What are the symptoms and treatment of ileocecal tuberculosis (TB)?

Symptoms and Treatment of Ileocecal Tuberculosis

Ileocecal tuberculosis should be treated with a standard 6-month regimen consisting of isoniazid, rifampicin, pyrazinamide, and ethambutol for 2 months, followed by isoniazid and rifampicin for 4 months, with potential extension to 9 months depending on clinical response. 1

Clinical Presentation and Symptoms

The ileocecal region is the most common site of abdominal tuberculosis involvement. Patients typically present with:

• Abdominal pain (particularly in right lower quadrant)
• Weight loss
• Fever and night sweats
• Anorexia
• Altered bowel habits (diarrhea or constipation)
• Vomiting
• Intestinal obstruction symptoms
• Abdominal mass
• Hematochezia (rare but reported) 2
• Ascites (if peritoneal involvement)

Most patients with ileocecal TB experience significant weight loss, with studies showing that successful treatment results in weight gain of 5-7 kg within 6 months of starting therapy 3.

Diagnostic Approach

Diagnosis of ileocecal TB can be challenging and should include:

1. Clinical evaluation - Assessment of symptoms, risk factors, and TB exposure history
2. Laboratory tests:
   • Complete blood count (may show anemia)
   • Elevated ESR
   • Tuberculin skin test (PPD)
3. Imaging studies:
   • Chest X-ray (to identify concurrent pulmonary TB)
   • Abdominal ultrasound or CT scan (may show bowel wall thickening, mesenteric lymphadenopathy)
4. Endoscopic evaluation:
   • Colonoscopy with biopsy of suspicious lesions
   • Characteristic findings include ulcers, nodules, and luminal narrowing

Histopathological confirmation is ideal but not always possible. In such cases, clinical diagnostic criteria can be applied with excellent response rates 4.

Treatment Regimen

First-line Treatment

The recommended treatment regimen consists of:

1. Initial phase (2 months):

   • Isoniazid (300 mg daily for adults)
   • Rifampicin (based on weight)
   • Pyrazinamide
   • Ethambutol

2. Continuation phase (4 months):

   • Isoniazid
   • Rifampicin

This regimen can be administered daily or thrice weekly under directly observed therapy (DOT) with similar efficacy 3.

Special Considerations

• Pregnancy: Pyrazinamide is not recommended due to inadequate teratogenicity data. Initial treatment should consist of isoniazid and rifampicin, with ethambutol added if primary isoniazid resistance is likely 5.

• Renal impairment: Dose adjustments may be needed for ethambutol and certain other drugs 6.

• Liver disease: Regular monitoring of liver function is required for patients with pre-existing liver disease. If AST/ALT rises to five times normal or bilirubin rises, rifampicin, isoniazid, and pyrazinamide should be stopped 6.

Monitoring Treatment Response

Treatment response should be monitored by:

• Clinical improvement (resolution of symptoms)
• Weight gain (typically 5-7 kg within 6 months)
• Endoscopic healing (complete healing of ulcerations typically occurs within 6 months) 3

Follow-up colonoscopy at 2 and 6 months is recommended to assess mucosal healing 3.

Complications and Management

Complications of ileocecal TB may include:

• Intestinal obstruction
• Perforation
• Fistula formation
• Massive bleeding (rare)

Surgical intervention may be required for complications such as obstruction, perforation, or bleeding that doesn't respond to medical management 1. For massive bleeding, endoscopic coagulation therapy has been reported as effective in some cases 2.

Treatment Duration and Follow-up

While the standard duration is 6 months, treatment may be extended to 9 months in cases with:

• Slow clinical response
• Extensive disease
• Immunocompromised patients

Regular follow-up is essential to monitor for treatment response, adverse effects, and potential complications.