|LETTER TO THE EDITOR
|Year : 2016 | Volume
| Issue : 1 | Page : 82-83
Unusual case of an anomalous congenital band causing acute small bowel obstruction in a case of abdominal tuberculosis
Bhagya Sannananja1, Hardik Uresh Shah1, Ganesh Avhad1, Aditi Agrawal2
1 Department of Radiology, Shri Harilal Bhagwati Hospital, Borivali, Mumbai, Maharashtra, India
2 Department of Surgery, Shri Harilal Bhagwati Hospital, Borivali, Mumbai, Maharashtra, India
|Date of Web Publication||4-Mar-2016|
Department of Radiology, Shri Harilal Bhagwati Hospital, Borivali, Mumbai - 400 103, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Sannananja B, Shah HU, Avhad G, Agrawal A. Unusual case of an anomalous congenital band causing acute small bowel obstruction in a case of abdominal tuberculosis. J Mahatma Gandhi Inst Med Sci 2016;21:82-3
|How to cite this URL:|
Sannananja B, Shah HU, Avhad G, Agrawal A. Unusual case of an anomalous congenital band causing acute small bowel obstruction in a case of abdominal tuberculosis. J Mahatma Gandhi Inst Med Sci [serial online] 2016 [cited 2020 Jul 14];21:82-3. Available from: http://www.jmgims.co.in/text.asp?2016/21/1/82/178130
Anomalous congenital bands are a rare cause of small bowel obstruction in adults.  Usually, it is the postoperative adhesions followed by tumors, inflammation, and hernia that cause obstruction.  In tropical countries, where tuberculosis (TB) is endemic, abdominal TB-causing adhesions and stricture is one of the most common causes of intestinal obstruction. 
A 23-year-old lady presented to the emergency room with a history of severe abdominal pain and 5-6 episodes of bilious vomiting since a day. The patient was on anti-TB therapy and had completed 5 months of treatment for pulmonary TB. There was no history of any abdominal surgery in the past.
On examination, the patient was afebrile with a pulse rate of 92/min and blood pressure 100/64 mmHg. Abdominal examination showed generalized abdominal tenderness with mild guarding. Blood investigation revealed hemoglobin level to be 10.5 g%, total leukocytes count 7400/ml, and platelet count of 240,000/ml. Serum creatinine was 0.9 mg% and serum electrolytes were within normal range. The erect abdominal radiograph showed dilated small bowel loops in the upper abdomen. On ultrasound examination, proximal small bowel loops were significantly dilated measuring 3.5 cm in maximum diameter. Multiple enlarged, hypoechoic lymph nodes were seen in the periportal region. In the setting of pulmonary TB and multiple enlarged, necrotic lymph nodes a diagnosis of small bowel obstruction probably due to stricture/adhesions secondary to abdominal TB was made. Contrast enhanced computed tomography (CT) scan showed dilated jejunal and proximal ileal loops. The small bowel loops showed an abrupt change in caliber with smooth beaking of dilated proximal ileal loop [Figure 1]. The bowel loops were not thickened at the site of change in caliber with distal bowel loops being collapsed. There were no ascites. Multiple enlarged rim enhancing lymph nodes were seen in the periportal region [Figure 2].
|Figure 1: Axial postcontrast computed tomography images. The transition in caliber of the proximalileal loop is clearly seen in this image (arrow) with collapsed proximal ileal loop. Multiple dilated small bowel loops with|
air fluid level inside are seen proximal to site of mechanical obstruction
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|Figure 2: Axial postcontrast computed tomography images showing rim enhancing centrally necrotic periportal group of lymph nodes (arrows). In addition, note grossly distended stomach and D2 portion|
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As the patient was severely symptomatic for mechanical small bowel obstruction, we went ahead with emergency laparotomy. On laparotomy, a vascular band was seen 30 cm proximal to the ileocolic junction in the antimesenteric border. The proximal ileal loops were herniated across the band, and the small bowel loops were dilated proximal to this band. The bowel loops were nonnecrotic. The band was divided after ligation. The periportal lymph nodes were sampled which showed caseating granulomas on histopathology. Postoperative period was uneventful, and the patient recovered well and was discharged.
Anomalous mesenteric bands are said to be due to abnormal adhesion of peritoneal folds during embryogenesis. , Small bowel obstruction secondary to anomalous bands is a rare entity contributing only about 3% of the total cases, and it is still much more uncommon in adults.  Most of the cases of intestinal obstruction in adults are due to postsurgical adhesions, obstructed hernia, and inflammation. , In tropical countries like India where TB is endemic, inflammatory causes particularly abdominal TB contributes significantly to the total number of cases of small bowel obstruction and usually is secondary to adhesions and stricture.
In our case, the patient was on treatment for pulmonary TB. Ultrasound and CT examination also showed necrotic periportal lymphadenopathy; with such a clinical scenario, first differential would have been small bowel obstruction due to TB secondary to adhesion/stricture. As the patient was severely symptomatic, we went ahead with laparotomy to find anomalous mesenteric bands as the cause for symptoms. Anomalous mesenteric bands presenting with obstruction are rare entity in adults. These bands being responsible for intestinal obstruction in the case of abdominal TB have not been reported previously as per the author's knowledge.
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[Figure 1], [Figure 2]