A 35-year-old Indian male presents with a 4-month history of right lower quadrant pain, low-grade fever, night sweats, and weight loss of 8 kg. Colonoscopy reveals multiple transverse ulcers in the ileocecal region with confluent caseating granulomas on biopsy. Chest X-ray is normal. Tuberculin skin test is positive (18 mm induration). The structure marked **A** in the diagram represents the recommended management approach for this patient. Which of the following best describes the rationale for this approach?
A. Surgical resection of the affected ileocecal segment as the primary definitive treatment, with anti-TB therapy reserved for disseminated disease
B. Anti-amoebic therapy as first-line management, since transverse ulcers are more characteristic of amebic colitis than tuberculosis
C. Standard 4-drug anti-tuberculous therapy (HRZE) for 6–9 months, with surgery reserved for complications such as perforation, obstruction, or stricture formation
D. A brief 2-week course of anti-TB drugs followed by reassessment, as intestinal TB typically responds rapidly to short-course therapy
Explanation
Why option 1 is correct
The diagnosis of ileocecal tuberculosis is established by the classic triad of transverse ulcers, confluent caseating granulomas, and positive TST in an endemic setting. According to WHO TB Guidelines 2022 and the Indian Society of Gastroenterology ITB Consensus, the standard management is a 4-drug regimen (HRZE: isoniazid, rifampicin, pyrazinamide, ethambutol) for 2 months followed by 4–7 months of HR continuation therapy, totaling 6–9 months. Surgery is reserved for complications—perforation, complete obstruction unresponsive to medical therapy, severe bleeding, or fistulae—and strictureplasty is preferred over resection to preserve bowel length. This patient has uncomplicated disease and should receive medical therapy first.
Why each distractor is wrong
Option 2: A 2-week course is grossly inadequate and contradicts all international and Indian guidelines. Intestinal TB requires prolonged therapy (6–9 months minimum) to achieve cure and prevent relapse. Short-course therapy would result in treatment failure and complications.
Option 3: Primary surgical resection without antitubercular therapy is inappropriate and harmful. Surgery is never first-line for uncomplicated ITB; it is reserved for complications only. Resection also risks loss of bowel length and nutritional morbidity. ATT must be the foundation of management.
Option 4: Anti-amoebic therapy is incorrect because the histopathology shows caseating granulomas (pathognomonic for TB), positive TST, and transverse ulcers—all features of TB, not amebic colitis. Amebic colitis presents with flask-shaped ulcers and trophozoites on histology, not granulomas.
High-YieldNEET PG
Ileocecal TB is managed medically with 6–9 months of HRZE-based therapy; surgery is only for complications (perforation, obstruction, stricture, bleeding).
WHO TB Guidelines 2022; Indian Society of Gastroenterology ITB Consensus
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