Intestinal tuberculosis (ITB), a form of extrapulmonary tuberculosis, continues to be a significant health burden in developing countries like India, where tuberculosis remains endemic [1]. It primarily affects the ileocecal region due to factors such as stasis, abundant lymphoid tissue, and fluid absorption in this area [2]. Despite advances in diagnostics, differentiating ITB from other conditions such as Crohn’s disease, intestinal malignancies, and enteric fever remains clinically challenging because of overlapping symptoms and imaging findings [3,4].

Patients with ITB often present with nonspecific symptoms such as abdominal pain, altered bowel habits, weight loss, fever, and sometimes acute abdomen, necessitating surgical intervention [5]. The diagnosis of ITB remains elusive in many cases until histopathological confirmation is obtained postoperatively. Histopathology typically reveals caseating granulomas, lymphocytic infiltration, and occasionally acid-fast bacilli (AFB) on Ziehl–Neelsen staining [6].

While medical management with anti-tubercular therapy is the cornerstone of treatment, surgical intervention becomes essential in cases of complications like obstruction, perforation, or diagnostic uncertainty [7]. Understanding the surgical outcomes and histopathological patterns in such cases can aid in timely intervention and appropriate management strategies.

This study aims to evaluate the surgical presentations, intraoperative findings, and histopathological profiles of patients undergoing surgery for suspected intestinal tuberculosis, thereby contributing to a better understanding of this complex and often underdiagnosed entity.

This prospective observational study was conducted at a tertiary care center over a period of 24 months. A total of 53 patients presenting with clinical suspicion of ITB and undergoing surgical intervention were enrolled consecutively after obtaining informed consent.

Inclusion criteria comprised adult patients (≥18 years) with signs and symptoms suggestive of ITB—such as chronic abdominal pain, weight loss, low-grade fever, altered bowel habits, or intestinal obstruction—who underwent surgical intervention based on clinical and radiological indications. Patients with known Crohn’s disease, malignancy, or HIV-positive status were excluded to avoid diagnostic overlap.

Preoperative assessment included detailed history, physical examination, routine hematological and biochemical investigations, Mantoux test, chest X-ray, abdominal ultrasound, and contrast-enhanced CT (CECT) of the abdomen. Colonoscopy with biopsy was performed when feasible.

Surgical procedures were undertaken based on acute indications such as obstruction, perforation, or diagnostic uncertainty. Operative findings were systematically recorded, including the site of involvement, presence of strictures, perforations, masses, lymphadenopathy, and ascites.

Histopathological analysis of surgical specimens was done using hematoxylin and eosin staining, and presence of caseating granulomas, lymphocytic infiltration, and giant cells were noted. Ziehl–Neelsen staining for acid-fast bacilli (AFB) was performed in all samples.

Postoperative outcomes including complications (e.g., wound infection, anastomotic leak), duration of hospital stay, need for reoperation, and in-hospital mortality were recorded.

Data were analyzed using SPSS Version 25.0. Descriptive statistics were used to summarize patient characteristics, surgical findings, histopathology, and outcomes. Categorical variables were expressed as frequency and percentage, and continuous variables as mean ± standard deviation.

The study included a total of 53 patients, with a mean age of 36.8 years. As shown in Table 1, males comprised a slightly higher proportion (58.5%) than females. The predominant presenting complaint was abdominal pain, reported in 84.9% of patients, followed by weight loss (71.7%), fever (54.7%), and altered bowel habits (39.6%). Approximately one-third of patients (32.1%) exhibited features suggestive of intestinal obstruction at presentation.

Intraoperative findings (Table 2) revealed ileocaecal involvement as the most common anatomical site affected, observed in 66% of patients. Multiple intestinal strictures were present in 39.6%, while mesenteric lymphadenopathy was noted in 58.5%. Less frequently observed intraoperative features included ascites (26.4%), perforations (13.2%), and mass lesions mimicking malignancy (15.1%).

Histopathological evaluation (Table 3) confirmed classic features of intestinal tuberculosis in most patients. Caseating granulomas were present in 73.6% of samples, which is a hallmark of tuberculosis. Other findings included lymphocytic infiltration (64.1%) and Langhans-type giant cells (41.5%). Notably, Ziehl–Neelsen staining for acid-fast bacilli (AFB) was positive in 32.1% of cases, underscoring the utility—but also limitations—of direct microbiological confirmation.

Postoperative outcomes (Table 4) indicated that wound infections occurred in 17% of patients, while anastomotic leaks were relatively uncommon (5.7%). Only two patients required reoperation. The mean duration of hospital stay was 10.2 days. One patient succumbed to postoperative complications, resulting in an in-hospital mortality rate of 1.9%.

Table 1: Demographic and Clinical Characteristics of Patients (N = 53)

Table 2: Intraoperative Findings

Table 3: Histopathological Findings

Table 4: Postoperative Complications and Outcomes

This study highlights the clinical spectrum, surgical indications, and histopathological findings among patients operated on for suspected intestinal tuberculosis (ITB). The majority of patients in our cohort presented with intestinal obstruction, which remains the most common surgical indication in ITB due to chronic inflammation, fibrosis, and stricture formation. These findings are consistent with previous literature that reports obstruction as a predominant presentation requiring operative management [8].

Perforation was observed in a subset of patients, underscoring the fulminant nature of tuberculous enteritis when diagnosis and treatment are delayed. Intestinal perforation, although less common than obstruction, has been recognized as a life-threatening complication in ITB and often necessitates emergency laparotomy [9]. Intraoperatively, the presence of multiple strictures, caseous mesenteric lymphadenopathy, and adhesions were frequent, which are hallmark features suggestive of tubercular etiology [10].

Histopathological confirmation remains the gold standard for diagnosis of ITB, especially in resource-limited settings where advanced diagnostic modalities may not be routinely available. In our series, granulomatous inflammation with caseation necrosis and Langhans giant cells was identified in a significant number of cases, aligning with diagnostic criteria reported in earlier studies [11]. However, acid-fast bacilli (AFB) were seen in only a minority of specimens, reflecting the known paucibacillary nature of intestinal TB [12].

Importantly, differentiating ITB from other granulomatous diseases such as Crohn’s disease continues to pose a diagnostic challenge. Several histological markers, including confluent granulomas, caseation, and lymphoid cuffing, have been proposed to aid differentiation, though overlap still exists [13]. Clinical and radiological correlation, along with therapeutic response to anti-tubercular therapy, often becomes necessary in ambiguous cases.

Surgical management not only aids in relieving life-threatening complications but also plays a crucial diagnostic role by providing tissue for histopathological evaluation. The outcomes of surgery in our study were favorable, with no perioperative mortality, echoing reports from similar settings where prompt surgical intervention has improved prognosis [14,15].

In conclusion, timely surgical intervention combined with histopathological confirmation is vital for the effective management of intestinal tuberculosis. Continued awareness and early clinical suspicion remain key, especially in endemic regions, to reduce morbidity associated with delayed diagnosis.

This study highlights the diagnostic and therapeutic challenges associated with intestinal tuberculosis, particularly in resource-limited settings where clinical and radiological findings may mimic other gastrointestinal pathologies. Surgical exploration continues to play a crucial role in both the management and confirmation of diagnosis, especially in cases presenting with complications such as obstruction or perforation. Histopathological analysis remains the gold standard for definitive diagnosis, with characteristic findings like caseating granulomas and Langhans giant cells being highly indicative. Although Ziehl–Neelsen staining for AFB had limited sensitivity, it still contributed to microbiological confirmation in a subset of cases. Overall, timely surgical intervention combined with histopathological evaluation ensures improved outcomes in patients with suspected intestinal tuberculosis.

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