Common Bile Duct Perforation in an Adult

Abstract Spontaneous or non-traumatic perforation of the extrahepatic biliary system is a rare clinical phenomenon, with few cases reported since its first mention in medical literature by Freeland in 1882. Given the rarity, misdiagnosis is common with the diagnosis almost always made during urgent exploratory laparotomy. We describe a case of spontaneous common bile duct (CBD) perforation in an 83-year-old female with no associative underlying disease process identified. The patient presented with sudden onset abdominal pain with no identifiable trigger, with minimal past medical history. Examination was remarkable for findings of epigastric tenderness and guarding. Haematological investigation was remarkable only for hyperamylasaemia and leucocytosis. Pneumoperitoneum was ruled out and following contrast CT abdomen and pelvis a working diagnosis of mild pancreatitis was made. US Abdomen and MRCP found no evidence of cholelithiasis, with minimal biliary duct dilatation. The patient continued to deteriorate on the ward, with aspiration of new intrabdominal fluid collection raising suspicion of perforated viscus. Exploratory laparotomy revealed a 1-cm defect in the CBD with frank bile leak. A T-tube was placed in the common bile duct defect, with an abdominal robertson drain also inserted. No further bile leak was identified via Tubogram, with the patient successfully discharged following multidisciplinary rehabilitation in intensive care and the ward setting. Surgeons should seek out this uncommon diagnosis in patients with hyperamylasaemia and suspected cholelithiasis who do not conform to normal biliary/pancreatic disease progression patterns.

Transverse Colonic Perforation in Renal Transplant Recipients During the Early Postoperative Period: A Case Series

There are very few cases of nondiverticulitis episodes of colonic perforation in the acute postoperative period following kidney transplantation described in the literature. Various nondiverticular causes of colonic perforations include ischemia, malignancy, cytomegalovirus (CMV) enterocolitis, and nonobstructive colonic dilatation. Immunosuppressive medication can contribute to colonic perforation, placing kidney recipients at risk for these complications. Since 2011, there have been 2 cases of transverse colonic perforation in the early postoperative period following renal transplantation at our institution. Both patients underwent urgent exploratory laparotomy with resection of perforated transverse colon and creation of a proximal colostomy. The aim of this study is to review the cases of colonic perforation following renal transplantation to gain a greater understanding of this rare occurrence. Despite the lack of a clear cause of perforation, it is imperative to have a high index of suspicion for colonic perforations in these immunocompromised patients to provide prompt surgical management and improved outcomes.

Acute Ischaemic Enterocolitis Due to a Thrombotic Event in a COVID-19 Patient

We describe the case of a COVID-19 patient who developed an intestinal ischaemia with thrombotic origin, confirmed by anatomo-pathological examination. A middle-aged woman affected with COVID-19 was evaluated in March 2020. Reverse transcriptase-polymerase chain reaction (RT-PCR) to detect SARS-CoV2 was performed. On the 16th day of being hospitalized, she presented with hemodynamic and respiratory impairment. The physical examination revealed abdominal distension. An urgent abdominal CT scan reported signs of pneumatosis in the distal ileum and ascending colon suggestive of ischaemia (Figure 1D), with mural irregularity predominantly in the ileum. An urgent exploratory laparotomy was performed. Ischaemia of the right colon, as well as patched ischaemia of the distal and middle ileum, was found (Figures 2A & 2B). A right hemicolectomy and resection of the distal-middle ileum with a terminal ileostomy were performed. Pathological examination reported: severe ischaemic colitis, with areas of mucosal necrosis and the presence of abundant small-calibre thrombi in the submucosa and medium-caliber vessels of the mesocolon. Re-examination of the CT scan revealed findings consistent with right lower lobe segmental pulmonary embolism, as well as inferior vena cava filling defects consistent with thrombi. COVID-19 is associated with a large and misleading field of complications, including coagulopathy. The combination of viral injury, cytokine release, and damage-associated molecular patterns induce localized microvascular inflammation, which triggers endothelial activation, leading to vasodilation and prothrombotic conditions. We report this case to alert physicians that they should be vigilant for signs of abdominal thromboembolic complications in patients suffering from COVID-19

Airway Challenges in a Preterm Neonate with Undiagnosed Complete Tracheal Rings Posted for Surgery

Preterm neonates are defined as those born before 37 weeks. The anatomical features of preterm neonates vary from that of an adult, such that they have a large tongue, an anterior funnel shaped larynx, angled vocal cords and an omega shaped epiglottis. Their physiological development also differ as they have a greater risk for apnoea of prematurity, airflow obstruction, bronchopulmonary dysplasia, low functional residual capacity and decreased transient oxygen tension. Congenital airway anomalies have a prevalence rate of 0.2-1 in 10,000 live births. Congenital Tracheal Stenosis (CTS) caused by complete tracheal rings is one of the rarest forms of all the airway anomalies that occur, which is characterised by presence of complete ‘O’ shaped cartilaginous rings of trachea devoid of a membranous part. The case discussed in the article is that of a day 26 preterm neonate with increasing abdominal distension and failure to thrive. The neonate was posted for an urgent exploratory laparotomy for abdominal decompression and ileostomy. Patient was kept on Continuous Positive Airway Pressure (CPAP) support for four days immediately after birth; however, intubation was never attempted nor required. With a history of respiratory depression and lack of history of previous intubation, difficult airway cart was kept ready prior to surgery. Supraglottic Airway (SGA) devices were at the core of airway rescue in this case of undiagnosed CTS. This case report shows how and why a preparation for difficult airway in preterm neonates is a necessity. It will provide as a guide if a similar case is encountered by the anaesthetist.

S2775 Use of Intravenous Antitubercular Therapy to Combat Intestinal Malabsorption in Disseminated Abdominal Tuberculosis

INTRODUCTION: Tuberculosis (TB) is a malicious disease with an estimated annual incidence of 10 million cases and about 1.5 million deaths. TB has the potential to spread to any organ system, including the gastrointestinal tract, by direct ingestion or hematogenous spread. Abdominal TB can be managed with typical medical therapy. However, some cases may require escalation of therapy if poor intestinal absorption is suspected. Intravenous (IV) anti-TB therapy is an option, but there are currently no guidelines with sufficient data to aid providers. We report a case of a young immunocompetent female with abdominal TB that required urgent exploratory laparotomy with ileostomy followed by IV anti-tuberculosis therapy. CASE DESCRIPTION/METHODS: An 18-year-old Philipino female with a 2-month history of subacute respiratory complaints, diarrhea, abdominal pain, and 20-pound weight loss was admitted for septic shock. She had lived in the United States for the past 8 years. Examination showed a frail, severely malnourished female. Computed tomography of her abdomen and pelvis showed multiple small hypodense lesions throughout the liver and a larger complex gas containing fluid collection in the pelvis. Exploratory laparotomy for abscess drainage revealed extensive metastatic appearing lesions involving the small bowel and small bowel mesentery. Her perforation was near the ileocecal junction and ileostomy was performed. Chest imaging showed bilateral infiltrates, most severe in the upper lobes. AFB smears of her sputum and surgical biopsies returned positive. Her respiratory status became tenuous after initiation of oral 4-drug therapy and there was concern for malabsorption of antitubercular medication given her malnourished state. IV Rifampin and Levaquin were added and continued during hospitalization. Her nutritional status was optimized over the course of 2 weeks and she was discharged on oral therapy. DISCUSSION: Disseminated TB which has spread to the abdomen can be difficult to diagnose and challenging to treat. Treatment for abdominal TB begins with standard oral therapy. Current guidelines do not address the implementation of IV therapy for individuals who are unable to take or absorb oral medications. This case represents an immunocompetent 18-year-old presenting critically ill from complications of abdominal TB ultimately requiring intravenous therapy. Further research and reports in this field could enrich provider knowledge and allow for appropriate treatment in similar patients.Figure 1.: Computed tomography of abdomen and pelvis demonstrating multiple hypodense lesions scattered throughout the liver representing disseminated tuberculosis.Figure 2.: Computed tomography of abdomen and pelvis demonstrating large 6 × 11 × 9 cm complex gas containing fluid collection in the pelvis representing abscess formation due to perforation at the ileocecal junction.