Date of Medical Observation
March 2007

Narration

A 22-year-old male was brought to the emergency room due to abdominal pain.

The pain was on and off for about 1 week and had no associated vomiting nor fever.

Physical examination however, revealed direct tenderness and muscle guarding on the right lower

The patient was then diagnosed with acute appendicitis. He was subsequently brought to the operating room for emergency appendectomy.

I made a Rocky Davis incision, entered the peritoneum and looked for the appendix, as routinely done

When I was able to expose the cecum, I noticed thickening and multiple granulomatous lesions involving the ileocecal area.

At this point in time, I was already thinking of  an ileocecal TB. I called my senior for help  who eventually scrubbed in with me.

I extended my incision into a Fowler Weir. After having enough exposure, I tried to look for the appendix as I traced the taenia coli.

The 3 taenias converged on the posterior aspect of the cecum but there was no appendix . We noticed multiple mesenteric lymphnodes.

We checked the cecum carefully. There was thickening on its wall and multiple whitish lesions were scattered on its entirity.

The cecum however did not appear obstructed after some manipulation. The rest of the bowels were normal looking and not distended.

We decided to get a mesenteric lymphnode biopsy and close the abdomen.

The patient  was advised to take quadruple anti-koch’s medication for 12 months.

Physical, Ethical, Psycho-social

Discovery, Stimulus, Reinforcement

Tuberculosis is not uncommon disease entity in our country. Statistics claim that almost every filipino is exposed to this disease.

Extrapulmonary tuberculosis, particularly in the gastrointestinal tract likewise is considerably  common.

Pre-operative evaluation is very crucial in this case. We should have requested at least a chest radiograph to confirm presence of PTB. Plain abdominal x-ray would yield minute calcifications consistent with mesenteric lymphnodes.

Even though the patient presented with a tender abdomen, His history was not  consistent with the diagnosis of acute appendicitis. Yet, there still an indication to operate.

I should have asked my senior to do a midline incision instead of a rocky davis, since I doubted my diagnosis pre-operatively.

This is to allow more adequate exposure and thorough evaluation of the whole gastrointestinal tract.

Ileocecal TB responds to anti-koch’s medication. A quadruple therapy for 12 months is the standard mode of treatment.

Indications for bowel resection were evidence of obstruction, bleeding or perforation.

END