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(A) (B)

Figure 18.2: (A) X-ray of the abdomen of an 8-year-old boy showing multiple dilated loops of the bowel. The patient presented with distended abdomen, fever,
vomiting, and constipation, with similar episodes reported in the past 6 months. (B) Operative findings of 8-year-old patient showing dilated loops of the bowel with
multiple caseous granulomas involving the whole intestine. The seromuscular coat was quite inflamed and friable. There was a mass at the ileocaecal junction
entrapping the bowel loops, resulting in an acute intestinal obstruction. Adhesionolysis, resection of the mass, and a double-barrel proximal ileostomy were done.
Primary anastomosis was avoided because the bowel looked fiery and friable with active tubercular infection (child had not received antitubercular drugs).

of antitubercular drugs, more radical procedures became popular in ingitis. For these, the recommendation is a 2-month therapy of INH,
an attempt to eradicate the disease locally. These procedures were not rifampin, pyrazinamide, and streptomycin once a day, followed by 7–10
tolerated well earlier by the malnourished patient. Moreover, the lesions months of INH and rifampin once a day.
are often widely spaced and not suitable for resection. The abdomen is The other recommended regimen is 2 months of the same four
closed without drainage even in the presence of ascites or peritonitis. drugs—INH, rifampin, pyrazinamide, and streptomycin—followed
The recommended surgical procedures today are conservative. A by 7–10 months of INH and rifampin twice a week. Capreomycin
period of preoperative drug therapy is controversial; however, 2 weeks or kanamycin may be given instead of streptomycin in areas where
of multidrug therapy is considered minimal to reduce the chances of resistance to streptomycin is common.
spread of active infection during surgery. Strictures that reduce the lumen Tuberculosis and HIV
by half or more and cause proximal hypertrophy or dilation are treated The use of a regimen that uses rifabutin instead of rifampin has been
by strictureplasty. This involves an incision along the antimesenteric advised when treating HIV disease and TB simultaneously.
side, which is closed transversely in two layers. A segment of bowel The treatment regimen for TB initially should include at least three
bearing multiple strictures or a single long tubular stricture may merit drugs and should be continued for at least 9 months. INH, rifampin, and
resection, with a 5-cm safe margin. Tubercular perforations are usually pyrazinamide with or without ethambutol or streptomycin should be
ileal and are associated with distal strictures. Resection and anastomosis administered for the first 2 months. Treatment of disseminated disease
are preferred because simple closure of the perforation is associated or drug-resistant TB may require the addition of a fourth drug.
with a high incidence of leakage and fistula formation and thus The tuberculin skin test, or Mantoux test, which is the standard
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higher mortality. For ileocaecal tuberculosis, limited resection of the marker of Mycobacterium tuberculosis infection in immunocompetent
ileocaecal area, rather than formal right hemicolectomy, involves lesser children, has poor sensitivity when used in HIV-infected children.
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dissection and thus less chance of injury to the duodenum or ureter. For Novel T cell assays may offer higher sensitivity and specificity, but
colonic lesions, resection is advocated. these tests still fail to make the crucial distinction between latent M.
Some obstructing intestinal lesions may also be relieved with tuberculosis infection and active disease, and they are limited by cost
antitubercular drugs alone without surgery. The mean time required for considerations.
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the relief of obstructive symptoms is usually 6 months. Symptom-based diagnostic approaches are less helpful in HIV-
Emergency surgery for intestinal obstruction is best avoided, as infected children, as TB-related symptoms cannot be differentiated
it carries 18–24% mortality. Thus, every patient who presents with from those caused by other HIV-associated conditions. HIV-infected
intestinal obstruction should initially be managed conservatively. children are at increased risk of developing active disease after TB
Tubercular perforations carry high mortality despite surgery. In exposure/infection, which justifies the use of INH preventive therapy
contrast, elective surgery for GI tuberculosis carries only 0.5–2% once active TB has been excluded. HIV-infected children should
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mortality. Despite the advent of newer antitubercular drugs, abdominal also receive appropriate supportive care, including cotrimoxazole
tuberculosis carries a mortality of 4–12%. This is largely due to prophylaxis, and antiretroviral therapy, if indicated. The management
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associated problems of malnutrition, anaemia, hypoalbuminaemia, and of children with TB/HIV infection could thus be vastly improved by
poor wound healing.
better implementation of readily available interventions.
Extrapulmonary Tuberculosis Multidrug-Resistant Tuberculosis
Most cases of extrapulmonary TB, including cervical lymphadenopa- Primary resistance is resistance to anti-TB treatment in an individual
thy, can be treated with the same regimens used to treat pulmonary TB. who has no history of prior treatment. Secondary resistance involves the
Exceptions include bone and joint disease, miliary disease, and men-
emergence of resistance during the course of ineffectual anti-TB therapy.