There are different possible pathways for the tubercle bacilli to cause ATB: (i) hematogenous spread from primary pulmonary TB, (ii) swallowing infected sputum, (iii) ingestion of infected food or drink (i.e. milk products), and (iv) direct invasion from infected adjacent lymph nodes and viscera (i.e. fallopian tubes in females) [1,2,4,7]. Rajput et al [8] and Arif et al [9] have observed preexisting pulmonary TB in 33.95% and 20% of the patients respectively.

Performing surgery at an Emergency Medical Unit in a dangerous war zone is more challenging than emergency surgery in an organized hospital in a peaceful area in that, less facilities in diagnosis and treatment are available, the surgical staff is not permanent and may have personal changes, and the patients are usually presented or transported later in the course of their disease. However, in most cases, emergency surgery in a war zone becomes inevitable in order to save a live. On the same mission in South Sudan that lasted two months we were forced to perform surgical drainage in other three TB patients, two of neck abscesses due to cervical lymphadenopathy and one of lumbosacral disease.

ATB includes the infection of GI tract, peritoneum, mesentery, abdominal lymph nodes and solid organs such as the liver, spleen and pancreas [1,2-4, 6,10,11]. Peritoneum and the ileocaecal valve are the most common sites of infection [1,4,11], and the most common mode of acute presentation is GI obstruction followed by perforative peritonitis [4,6,11]. Depended upon the prominent form of ATB, relative characteristic features may include: multiple intestinal strictures with or without intestinal perforation [1,4,6,10], dense fibrosis in interloops [10], thickenings of the peritoneum with infiltration of the mesenteric leaves [1,3], smudged or dirty appearance of the omentum [3], and ascites (exudative form)[11]. Plast(er)ed abdomen or abdominal cocoon is a form of sclerosing and capsulating peritonitis found in a small proportion of cases [4,11].

ATB is a diagnostic challenge, particularly in the absence of evidence of pulmonary infection and family history or the lacking of a specialized laboratory [1,3,6,10], as in our case. Initial clinical features are insidious, vague and non-specific, frequently resulting in misdiagnosis or making an accurate diagnosis delayed [1,3,6,7]; an overlooked diagnosis may result in significant morbidity and mortality [2,7]. The most common clinical symptoms and signs are abdominal pain or distention, malaise/anorexia, body weight loss, ascites, fever (low-grade), and menstrual abnormalities (females) over the past few weeks or months [1,3,6,7]. In that time, laboratory results may show only leukocytosis, hypoalbuminemia and C-reactive protein elevation [3,6,7]. Tuberculin skin tests are not always positive [7]. In most cases sputum or ascitic fluid (obtained via paracentesis or laparoscopy) for acid-fast bacilli (AFP) staining are also negative [6,7]. Chest X-rays may or may not suggest the presence of pulmonary disease [3,6,12], and abdominal computed tomography (CT) (if available) can reveal irregular nodular thickenings of the peritoneum, omentum or the bowel, a mesenteric mass or ascites [3,6,7]. Moreover, in elective cases, diagnosis can be confirmed with positive results from histopathology and cultures of tissues or peritoneal fluid obtained via ultrasound- or CT-guidance, laparoscopy or colonoscopy [3,7]. TB and ATB are variably associated with immunodeficiencies / immunosuppression (HIV/AIDS infections) [1,4,6,7] or Vitamin D deficiency [4]; HIV serology testing can be useful [6,7].

The emergency of acute abdomen due to GI obstruction or perforation or abscess should fasten the establishment of the diagnosis [1,6,7,13]. In this case, diagnosis is suspected based on the macroscopic appearance of abdominal tissue suggestive of ATB during emergent surgery (as in our case that was forced to be treated in the poor-health condition war zone), helped by laboratory results and radiologic findings and confirmed with AFP staining (if available) or, later, with positive cultures/histopathology results from tissue biopsies or peritoneal fluid [1,3,6,7,11].

During the process of diagnostic evaluation, it is necessary to differentiate between the intestinal form of ATB and other granulomatous diseases which have predilection for the ileocaecal valve (Crohn’s disease) [1,5,12], as well as between its peritoneal form and the disseminated carcinomatosis, primary liver disease, mesothelioma or lymphoma [1,3,7,11].

For both elective cases and emergent complicated cases, permanent cure can only be achieved by a full course of ATD therapy [3,6,11]. This medication may include isoniazide, rifampin, ethambutol and pyrazinamide (occasionally, streptomycin), it is ensured by supplementation with Vitamins B6 and D and lasts for 6-18 months (mean, 12) [2, 4,7].

Traditionally, the role of surgery has been described as being limited to managing the complications of ATB [2,6,7]. The choice of surgical procedure depends on a variety of factors, such as the site and the extent of disease, the status of remaining gut, the general condition of the patient, and the surgeons expertise [4,6,7]. In toxic and unstable patients (“burst abdomen”, septicaemia), intense resuscitation is mandatory [2]. Commonly, emergent surgery  is a two-stage open procedure involving segmental resection(s), exteriorization of bowel ends, adhesiolysis/stricturoplasty, and abdominal washouts [2,4,6,13]. Tissue for histopathological examination is taken [4]. Less commonly, a primary repair involving intestinal anastomosis can be chosen [2,4,6]. In some cases (i.e. peritonitis, prolonged sepsis), the abdominal closure is impossible or it is simply avoided to safeguard against early postoperative abdominal dehiscence (as in our case) or to facilitate postoperative visits; in this case, a Bogota Bag can be used, and a delayed closure is successively achieved. Redo surgery for reversal of a defunctioning stoma is undertaken after 10-12 weeks of ATD therapy [2,4,6]. Postoperative complications include wound infection or dehiscence, anastomotic leak, stoma retraction or prolapse, respiratory tract infection and inscisional hernia [2,4,6,7]. In-hospital early mortality ranges 2.14%-18% [2,4,8,13].