Successful Multidisciplinary Treatment of Small Bowel Obstruction With an Ileal Stricture Resulting in Bowel Perforation in the Setting of Multidrug-Resistant Gastrointestinal Tuberculosis: A Case Report

TL;DR

A man with multidrug-resistant tuberculosis developed a bowel obstruction and perforation, which was successfully treated with a combination of conservative and surgical approaches.

Contribution

This case report highlights a successful multidisciplinary treatment approach for a rare complication of multidrug-resistant gastrointestinal tuberculosis.

Findings

Conservative management with bowel rest and TPN improved the patient's condition initially.

A bowel perforation required emergency surgery followed by successful recovery and resumption of TB treatment.

The patient was discharged after 23 days with a multidisciplinary follow-up plan.

Abstract

We present the case of a male in his 40s who recently emigrated from Russia and was actively undergoing treatment for multidrug-resistant (MDR) pulmonary tuberculosis (TB) with the BPaL-M (bedaquiline, pretomanid, linezolid, moxifloxacin, and pyridoxine) regimen who presented to the emergency department (ED) with abdominal pain, vomiting, and no bowel movements. A computed tomography (CT) scan of the abdomen and pelvis revealed a small bowel obstruction (SBO) from ileal stricture consistent with gastrointestinal (GI) TB. He did not require an emergent surgical intervention and was managed conservatively via bowel rest and initiation of total parenteral nutrition (TPN). An oral BPaL-M regimen was held and an intravenous (IV) regimen consisting of linezolid, moxifloxacin, meropenem, and ampicillin/sulbactam was started per infectious disease (ID) recommendations. He improved clinically over the next several days and was started on a diet that was initially well tolerated. Shortly after transitioning to a regular diet, he developed severe abdominal pain. A CT scan of the abdomen and pelvis revealed pneumoperitoneum and he was taken emergently to the operating room (OR) for exploratory laparotomy (ex-lap). A perforation was found in the terminal ileum and he underwent a right hemicolectomy. He returned to the OR two days later for ileocolic anastomosis and fascial closure. A diet was initiated once again which was tolerated well. He was then transitioned back to his oral BPaL-M regimen which was also tolerated well. He was discharged home on an oral diet after a 23-day hospital course with follow-up appointments with acute care surgery (ACS) and ID.

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