A 15 year old male child, presented with complaint of cholicky abdominal pain since 7 days and distension since 3 days. He had a past history of pulmonary tuberculosis and was a defaulter. On examination, the abdomen was mildly distended and tenderness was present in the periumblical region. A firm to hard mobile mass approximately 5 cm. x 7 cm. in size was palpable in umbilical region. It was intra-abdominal and intra-peritoneal. Bowel sounds were exaggerated. Per rectal examination was normal. ESR was 110 mm in 1st hr. On plain X-ray examination, significant air fluid levels and dilated small bowel loops were found (Fig.1).
USS examination showed features of intestinal obstruction with ascites. CT revealed small bowel obstruction with minimal fluid collection. On exploratory laparotomy, gut loops were found to be adherent and encased in a membrane (Fig.2).
A stricture was also present in the jejunum. Mesentric lymph nodes were enlarged. The membrane was dissected and adhesilolysis was done along with sticturoplasty of the jejunal stricture. The white fibrous membrane and the enlarged lymph node were sent for histopathologcal examination. On histopathological examination of the lymph node showed characteristic granulomatous lesions showing caseous necrosis in the centre, and a prominent cuff of lymphocytes and plasma cells at the periphery. Acid-fast stain of the small granulomas was positive. Pieces from membrane showed loose connective tissue, infiltration by an admixture of lymphocytes, plasma cells, and giant cells. Patient was started on antitubercular treatment postoperatively and the outcome was satisfactory.