Primary tubercular caecal perforation: a rare clinical entity
© Jain et al; licensee BioMed Central Ltd. 2010
Received: 11 November 2009
Accepted: 31 March 2010
Published: 31 March 2010
Intestinal tuberculosis is a common problem in endemic areas, causing considerable morbidity and mortality. An isolated primary caecal perforation of tubercular origin is exceptionally uncommon.
We report the case of a 39 year old male who presented with features of perforation peritonitis, which on laparotomy revealed a caecal perforation with a dusky appendix. A standard right hemicolectomy with ileostomy and peritoneal toileting was done. Histopathology revealed multiple transmural caseating granulomas with Langerhans-type giant cells and acid-fast bacilli, consistent with tuberculosis, present only in the caecum.
We report this extremely rare presentation of primary caecal tuberculosis to sensitize the medical fraternity to its rare occurrence, which will be of paramount importance owing to the increasing incidence of tuberculosis all over the world, especially among the developing countries.
Intestinal tuberculosis is an extremely common occurrence in India. Any portion of the gastrointestinal tract may be affected by it, and various pathogenic mechanisms are involved. However, a primary isolated caecal perforation due to tuberculosis is an unusual occurrence, without the concomitant involvement of the ileum or ascending colon. We report this extremely rare presentation, the diagnosis of which was made retrospectively, with a view to sensitize the entire world to this entity.
We then performed a retrospective analysis of our management effort towards the patient, the x ray chest was normal, mantoux test was negative, ESR was 18 mm at 1 hour, and sputum was negative(three samples). The patient was started on anti-tubercular therapy (DOTS Category 1 - incorporating 4 drugs, viz. isoniazide, rifampicin, pyrizinamide and ethambutol for initial 2 months of the intensive phase, and isoniazide and rifampicin for the next 4 months of the continuation phase), with satisfactory results as regards the improvement in the overall patient condition, with 6 kgs weight gain over two months. The patient became comfortable, ambulatory; Ileostomy was functional and viable and main wound healing occurred via secondary intention. The patient was followed up on a regular 2 weekly basis with ileostomy closure performed after 3 months, without incident.
Isolated caecal perforation, that too tubercular in origin, is a rare entity. Caecal perforations are commonly encountered as a part and parcel of various associated disease processes, in accordance with Laplace's law. Laplace's law dictates that the intraluminal pressure needed to stretch the wall of a hollow tube is inversely proportional to its radius. The cecum has the largest diameter of the colon, and as such, requires the least amount of pressure to distend [1–3]. The diameter of the cecum in which perforation is imminent has been estimated to be between 9 cm and 16 cm .
Caecal perforations are usually seen associated with entities such as diverticular disease, inflammatory bowel diseases, ogilville syndrome, closed loop obstructions, pancreatic carcinomas, colorectal cancers, hirschsprung's disease, etc, in the presence of a patent ileo-caecal valve.
In dealing with an emergency colonic obstruction leading to a caecal perforation, few authors favour some form of primary anastomosis as opposed to others favoring creating of an initial stoma after a standard right hemi-colectomy. Many others have recommended subtotal or extended right hemicolectomy for emergency left colon or distal transverse colon obstruction. This is advisable in cecal perforations complicating large bowel obstruction, and in those patients who have a high risk of a metachronous lesion developing. This is also advisable if the proximal colon cannot be evaluated before operation by colonoscopy or barium enema. Though tuberculosis is eminently treatable medically, surgery is still often required for the suspected or confirmed abdominal variety, presenting with complications or as any atypical diagnostic problems .
Ileocecal tuberculosis has always been elusive to physicians, patients often ending in the surgical ward with acute or subacute obstruction, intractable vomiting and diarrhea and often chronic abdominal masses. The precise incidence of gastrointestinal tuberculosis is not known, due to a lack of random samples of populations studied. However, the reported incidence varies from 0.02% to 5.1% in various autopsy series. Furthermore, the exact mechanism responsible for an isolated involvement of the caecum remains unknown. Clinicians require an extremely high index of suspicion to be able to diagnose these cases at an early stage, based on clinical signs and symptoms. The rarity of this case, as encountered by us, lies in the occurrence of an isolated primary caecal tubercular perforation, without any prior evidence, investigative or clinical finding of the same.
A spontaneous primary caecal perforation can be tubercular in origin even in the absence of features suggestive of the same, and thus this unusual entity must be borne in mind for 'what the mind knows is what the eyes see'.
The patient has granted his written and informed consent for publication of this work.
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- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/10/12/prepub