# Intestinal Tuberculosis > Intestinal tuberculosis for FMGE Surgery: ileocaecal predilection, imaging versus Crohn's, ATT first, strictureplasty and resection indications. - Canonical URL: https://prepelephant.com/topics/fmge/surgery/intestinal-tuberculosis-surgery - Exam / course: FMGE · Subject: Surgery - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Intestinal Tuberculosis", PrepElephant, https://prepelephant.com/topics/fmge/surgery/intestinal-tuberculosis-surgery ## Direct answer Abdominal tuberculosis in India concentrates in the ileocaecal region, where Peyer's patches, stasis and abundant lymphoid tissue let Mycobacterium tuberculosis establish caseating granulomas that produce a hypertrophic mass, circumferential strictures or miliary peritoneal seeding. Most patients are managed medically on antitubercular therapy — the National TB Elimination Programme regimen of isoniazid, rifampicin, pyrazinamide and ethambutol for two months followed by isoniazid and rifampicin for four months — with surgery reserved for complications: complete or recurrent intestinal obstruction, free perforation, massive bleeding, and a mass where malignancy cannot be excluded. Strictureplasty or resection-anastomosis is chosen by stricture anatomy, and every resected specimen goes for histology and culture because the diagnosis is often only confirmed after the bowel is opened. ## What you must remember - **Why ileocaecal:** heavy lymphoid aggregation, slower transit and stasis, increased absorption, and proximity to mesenteric nodes — hence the classic "ileocaecal mass with subacute obstruction" presentation. - **Three pathological forms:** ulcerative (longitudinal ulcers with stricturing, transverse ulcers in typhoid — a favourite contrast), hypertrophic (caecal mass mimicking carcinoma, often with a mass in the right iliac fossa), and fibrotic-stricture type producing obstruction; peritoneal TB gives the classic "doughy" abdomen with ascites. - **Clinical picture:** chronic abdominal pain, weight loss, low-grade evening fever, altered bowel habit, a right iliac fossa mass, and anaemia; a positive chest X-ray is present in only a minority, so a normal chest film never excludes it. - **Investigations:** contrast-enhanced CT shows ileocaecal thickening, mesenteric adenopathy with central necrosis and "omental cake"; colonoscopy with biopsy showing caseating granulomas or acid-fast bacilli is the confirmatory test; ascitic fluid exudate with lymphocyte predominance and adenosine deaminase elevation supports peritoneal disease. - **Tuberculosis versus Crohn's (the exam discriminator):** TB favours caseation, constricted contracted caecum, ileocaecal valve deformity, skip lesions less common, and chest involvement; Crohn's favours transmural non-caseating granulomas, skip lesions, perianal disease and fistulas — in doubt, start empirical antitubercular therapy only after biopsy. - **Surgical indications:** complete obstruction not settling on conservative management, free perforation with peritonitis (typically sealed-off perforations present late in India), localised stricture causing recurrent obstruction, massive bleeding, and diagnostic laparotomy/laparoscopy for an undiagnosed mass. - **Surgical choices:** short multiple strictures in a patient with poor reserve suit strictureplasty (Heineke-Mikulicz type); a destroyed ileocaecal segment or intractable mass needs right hemicolectomy with ileotransverse anastomosis; frozen abdomen gets a stoma, not an anastomosis. - **Peri-operative rule:** antitubercular therapy is continued through surgery; anastomotic healing is not compromised when therapy is on board, and every specimen is sent for histopathology, AFB culture and cartridge-based nucleic acid amplification testing where available. ## A worked right iliac fossa case A 28-year-old woman presents with four months of colicky pain, 8 kg weight loss and a tender right iliac fossa mass; she has evening fevers. The pathway: exclude obstruction with a plain film, stage with contrast CT (concentric ileocaecal thickening, necrotic nodes), and attempt colonoscopy — caseating granulomas on biopsy settle it. If biopsies are non-committal, as they often are, the decision is between diagnostic laparoscopy with node biopsy and a short empirical antitubercular trial with planned reassessment; in the Indian setting the mass that shrinks on therapy is the mass that was TB. She improves on ATT but returns at three months with recurrent colicky pain, distension and a stricture on follow-through: after optimising nutrition and confirming the stricture with imaging, a limited resection with primary anastomosis is performed, because a single short terminal ileal stricture is better resected than strictureplastied when a mass coexists. Had her first presentation been a sudden rigid abdomen with free air, the operation happens first and the diagnosis comes later from the specimen. ## How the exam frames it NBE stems bank on three contrasts. First, typhoid versus tubercular ulcer: the typhoid ulcer is longitudinal along the terminal ileal Peyer's patches and perforates in the third week, while the tubercular ulcer is transverse and strictures rather than perforates freely. Second, the right iliac fossa mass differential in a young Indian adult — tuberculosis, Crohn's, lymphoma, actinomycosis, and appendicular mass — with the exam expecting CT and biopsy, not a blind laparotomy. Third, the timing question: when to operate in obstruction — the expected answer is conservative drip-and-suck management with ATT first for subacute obstruction, reserving surgery for failure, because operating through matted inflamed bowel raises enterocutaneous fistula risk. ## Frequently asked questions ### Which part of the intestine is most commonly involved in abdominal tuberculosis? The ileocaecal region, because of its abundant lymphoid tissue, relative stasis and absorption, producing a hypertrophic caecal mass or terminal ileal strictures. ### What is the first-line treatment of intestinal tuberculosis? Antitubercular therapy per national programme regimens — two months of isoniazid, rifampicin, pyrazinamide and ethambutol, then four months of isoniazid and rifampicin — with surgery reserved for complications. ### When is surgery indicated in intestinal tuberculosis? Complete or recurrent obstruction despite medical therapy, free perforation with peritonitis, massive haemorrhage, and an undiagnosed ileocaecal mass where malignancy cannot be excluded. ### How is a tubercular stricture managed surgically? Short strictures may be treated by strictureplasty, while a destroyed ileocaecal segment is managed by right hemicolectomy with ileotransverse anastomosis, continuing ATT through the peri-operative period. ### How does intestinal tuberculosis differ from Crohn's disease histologically? Tuberculosis shows caseating granulomas with possible acid-fast bacilli, whereas Crohn's shows non-caseating transmural granulomas with skip lesions and fistulising tendency.