Multiple tuberculous perforations of ileum.

Tuberculous ulceration of the intestine has become uncommon with the decrease in the incidence of pulmonary tuberculosis. Free perforation of a tuberculous ulcer into the peritoneal cavity is even less common. This case report deals with an example of multiple perforations of tuberculous ulcers of the ileum associated with florid pulmonary tuberculosis. CASE HISTORY The patient, a 57-year-old English labourer known to be an alcoholic, gave a history of intermittent cough for two years, worse for the past six weeks. During the latter period he had had difficulty in swallowing, and had vomited after most meals. He lived alone and had survived on tea and biscuits during this time. On examination he was found to be grossly dehydrated, with signs of bilateral bronchopneumonia. A chest radiograph and the finding of large numbers of acid-fast bacilli in the sputum confirmed the diagnosis of pulmonary tuberculosis. Therapy with Pasinah 320 and strepto-mycin was started on the day of admission. Thirty-six hours later the patient developed lower abdominal pain which gradually increased. He became tender over the whole of the abdomen, maximal in the right hypochondrium and right iliac fossa. The patient was in a state of peripheral circulatory failure: blood pressure was 75/55 mm Hg. A provisional diagnosis of perforation of a peptic ulcer or gastric carcinoma was made. Supine and erect radiographs of the abdomen were taken and free gas under the diaphragm was seen, confirming the diagnosis of a perforated viscus. After an initial period of resuscitation a laparotomy was performed. This revealed a large volume of free intestinal fluid in the peritoneal cavity due to four longitudinal perforations along the antimesenteric border of the terminal ileum, each measuring approximately 10 x 5 mm. A diagnosis of perforation of tuberculous ulcers was made, and a biopsy later confirmed this. The liver was noted to be cirrhotic. In view of the patient's poor condition, simple suture of each ulcer in two layers in a transverse direction was performed. The peritoneal cavity was drained. The patient's immediate postoperative condition was poor, but with antituberculous drugs, physiotherapy, and high calorie intravenous therapy (including alcohol), gradual improvement was seen. Tracheostomy was performed on the fifth postoperative day in view of difficulty in coughing up the increasingly viscid sputum. 381 over the next few days, he became jaundiced and died suddenly on the tenth postoperative day. Necropsy (Dr W. S. A. Allen) confirmed gross con-fluent …