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CASE REPORT

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Tri Hapsoro Guno*, Barry A Putra*, Telly Kamelia**, Dadang Makmun***
*Faculty of Medicine, Universitas Indonesia/Dr. Cipto Mangunkusumo General National Hospital
Jakarta
**Division of Pulmonology, Department of Internal Medicine, Faculty of Medicine, Universitas
Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta
***Division of Gastroenterology, Department of Internal Medicine, Faculty of Medicine
Universitas Indonesia/Dr. Cipto Mangunkusumo General National Hospital, Jakarta

Corresponding author:
Dadang Makmun. Division of Gastroenterology, Department of Internal Medicine, Dr. Cipto Mangunkusumo
General National Hospital. Jl. Diponegoro No.71 Jakarta Indonesia. Phone: +62-21-3153957;
Facsimile: +62-21-3142454. E-mail: hdmakmun@yahoo.com

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Tuberculosis was still a global health problem. Beside lung, tuberculosis also manifest in other organs, one
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symptoms so that its diagnostic procedure was not rarely inconclusive. We reported a 24 years old woman with
chief complain of worsening abdominal pain in all region, accompanied by nausea, vomiting, bloating, and absent
bowel movement. She also had a fresh bloody stool. She had an active pulmonary tuberculosis on initiation phase
treatment. Physical examination suggest a bowel obstruction sign with distended abdomen and increase bowel
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for malignancy similar to computerized tomography (CT) scan result, but pathlogic result showed an active
colitis without any sign of malignancy. Because of its contradiction, the second colonoscopy was performed and
concluded as intestinal tuberculosis, matched with second pathologic examination. Although polymerase chain
reaction (PCR) tuberculosis (TB) showed a negative result, a further clinical judgement concluded this as an
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drugs and planned to have colonoscopy evaluation. After general condition was good and obstructive ileus sign
was relieved, patient planned for outpatient care.
Keywords: intestinal tuberculosis, colonoscopy, abdominal pain, diagnosis, therapy

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Tuberkulosis (TB) masih merupakan masalah kesehatan global. Selain pada paru, TB juga bermanifestasi
pada organ lain, salah satunya organ abdomen. Tuberkulosis abdomen merupakan penyakit kompleks dengan
WDQGD GDQ JHMDOD QRQVSHVLN VHKLQJJD SURVHGXU GLDJQRVWLNQ\D WLGDN MDUDQJ DNDQ PHQJKDVLONDQ GDWD \DQJ
inkonklusif. Pada laporan kasus ini, dilaporkan seorang perempuan berusia 24 tahun dengan keluhan nyeri
perut yang memberat di semua bagian, disertai mual, muntah, kembung, dan tidak bisa buang air besar.
Pasien juga mengeluarkan tinja bercampur darah segar. Dia menderita TB paru aktif pada pengobatan fase
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Pada temuan prosedur kolonoskopi, terdapat massa yang menghambat lumen usus di daerah ileosekal, diduga
adanya keganasan, mirip dengan hasil computerized tomography (CT) scan, namun hasil pemeriksaan patologi

134 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy


Diagnostic and Therapeutic Approach in Intestinal Tuberculosis

menunjukkan kolitis aktif tanpa tanda-tanda keganasan. Karena kontradiksi ini, maka dilakukan kolonoskopi
kedua dan disimpulkan sebagai tuberkulosis usus, sesuai dengan pemeriksaan patologi yang kedua. Walaupun
reaksi berantai polymerase TB menunjukkan hasil negatif, penilaian klinis lebih lanjut menyimpulkannya
sebagai kasus tuberkulosis usus. Pasien akhirnya diterapi sebagai pasien tuberkulosis usus dengan obat anti
tuberkulosis kategori satu dan direncanakan untuk menjalani evaluasi kolonscopi. Setelah kondisi umum baik
dan gejala ileus obstruktif tidak ada, pasien direncanakan untuk rawat jalan.
Kata kunci: TB usus, kolonoskopi, nyeri perut, diagnosis, terapi

,1752'8&7,21 and vomiting. The pain actually was present since three
months ago but was reliefed without any medical drugs.
Tuberculosis (TB) was a worldwide emergency
She also feels her stomach bloating and full with frequent
with high mortality and morbidity. TB remained one
vomits per day. She could not defecate since three days
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days. No fever reported. Sometimes fresh bloody stool
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was also complained starting about four months before
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admission. From the previous examination patient was
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diagnosed as a new pulmonary tuberculosis case on
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Extrapulmonary TB was a Mycobaterium tuberculosis
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examination from sputum showed a negative result. It
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tuberculosis therapy. There were no history of Diabetes
site of the largest proportion of extrapulmonary TB
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family history of Diabetes mellitus and malignancy.
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Patient was an administration staff in a private company.
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Diagnostic approach for extrapulmonary TB consist
of intravenous drug use and promiscousity.
of clinical examination with other examination such
Physical examination shows a moderately ill
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also bacteriological examination to make sure wether
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pulmonary TB was also present or not.1 Abdominal
Body mass index showed normal weight. Examination
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RI KHDG QHFN DQG WKRUD[ ZDV ZLWKLQ QRUPDO OLPLW
sign and symptoms. Most of its diagnostic procedure
Abdominal examination reveals a bloating abdomen
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This report will present an intestinal tuberculosis case
frequency of bowel sound. On percussion tymphanic
with partial obstruction ileus as its main symptoms. As
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pain and organomegaly. Extremity was warm with
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was an interesting case to learn about diagnostic and
was normal in all limb. Digital rectal examination
therapeutic approach in patietns with intestinal TB
showed a small hemorrhoid mass with normal tonus
problems.
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Laboratory examination showed hemoglobin
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worsening abdominal pain since three days before test was normal. Electrolyte level and ECG result was
admission as a chief complaint. The abdominal pain felt QRUPDO &KHVW ;UD\ VKRZHG DQ LQOWUDWH SURFHVV RQ
DVFUDPSLQDOODEGRPLQDOUHJLRQIROORZHGE\QDXVHD right lung parenchyme with pleural effusion on the right

Volume 17, Number 2, August 2016 135


Tri Hapsoro Guno, Barry A Putra, Telly Kamelia, Dadang Makmun

OXQJ7KUHHZD\DEGRPLQDO;UD\VKRZHGDPXOWLSOH and jejenum as the most location found. Abdominal


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wall with bowel air that found in distal part suspiction XQVSHFLFFOLQLFDOSUHVHQWDWLRQODFNRISRVLWLYHQGLQJ
of partial obstructive ileus. Abdominal ultrasonography IRUDFLGIDVWVWDLQLQJDQGP\FREDFWHULDOFXOWXUH
VKRZHGDQDVFLWHVLQOHIWIRVVDVSOHQRUHQDOOHIWSUDFROLF Intestinal tuberculosis was found mostly in young
and perivesical region. Thoracic ultrasound reveal ZRPHQWZRWKLUGDPRQJWKHPZDV\HDUVROG
bilateral pleural effusion then continued by diagnostic 7KHSRVVLEOHULVNIDFWRUZDVPDOQXWULWLRQKHDOWKFDUH
WKRUDFRFHQWHVLVZLWKUHVXOWRIH[XGDWHSOHXUDOHIIXVLRQ DFFHVVLELOLW\ DQG VSUHDG RI VDOSKLQJLWLV WXEHUFXORVLV
ZLWK$'$ OHYHO RI  8/ VXJJHVWHG WXEHUFXORVLV into abdominal organs. Its has a wide clinical spectrum
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patient has a tuberculosis infection of lung and pleural exacerbated manifestation.
cavity with partial obstructive ileus suspected caused $VWXG\E\.KDQHWDOVKRZHGWKDWDPRQJDEGRPLQDO
by carcinoma of colon with intestinal tuberculosis was WXEHUFXORVLV LQWHVWLQDO WXEHUFXORVLV ZDV WKH KLJKHVW
the differential diagnosis. IUHTXHQF\  IROORZHGE\SHULWRQLWLVWXEHUFXORVLV
Colonoscopy examination initially showed an  LQWUDDEGRPLQDOYLVFHUDOWXEHUFXORVLV  DQG
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There was a bloody frail mass occluding the lumen of intestinal tuberculosis was in ileum and caecum.
60 cm from anus and scope cannot move further for Ileocaecal was the preferred location of tuberculosis
HYDOXDWLRQUHYHDOHGDSRVVLELOLW\RIFRORQFDUFLQRPD mycobacterium infection because of it was a physiologic
A biopsy was done and pathology examination VWDWLVDUHDZKHUHXLGDQGHOHFWURO\WHDEVRUSWLRQZDV
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cript destruction with no sign of malignancy. CT scan WLVVXHWKDWFDQEHIRXQGWKHUH0FHOOLQ3H\HUVSODTXH
ZLWK FRQWUDVW WKHQ SHUIRUPHG VKRZHG D WKLFNHQLQJ will fagositized M. Tuberculosis bacteria and would
DQGFRQWUDVWHQOLJKWPHQWLQFDHFXPLQWUDOXPLQDOZDOO be the entry point for M. Tuberculosis to spread to the
sugest a malignancy that involved terminal ileum with adjacent organs.Our patient has several risk factors for
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obstructive ileus with dilatation of small intestine wall years old) with abnormalities on ileum and ileocaecal
DQG PXOWLSOH DLU XLG OHYHO GDQ IRUP D VWHS ODGGHU region was the part of intestine that having similar to
From analysis that pathological result of biopsy was intestinal tuberculosis in general.
not match to the CT scan result. ,Q KLVWRSDWKRORJLF H[DPLQDWLRQ JUDQXORPDWRXV
As the possibility of intestinal tuberculosis was still WXEHUFOHZLWKFRQXHQWVKDSHLQYDULRXVVL]HZDVWKH
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ileocaecal llumen was found. An intestinal tuberculosis that if affect all intestinal mucosa will result in stricture
was suggested and the second biopsy was done. The formation. A deeper lesion would show a different stages
pathological examination result showed a suggestive RI EURVLV 0RVW RI LW VKRZLQJ D QRQVSHFLF FKURQLF
tuberculosis infection with granuloma tissue consist LQDPDWLRQZLWKRXWDQ\JUDQXORPD0HVHQWHULFO\PSK
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ZDVQHJDWLYH3DWLHQWZDVQDOO\WUHDWHGIRULQWHVWLQDO patients consuming tuberculosis drugs.,QWKLVSDWLHQW
WXEHUFXORVLVZLWKUVWOLQHDQWLWXEHUFXORVLVGUXJVDQG a hyperthrophic lesion of polypoid mass was found in
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evaluation. but its pathological examination showed an tuberculosis
infection with dathia langhans cell found on the tissue.
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Gastrointestinal tuberculosis was the most
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commonly forms of abdominal tuberculosis with
below.
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136 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy


Diagnostic and Therapeutic Approach in Intestinal Tuberculosis

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Ulcerative Chronic diarhea, malabsorption, bowel HQWHUROLWKERZHOREVWUXFWLRQ GLODWDWLRQZLWKPXOWLSOH
perforation, rectal bleeding (Colonic TB)
Hypertrophic Bowel obstruction or ileocecal lump DLUXLGOHYHODVFLWHVSHUIRUDWLRQRULQWXVXVVHSVLRQ 
Stricture/constriction Subacute bowel obstruction (vomiting, O\PSKQRGHFDOFLFDWLRQJUDQXORPDDQGVRPHWLPHV
constipation, colic and abdominal
distention). Bowel dilatation and movement KHSDWRVSOHQRPHJDO\ 7KLV ZDV SDWLHQWV DEGRPLQDO
on inspection to acute instestinal x-ray during hospital admission. This patient also
obstruction.
Anorectal 6WULFWXUHRUVWXODDQL having an active pulmonary tuberculosis with intestinal
Gastroduodenal Ulcus peptikum with or without gastric tuberculosis.
outlet obstruction or perforation
Hepatosplenic Hepatosplenomegaly and granuomaotus
hepatitis on microscopic examination (part
of disseminated TB)
Peritoneum Abdominal distention and ascites
Lymph nodes Lump or mass on central abdomenmay be
felt as dulll pain on abdomen.

A specific symptoms of ileocaecal tuberculosis


is bomborygmi bowel sound and frequent vomiting.
Several findings on physical examination was
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lower quadrant. Ascites and bowel dilatation with A B
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chronic appendicitis.The main symptoms reported in
this patient was abdominal pain with some constitutional
tuberculosis symptoms and bowel obstruction symptoms
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physical examination a distended and dilated abdomen
with more frequent bowel sound. For younger patient )LJXUH  7KRUD[ DQG DEGRPLQDO [UD\ UHVXOW $ ULJKW OXQJ
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with symptoms mention above should be suspected SRVLWLRQ DEGRPLQDO [UD\ VKRZHG D GLVWDO ERZHO DLU ERZHO
for intestinal tuberculosis with sugestive a stricture or GLODWDWLRQZLWKZDOOWKLFNHQLQJPXOWLSOHLDUXLGOHYHODQGQR
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constriction lesion.
Laboratory examination was an important tool in
Barium meal study showed a hypersegmentation
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LQ VPDOO ERZHO ZLWK PXOWLSOH VWULFWXUH VHJPHQWDO
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enema would show spasm and edema in ileocaecal
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region. Double contrast examination may showed
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irregulity of distal ileum wall.Ultrasonography could
diagnosis. 
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Radiologic examination has an important role
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in intestinal tuberculosis diagnosis. Among several
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lesion with symmetrical circumferential thickening in
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caecum and terminal ileum. A further disease would
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intestinal tuberculosis suggestion using combination
node enlargement seen as central mass in ileocaecal
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CT Scan was one of the best modalities to examine
and lesion in hepatic flexure was present. This
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radiologic examination was relatively fast and cost
pulmonary tuberculosis coincidence was found
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abdominal malignancy as differential diagnosis.4

Volume 17, Number 2, August 2016 137


Tri Hapsoro Guno, Barry A Putra, Telly Kamelia, Dadang Makmun

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)LJXUH  &7 VFDQ UHVXOW RI LOHRFDHFDO WXEHUFXORVLV $  inflammatory cell and also eosinophil with mild
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cript distortion suggestive for active chronic colitis
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the secondary colonoscopy was proposed.
Second colonoscopy showed a granular polypoid
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terminal ileum with ileocaecal stenosis then biopsy

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WKH VFRSH FDQQRW JR IXUWKHU DERYH WKH PDVV %  6HFRQG
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Mostly it was found as pink nodule in caecum with UHJLRQLOHRFHFDOYDOYHDQGWHUPLQDOLOHXPZLWKVWHQRVLVLOHR
FHFDOOXPHQ
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ODUJH  PP $ VWULFWXUH FRXOG DOVR EH IRXQG was done for PCR TB and pathologic examination.
2WKHUSRVVLEOHQGLQJVZDVHGHPDWRXVSVHXGRSROLSRLG Secondary pathologic examination showed an
ileocaecal folds and deformity in ileocaecal valve. LQOWUDWHGODPLQDSURSULDIURPFKURQLFLQDPPDWRU\
Differential diagnosis of this findings was colon FHOO 301 FHOO DQG HRVLQRSKLO ZLWK EURWLF WLVVXH
carcinoma. and wider cript distances. There were also found
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also can be donne for pathologic and microbiologic ODQJKDQV FHOO DQG O\PSKRF\WH LQOWUDWLRQ 9LOOLRXV
H[DPLQDWLRQ $FWXDOO\ SDWKRORJLF H[DPLQDWLRQ VKRUWHQLQJFRQFOXGHGDVJUDQXORPDWRXVLOHLWLVFDXVHG
was nor reliable because of its lesion that found in by Mycobacterium tuberculosis infection. PCR TB
submucosal layer while colonoscopy procedure can HVDPLQDWLRQ VKRZHG D QHJDWLYH UHVXOW EXW FOLQLFDO
RQO\WDNHPXFRVDOOD\HU,QDFDVHUHSRUWJUDQXORPD H[DPLQDWLRQHSLGHPLRORJLFDOGDWDFRORQRVFRS\DQG
ZLWKFDVHDWLRQZDVIRXQGLQRIRQHWKLUGSRVLWLYH pathology examination result as mention above made
result. Acid fast staining result was varous. Positive LQWHVWLQDOWXEHUFXORVLVDVWKHQDOGLDJQRVLVRIWKLVFDVH
culture did not always correlate to the presence of Based on WHO guidelines for extrapulmonary TB
granuloma. Combination of both histopathology LQIHFWLRQ SDWLHQW UHFHLYHG VWDQGDUG UVWOLQH GUXJV
and culture from biopsy was expected to increase for TB. Short-course chemotherapy was proven to be
GLDJQRVWLFDELOLW\LQPRUHWKDQRIFDVHV effective as standard therapy in pulmonary tuberculosis
This patient has been undergo two colonscopy FDVH DQG DOVR IRU H[WUDSXOPRQDU\ WXEHUFXORVLV
procedure. First colonoscopy found mass of ascenden because of paucibasilar condition that commonly
colon with fragile and bloody characteristic that found. Tuberculosis standard therapy was divided
occlude lumen about 60 cm from anus. Pathologic LQWR WZR PDLQ SKDVH LQLWLDO SKDVH RU EDFWHULFLGDO
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138 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy


Diagnostic and Therapeutic Approach in Intestinal Tuberculosis

'XULQJLQLWLDWLRQSKDVHPDMRULW\RIEDFLOLQWXEHUFOH regime was planned initially for 6 month therapy with


was eliminated and clinical condition was improved. colonoscopy evaluation at the end of therapy.
Continuation phase was aimed to kill the remaining Intestinal tuberculosis complication was bowel
mycobacterium and to prevent relapse. obstruction caused by lumen narrowing from caecum
Extrapulmonary TB there were not determined K\SHUSODVLD VWULFWXUH DQG DGKHVLRQ /\PSK QRGH
\HW LQ GUXJ GXUDWLRQ WKHUDS\ PD\ YDU\ EHWZHHQ  involvement could lead to bowel loop disorder by
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manifestation. Several RCT reported the effectivity of ZDVDOVRFRPPRQO\IRXQGLQLQWHVWLQDOWXEHUFXORVLVWKH
6-months therapy but clinical judgement could make possible mechanism is bacterial overgrowth in statis
the therapy longer. Intestinal tuberculosis therapy ERZHOELOHDFLGGHFRQMXJDWLRQDQGUHGXFHGLQWHVWLQDO
was similar to other extrapulmonary tuberculosis surface area for nutrition absorption as the present of
with drug regime given for at least 6 month. The ulcer and infection in lymphatic system.
UVW WZR PRQWKV ZDV DQ LQWHQVLYH SKDVH FRQVLVW RI %DVLFDOO\ H[WUDSXOPRQDU\ WXEHUFXORVLV WKHUDS\
ULIDPS\FLQLVRQLD]LGHHWKDPEXWRODQGS\UD]LQDPLGH ZDVVKRZLQJDJRRGUHVXOWH[FHSWIRUPHQLQJLWLVDQG
%DODVXEUDPDQLXP HW DO FRPSDUHG  DQG  PRQWKV spondilitis tuberculosis where only few cases that fully
WKHUDS\ ZLWK VWUHSWRP\FLQ LQ WKH UVW WZR ZHHNV  healed. Khan et al reported that antituberculosis drug
LQSDWLHQWVLQ,QGLDVKRZHGDVXFFHVVIXOUDWHRI treatment for abdominal tuberculosis was responsive
DQGUHVSHFWLYHO\&RQYHQWLRQDODQGVKRUW LQZLWKDPRQJWKHPXQGHUJRIXUWKHUVXUJLFDO
FRXUVHWKHUDS\ZDVVOLJKWO\EHWWHUEXWLQGDLO\FOLQLFDO management because of complication. Other literature
SUDFWLFHDORQJHUWKHUDS\IRUPRQWKVFRXOGEH UHSRUWHGDVXUJLFDODSSURDFKLQFDVHV+LJK
GHFLGHGEDVHGRQFOLQLFDOQGLQJV Corticosteroid mortality among surgical management was predicted
effectivity in tuberculosis infection in animal study GXH WR SUHYLRXV FRPSOLFDWLRQ VXFK DV SHUIRUDWLRQ
caused an increase in virulence of Mycobaterium PDOQXWULWLRQ DQG VHSVLV$EGRPLQDO WXEHUFXORVLV
tuberculosisEXWLIDGPLQLVWHUHGZLWKDQWLWXEHUFXORVLV PRUWDOLW\ZDVDERXWZLWKZRUVHQULVNIDFWRULV
GUXJVWKHHIIHFWZDVQRWVHHQCorticosteroid could ROGHUDJHGHOD\HGWKHUDS\LQLWLDWLRQDQGOLYHUFLUUKRVLV
be used in life-threatening tuberculosis. Steroid use as comorbid.
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adhesion in intestinal tuberculosis. Usual dosage used
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IRUZHHNV,QGLDJQRVWLFSUREOHPVFDVHVHYHUDO 1. Direktorat Jenderal Pengendalian Penyakit dan Penyehatan
/LQJNXQJDQ3HGRPDQ1DVLRQDO3HQJHQGDOLDQ7XEHUNXORVLV
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but should not delay the diagnostic procedure for other  :RUOG +HDOWK 2UJDQL]DWLRQ &RXQWU\ SURILOHV,QGRQHVLD
SRVVLEOHGLVHDVHVXFKDVPDOLJQDQF\O\PSKRPDDQG *OREDO7XEHUFXORVLV5HSRUW>VHULDORQOLQH@>FLWHG
&KURQVGLVHDVH 1RYHPEHU@$YDLODEOHIURP85/KWWSZZZZKR
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Surgical management for intestinal TB was used
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WRWUHDWDQ\FRPSOLFDWLRQVXFKDVERZHOREVWUXFWLRQ Extrapulmonary tuberculosis: epidemiology and risk factors.
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to conservative therapy. Perforation was treated 4. .KDQ 5$ELG 6 -DIUL:$EEDV = +DPHHG .$KPDG =
Diagnostic dilemma of abdominal tuberculosis in non-HIV
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patients: an ongoing challenge for physicians. World J
stricturoplasty. Bypass surgery such as entero- *DVWURHQWHURO
enterostomy and ileotransverse colostomy was not yet  $PLQ=%DKDU$7XEHUNXORVLV3DUX,Q6HWLDWL6$OZL,
UHFRPPHQGHGEHFDXVHRIPDODEVRUSWLRQDQGVWXODWLRQ 6XGR\R$: 6LPDGLEUDWD 0 6HWL\RKDGL % 6\DP$) HGV
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obstruction should be succesfull and not followed by 6. 5DYLJOLRQH 0& 2
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surgical management. .DVSHU'//RQJR'/%UDXQZDOG(+DXVHU6/-DPHVRQ
,QWKLVSDWLHQWDQWLWXEHUFXORVLVGUXJZDVSUHYLRXVO\ -/HGV+DUULVRQ
V3ULQFLSOHVRI,QWHUQDO0HGLFLQHth ed.
prescribed for active pulmonary tuberculosis is 1HZ<RUN0F*UDZ+LOOS
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used for intestinal tuberculosis. Patients has been  &KXJK 6 -DLQ 9$EGRPLQDO WXEHUFXORVLVFXUUHQW FRQFHSWV
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Volume 17, Number 2, August 2016 139


Tri Hapsoro Guno, Barry A Putra, Telly Kamelia, Dadang Makmun

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Tuberculosis: Clinicopathologic Analysis dan Diagnosis by
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SS. Analysis of Colonoscopic Finding in The Differential
Diagnosis Between Intestinal Tuberculosis and Crohn's
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6\DP$)HGV%XNX$MDU,OPX3HQ\DNLW'DODPth ed. Jakarta:
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14. Tuberculosis Coalition for Technical Assistance. International
Standards for Tuberculosis Care (ISTC). The Hague:
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therapy for abdominal tuberculosis: a multicenter randomized
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16. World Health Organization (WHO). Treatment of Tuberculosis
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therapy in tuberculosis management: A critical reappraisal.
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corticosteroid therapy in tuberculosis management: a critical
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140 The Indonesian Journal of Gastroenterology, Hepatology and Digestive Endoscopy