according to estimates by the who , there are approximately 9.4 million patients a year diagnosed with tuberculosis ( tb ) , with an annual mortality of 1.7 million .
historically , the majority of tb cases are pulmonary ; however , cases of extrapulmonary tb , including abdominal tb , are increasingly being reported in the uk .
traditionally thought to be a disease of developing asian and african countries , it is now increasing in prevalence in the west . contributing factors to the rising incidence of abdominal tb in the uk are the increasing prevalence of hiv , immigration from developing countries and an ageing population [ 3 , 4 ] .
abdominal tb often involves the gastrointestinal ( gi ) tract , peritoneum , mesentery , abdominal lymph nodes and solid organs , and usually causes non - specific symptoms like in our case , making the diagnosis difficult and a high index of suspicion necessary .
we , here , present the case of an immunocompetent patient , from a non - tb endemic country , who developed intestinal tb involving the caecum .
a 43-year - old afro - caribbean gentleman was admitted to the ed suffering from haemoptysis .
he had previously been noted to have an enlarged lymph node in the right posterior triangle of neck which had been biopsied . at the time of presentation , the results of the histopathology were pending .
he had also been suffering from weight loss of 18 kg over the previous 3 months along with night sweats and a reduced appetite . on examination ,
since his history and clinical findings were very suspicious of tb , he was reviewed by the respiratory team .
empirical anti - tubercular therapy was suggested after sputum cultures were sent for acid fast bacilli ( afb ) and a ct thorax showed a right upper lobe collapse and a 3-cm apicoposterior cavity .
there was also consolidation seen in the right middle and lower zone as well as the left lung ( fig .  1 )
figure  1:ct thorax  right - sided upper and mid zone collapse + consolidation .
seventy - two hours after starting his anti - tubercular therapy , he took a turn for the worse and was transferred to the icu for ventilatory and inotropic support .
he had 1 l of bleeding per rectum and dropped his haemoglobin ( hb ) from 140 to 65
a ct abdomen + pelvis with contrast was performed , which showed a large ( 20 cm ) inflammatory caecal mass with a moderate amount of intra - abdominal free fluid ( fig .  2 ) .
selective angiography of the superior mesenteric artery demonstrated the bleeding point in the caecum and this was embolized superselectively with coils ( fig .  3 ) . 

the posterior wall of the caecum was perforated and visibly the nidus of the bleeding ( fig . 
figure  4:grossly enlarged and perforated caecum with a suction device demonstrating the depth of the cavity . grossly enlarged and perforated caecum with a suction device demonstrating the depth of the cavity .
postoperatively , the patient made a good recovery and had no further episodes of bleeding or drop in hb .
the histology from both the initial lymph node biopsy as well as the caecal mass came back positive for tb , as did his sputum cultures .
he was discharged on post - op day 10 with a plan to complete his full course of anti - tubercular therapy and undergo both surgical and respiratory outpatient follow up .
gi involvement of tb can result in stricture formation , intestinal obstruction , perforation , fistulas and small bowel volvulus .
intestinal perforation is uncommon but when does occur is a serious and life - threatening complication  mortality rates secondary to perforation are estimated to be > 30% .
early recognition of abdominal symptoms and intervention may improve the prognosis of tuberculous intestinal perforations .
recommended treatment is the resection of the affected bowel followed by end - to - end anastomosis .
however , for an inflammatory caecal mass of uncertain aetiology as in our case , right hemicolectomy has been recommended because of the concern of possible malignancy .
some perforations occur before or shortly after antituberculous therapy begins , suggesting a natural progression of the condition , thought to be caused by a reactive thickening of the peritoneum and subsequent adhesion formations , leading to proximal dilatation and perforation .
other cases had evidence of improvement during the course of treatment , before a later perforation .
there have also been multiple cases of intestinal perforations occurring after completion of antituberculous therapy .
it has been hypothesized that a paradoxical response to treatment may be responsible for these cases . this is similar to the disease progression in our case  the previously asymptomatic patient from the gi point of view acutely decompensated and developed caecal distention and perforation within 72 h stating anti - tubercular therapy .
isolated caecal perforation that too tubercular in origin is extremely rare and only one other case has been reported . if perforation does occur , it is in accordance with laplace 's law which states that the intraluminal pressure needed to stretch the wall of a hollow tube is inversely proportional to its radius .
the caecum has the largest diameter of the colon and therefore requires the least amount of pressure to distend .
perforation of the caecum has been found to occur when the diameter reaches 16 cm  in our case , it was 20 cm and therefore perforation was not unexpected .
the extent of caecal distension seen in our case is unheard of in the literature and underlines the insidious nature of intestinal tb : our patient never complained of any gi signs or symptoms to suggest intestinal tb until he decompensated and bleed massively per rectum . in conclusion ,
diagnosis of intestinal tb can be challenging hence requiring a high index of suspicion and caecal distension , and perforation can be paradoxically triggered by anti - tubercular therapy .
furthermore , the massive distension of the caecum reported in our case can be explained by laplace 's law .
 a 43-year - old man presented to the hospital with haemoptysis . when worked up , his history and examination were highly suggestive of pulmonary tuberculosis ( tb ) . 
 he subsequently developed a massive upper gastrointestinal bleed and underwent an emergency laparotomy , which revealed a massively dilated caecum measuring 20 cm in diameter . 
 the caecum had perforated due to acute decompensation of intestinal tb . though common in developing countries , tb is rare in the uk , especially the intestinal kind . 
 the most striking feature of this case is , however , the size of the caecal distension caused by the tubercular inflammation and subsequent perforation  something unheard of in the literature . 
 this massive caecal distention would be explained by the law of laplace . in conclusion , 
 massive distension and caecal perforation are possible consequences of intestinal tb , especially in the 4872 h immediately after starting anti - tubercular therapy . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICT OF INTEREST STATEMENT