Dr.Sameera Fathima

1. Presented by: Under the guidance of
SAMEERA FATHIMA MR.MOHD.FAREEDULLAH
Pharm D (PB)-1st year Associate Professor &HOD
170721883006 Department Of Pharmacy Practice
* CASE PRESENTATION ON
INTESTINAL TUBERCULOSIS

2. *INTRODUCTION
Tuberculosis is a life threatening disease which can virtually affect any oragan system.
Intestinal tuberculosis (TB) is a most common type of extra pulmonary
tuberculosis,comprising of tuberculosis of gastrointestinal tract, peritoneum ,omentum ,
mysentery and it’s lymphnodes and other abdominal organs such as liver,spleen and pancreas.
The ileocecal region is the most commonly affected site; the most commonly affected parts of
the intestine are the terminal ileum and cecum.
ETIOLOGY: Infection of GIT TB by mycobacteria can occur in five ways:
1. Sputum ingestion by a patient with active pulmonary disease from Mycobacterium
tuberculosis
2. Hematogenous spread from a distant focus
3. Lymphatic spread through infected nodes
4. Direct extension from a contiguous site
5. Ingestion of milk products infected with Mycobacterium bovis – particularly seen with
consumption of raw milk

3. *
Intestinal tuberculosis
ULCERATIVE TYPE HYPERPLASTIC TYPE
Formation of mucosal ulcers Extensive inflammatory changes
Bleeding Obstruction
Perforation Mass
Fistulation
Stricture

4. *
Ingestion of Infected
milk or sputum
Entry of bacilli into
the mucosa of the GI
tract
Granulomas in the
submucosa
Caseation necrosis
Spread into deeper
layers of intestine
Ulceration of the
overlying mucosas
Spread into
adjacent lymph
nodes&
peritoneum

6. 1. Blood examination may show varying degree of anemia, leucopenia and
raised ESR
2. Serum biochemistry: Serum albumin level may be low.
3. PPD skin testing/mantoux test: (This gives supportive evidence to the
diagnosis of abdominal tuberculosis in 55 to 70% patients if positive,
however, a negative tuberculin test may also be observed in one-third of
patients).
4. Imaging Techniques:
1.Plain X-ray abdomen and chest: Plain X-ray of abdomen (erect and supine
films) is useful simple investigation.
2. Barium Studies: Barium contrast studies are useful for the diagnosis of
intestinal tuberculosis. It has been documented that barium studies are useful
in 75% patients with suspected intestinal tuberculosis.

7. 3.Computed Tomography (CT) : Abdominal CT scan is
better than ultrasound for detecting high density ascites,
lymphadenopathy with caseation.
4. MRI (Magnetic Resonance Imaging)
5. Endoscopy: Endoscopy visualizes the tubercular lesion
directly, hence, is a useful tool in the diagnosis of colonic and
gastro-duodenal tuberculosis; and helps in the confirmation
of the diagnosis by obtaining histopathological evidence of
tuberculosis.
6.Laparoscopy: Laparoscopy examination is an effective
method of diagnosing tuberculosis.
7.Colonoscopy

8. *
(e.g. isoniazid, rifampicin, ethambutol and pyrazinamide)
*

9. •Patient’s name : XYZ
•Age : 34
•Unit : Gastroeterology
•Gender : Male
•Past history : Nil
•DOA : 06/12/21
•DOD : 13/12/21
•Chief complaints : Pain in
abdomen :20days a/w nausea,
vomiting,increased no.of stools.
•Family History : Nil
•Provisional Diagnosis : Intestinal
TB and crohn’s disease.
•Final Diagnosis :Intestinal TB
PATIENT’S DEMOGRAPHIC PROFILE

10. LAB INVESTIGATION REPORTS
Hematology Day1 Normal values
Hgb 11.7 13.0-17.0 g/dl
RBC 4.86 3.70-6.50 106/mm3
WBC 5.42 4.00-11.00103/mm3
Plt 3.58 1.5-4.5lakhs/cumm
Neuro 61 45-75103/mm3
Lympho 31 18-45103/mm3
• HIV 1+2, HbsAG, MTB DNA, was found to be non – reactive.

11. RFT :
RFT DAY 1 NORMAL VALUES
Sr.creatinine 0.8 0.6-1.5mg/dl
Sr.urea 10 10-45mg/dl
Sr.albumin 2.9 3.5-5.0g/dl
LFT :
LFT DAY 1 NORMAL VALUES
Total protien 5.9 6.0-7.5 g/dl
ELECTROLYTES :
ELECTROLYTES DAY 1 NORMAL VALUES
Sr.sodium 140 136-145mmol/l
Sr.potassium 5.1 3.5-5.0mmol/l
Sr.chlorine 98 95-105 mmol/l

12. • CT SCAN –COMPUTED TOMOGRAPHY OF ABDOMEN:
 Ileocolocolic intussusception in right ILIAC region with telescoping of caecum,
terminal ileum, appendix, and ascending colon into the transverse colon.
 Mild Hepatomegaly.
• COLONOSCOPY REPORT :
• Rectal examination :
normal anal tone
no fissure or fistula
no blood staining
• Impression : Colonic ulcers with narrowing in transverse colon.
• USG-KNEE:
 Well defined anechoic collection noted around knee extending supra patellar region, medial
and lateral side of knee joint.
 Infective supra patellar brusitis
• ESR:ERYTHROCYTE SEDIMENTATION RATE
1ST HOUR 2ND HOUR NORMAL VALUES
85mm 120mm 0-13mm

13. MEDICATIONS GENERIC NAME DOSE FREQ DAY
1
DAY2 DAY3 DAY4 DAY5 DAY6 DAY 7
Inj.Cifran Ciproflaxacin 200m
g
BD     × × ×
Inj.Metrogyl Metronidazole 50mg TID     × × ×
Inj.Pan Pantaprazole 40mg OD     × × ×
Inj.Meaxon plus Folic acid
+methylcobalamine
+niacinamide
100m
g
OD     × × ×
Inj.Tramadol Tramadol 5omg SOS  × ×  × × ×
Tab.Dolonex Piroxicam 20mg SOS × ×  × × × ×
Inj.Zofer Ondansetrone 4mg TID × × ×  × × ×
Tab.AKT4 Ethambutal+Isoniazide
+Pyrazinamide+Rifampi
cin
1tab OD × × × ×   
Tab.Benadon Pyridoxine 40mg OD × × × ×   
Tab.Mesacol-OD Mesalamine 2tab OD × × × ×   
Tab.Drotin-DS Drotaverine 1tab SOS × × × ×   
TREATMENT

14. DAY DAY2 DAY3 DAY4 DAY5 DAY6 DAY7
BLOOD PRESSURE 110/70 120/80 110/70 110/70 120/80 110/70
PULSE RATE 102 100 92 84 98 84
ON EXAMINATION Abdominal
pain
yesterday
night.
Rt.knee pain
&swelling,abd
pain decresed
Rt.knee
swelling,vomit
ing 1 episode
No fresh
complaint
s
Colonic ulcers with
narrowing
Stooped all
previous
medication
Burning
sensation in
abdomen
MEDICATION Rx: CST TAB.Dolonex-
20mg SOS
INJ.ZOFER-
4mg TID
INJ.TRAMA
DOL in 100ml
NS
INJ.PCM
1gm IV TID
CST
TAB.AKT4 1 tab OD
TAB.BENADON
40mg OD
TAB.MESOCOL OD
2Tabs
TAB.MEAXON PLUS
OD
TAB.DROTIN-DS
SOS
INJ.PAN 40MG OD
CST
DAY NOTES

16.  SUBJECTIVE DATA:
A 35 years old male patient was admitted in the gastroenterology department with the chief
complaints of pain in abdomen:20 days associated with nausea, vomiting, increased no. of loose
stools.
Patient have no history of Tuberculosis.
 OBJECTIVE DATA:
1. HEMOGLOBIN : 11.7 g/dl (13.5-17.5)
2. ESR (ERYTHROCYTE SEDIMENTION RATE)
1st hour – 85mm ( 0-13mm )
2nd hour – 120mm (0-13mm)
3. SERUM ALBUMIN - 2.9g/dl (3.5-5.0)
4. TOTAL PROTIEN – 5.9g/dl (6.0-7.5)
5. CT SCAN(COMPUTED TOMOGRAPHY) OF ABDOMEN :
• Ileocolic Intussusception in right ILIAC region with telescoping of caecum
• Mild Hepatomegaly
6. COLONOSCOPY REPORT:
• Colonic ulcers with narrowing in transverse colon.
7. ULTRASONOGRAPHY OF KNEE:
• well defined anechoic collection noted around right knee extending supra patellar region,
medial&lateral side of knee point.

18. PROBLEM 1: to reduce ulcers prophylaxis and acid reflux
MEDICATION: Inj.pan 40mg OD (Pantaprazole)
PROBLEM 2: to treat anaemia and deficiency of folic acid
MEDICATION : Inj.Meaxon plus 100mg OD (folicacid+methylcobalamine+niacinamide)
PROBLEM 3: to reduce pain and inflammation
MEDICATION: Inj.ultram 50mg SOS(tramadol)
Tab-Dolonex 20mg SOS (piroxicam)
PROBLEM 4 :to reduce vomiting
MEDICATION : Inj.zofer 4mg IV TID (Ondanseteron)
PROBLEM 5 :to treat tuberculosis infection
MEDICATIONS:Tab.AKT4–OD
(Combination of ethambutol,isoniazide,pyrazinamide and rifampicin)

20. MEDICATIONS GENERIC NAME DOSE FREQ DAY
1
DAY2 DAY3 DAY4 DAY5 DAY6 DAY 7
Inj.Cifran Ciproflaxacin 200m
g
BD     × × ×
Inj.Metrogyl Metronidazole 50mg TID     × × ×
Inj.Pan Pantaprazole 40mg OD     × × ×
Inj.Meaxon plus Folic acid
+methylcobalamine
+niacinamide
100m
g
OD     × × ×
Inj.Tramadol Tramadol 5omg SOS  × ×  × × ×
Tab.Dolonex Piroxicam 20mg SOS × ×  × × × ×
Inj.Zofer Ondansetrone 4mg TID × × ×  × × ×
Tab.AKT4 Ethambutal+Isoniazide
+Pyrazinamide+Rifampi
cin
1tab OD × × × ×   
Tab.Benadon Pyridoxine 40mg OD × × × ×   
Tab.Mesacol-OD Mesalamine 2tab OD × × × ×   
Tab.Drotin-DS Drotaverine 1tab SOS × × × ×   
TREATMENT

21. DAY DAY2 DAY3 DAY4 DAY5 DAY6 DAY7
BLOOD PRESSURE 110/70 120/80 110/70 110/70 120/80 110/70
PULSE RATE 102 100 92 84 98 84
ON EXAMINATION Abdominal
pain
yesterday
night.
Rt.knee pain
&swelling,abd
pain decresed
Rt.knee
swelling,vomit
ing 1 episode
No fresh
complaint
s
Colonic ulcers with
narrowing
Stooped all
previous
medication
Burning
sensation in
abdomen
MEDICATION Rx: CST TAB.Dolonex-
20mg SOS
INJ.ZOFER-
4mg TID
INJ.TRAMA
DOL in 100ml
NS
INJ.PCM
1gm IV TID
CST
TAB.AKT4 1 tab OD
TAB.BENADON
40mg OD
TAB.MESOCOL OD
2Tabs
TAB.MEAXON PLUS
OD
TAB.DROTIN-DS
SOS
INJ.PAN 40MG OD
CST

22. MEDICATIONS GENERIC
NAME
DOSE FREQ DURATION
Tab.AKT4 Ethambutal+Ison
iazide+Pyrazina
mide+Rifampicin
1tab OD 1month
Tab.Benadon Pyridoxine 40mg OD 1month
Tab.Mesacol-OD Mesalamine 2tab OD 1month
Tab.Razo Rabeprazole 20mg OD 15 days
Tab.Drotin-DS Drotaverine 1tab BD 1 week
Tab.Meaxon plus Folic acid
+methylcobalami
ne
+niacinamide
1tab OD 1month

23.  PHARMACIST INTERVENTIONS:
No drug-drug interactions were found.
 PATIENT COUNSELLING
 REGARDING DISEASE:
Gastrointestinal tuberculosis is defined as infection of the peritoneum, hollow or solid abdominal
organs, and abdominal lymphatics with Mycobacterium tuberculosis organisms. The most common
symptoms are pain in the abdomen, loss of weight, anorexia, recurrent diarrhea, low-grade fever,
cough, and distension of the abdomen.
 REGARDING MEDICATIONS :The patient was advised to take medicine on time.Do not
crush or chew the tablets and do not miss any dose.
• Rabeprazole to be taken 30 min before meals.
• Tab AKT4 – Take tablet atleast 1 hour before taking antacids.
 Avoid tyramine rich food (cheese,redwine ) and histamine containing food (tropical fish) while
taking this medication.
• Tab Drotin –take with/without food,but it is better to take it at a fixed time.
• Tab Meaxon plus – shouldn’t drink alcohol while taking this drug.

24.  REGARDING LIFE STYLE MODIFICATIONS :
• Eat healthy diet.
• Avoid taking too much processed or junk food.
• Complete the full course of treatment.
• Take medications on time, do not miss any dose.
• Avoid or reduce stress and make time to rest.
• Never skip your routine checkups.
• Eat more fruits and vegetables
• Eat healthy fats and proteins
• Drink plenty of water
• Avoid saturated food which can be damaging to the liver

25. CLINICAL PEARL
• Intestinal tuberculosis (TB) is very common in the developing world but it is rarely seen in
western countries.
• Its reappearance has increased in association with the acquired immunodeficiency syndrome
(AIDS).The occurrence of abdominal TB is dependent of pulmonary disease in most patients.
• In patients with abdominal TB, the highest incidence of disease was noted in the
gastrointestinal tract and in the peritoneum, followed by the mesenteric lymph nodes. Within
the gastrointestinal tract, the ileocecal area is the most common site of involvement.
• A third of patients will report a family history of tuberculosis.
• TB can occur in persons of any age, although it is uncommon in children and in older persons
whose immune systems are weak.
• The mode of spread is either through hematogenous spread from active pulmonary or miliary
tuberculosis, swallowing of infected sputum or ingestion of contaminated milk or food, and
contiguous spread from adjacent organs.
• Most cases of abdominal tuberculosis involve the intestine with the commonest site being the
ileocecal region due to abundance of lymphoid tissue (Payer’s patches).
• Ileocecal junction is involved in 80-90% of the patients.
• Proximal small intestinal disease is seen more commonly with Mycobacterium avium-
intracellular (MAI) complex infection, predominantly one involving the jejunum.

26. CASE STUDY
A 38-year-old female underwent exploratory laparotomy after presenting with two-months history of
abdominal distension and intermittent pain, along with constipation, anorexia, and significant weight
loss. She provided no history of close contact with TB patient. She underwent an adhesiolysis of
intestinal and omental, also peritoneal biopsy which was confirmed a chronic granulomatous
inflammation caused by TB without any signs of malignancy. The physical examination on
subsequent presentation showed no adventitious breath sounds, an abdominal scar from the
laparotomy, without organomegaly. Her chest x-ray was showed no abnormalities, while abdominal
ultrasonography revealed adnexal cystic mass, and minimal ascites. However, her whole abdominal
CT-scan prior surgery just confirmed the signs of malignant ascites. She was slight anemia with a
haemoglobin of 9.8 g%, and her serum level of Ca-125 was slightly increase 74.48 IU/mL. She was
then diagnosed with ITB and received 6 months of ATD.

27. N