In this review, the underlying cause of bowel obstruction was tuberculosis in 22.4% of patients, a figure which is comparable with 21.8% reported by Ali et al in Pakistan. However, this figure is higher than that observed in many other studies [23–26]. These differences in the rate of tuberculous intestinal obstruction reflect differences in the prevalence and risk factors for developing complications of TB such as bowel obstruction among different study settings. The figures for the rate of tuberculous intestinal obstruction in our study may actually be an underestimate and the magnitude of the problem may not be apparent because of high number of patients excluded from this study.
This study showed that males were slightly more affected than females with a male to female ratio of 1.8:1 which is comparable to the global ratio of 1.5 to 2.1:1 . Some workers report that the disease is more common in males in the western countries while in developing counties the females predominate . We could not find in literature the reasons for this gender differences.
Intestinal tuberculosis, like tuberculosis elsewhere in the body affects the young people at the peak of their productive life . This fact is reflected in our study as the highest age incidence of the patients was in the second and third decades of life and more than seventy percent of our patients were aged forty years and below. This is in accordance with the results of other workers [16, 30]. The presentation of tuberculous intestinal obstruction in this age group has serious impacts on the national economy and production, as working and productive class of community is replaced by sick and ill individuals.
Intestinal obstruction resulting from tuberculous has been reported to be more prevalent in people with low socio-economic status . This observation is reflected in our study where most of patients had either primary or no formal education and more than seventy-five percent of them were unemployed. The majority of patients in the present study came from the rural areas located a considerable distance from the study area and more than eighty percent of them had no identifiable health insurance. Similar observation was reported by others [10, 31–35]. This observation has an implication on accessibility to health care facilities and awareness of the disease.
The clinical presentation of tuberculous intestinal obstruction in our patients is not different from those in other studies [35, 36], with abdominal pain being common to all the patients. The clinical presentation of abdominal TB is usually non-specific [37, 38] and, therefore, often results in diagnostic delay and hence the development of complications such as intestinal obstruction . In keeping with other studies [33, 35, 36], the majority of our patients had symptoms of more than 6 months duration at the time of presentation. The reasons or late presentation in this study may be attributed to the fact that the diagnosis of intestinal TB in its initial stages is usually difficult due to vague and non-specific symptoms as a result patients remain undiagnosed for prolong periods, receiving symptomatic treatment and subsequently present late with complications such acute or sub-acute intestinal obstruction.
In our study, associated pulmonary tuberculosis was found in 23.7% of cases, a figure which is comparable with Baloch et al. However, higher figures of associated pulmonary tuberculosis have been reported by others [10, 40]. We could not find in literature, the reasons for these differences.
The presence of co-existing medical illness has been reported elsewhere to have an effect on the outcome of patients with tuberculous intestinal obstruction . This is reflected in our study where patients with co-existing medical illness had significantly high mortality rate.
The prevalence of HIV infection in the present study was 21.2%, a figure that is significantly higher than that in the general population in Tanzania (6.5%) . However, failure to detect HIV infection during window period and exclusion of some patients from the study may have underestimated the prevalence of HIV infection among these patients. High HIV seroprevalence among patients with tuberculous intestinal obstruction was also reported by Fee et al. This difference in HIV seroprevalence among patients with tuberculous intestinal obstruction reflects differences in the overall prevalence for risk factors for HIV infection in general population from one country to another. High HIV seroprevalence in our study may be attributed to high percentage of the risk factors for HIV infection reported in the present study population.
The clinical picture of tuberculous intestinal obstruction may be complex when tuberculosis occurs with HIV infected patients . HIV infection has been reported to increase the risk of surgical site infection and mortality . In the present study, the rate of surgical site infections and mortality was found to be significantly higher in HIV positive patients than in non HIV patients. Also higher rate of SSI was observed among HIV patients with low CD 4 count (< 200 cells/μl). Patients with AIDS usually have a more severe form of involvement than those who did not have AIDS [37, 46]. However, the treatment of bowel obstruction due to tuberculosis in AIDS patients has been reported to be the same as in non-HIV infected patients  but multi-drug-resistant tuberculosis is more common in patients with AIDS .
Emergency surgical intervention is considered to be the standard treatment of choice for patients with tuberculous intestinal obstruction . In keeping with other studies [10, 15, 26, 35, 36], the majority of patients in this study underwent emergency surgical treatment. One of the many factors affecting the surgical outcome in patients with tuberculous intestinal obstruction is time interval between duration of onset of intestinal obstruction and surgical intervention [35, 36]. In the present study, the majority of patients were operated more than 24 hours after the onset of illness. Similar observation was reported by other studies done elsewhere [30, 36]. Delayed definitive surgery in the present study may be attributed to late presentation due to lack of accessibility to health care facilities, lack of awareness of the disease as a result some patients with tuberculous intestinal obstruction may decide to take medications in the pre-hospital period with hope that the symptoms will abate. It is also possible that some clinicians managing the patients initially may not have considered as a possible diagnosis. In resource-poor countries like Tanzania, difficulties in diagnosis of intestinal TB, patient transfer, and inadequate medical treatment often result in delayed presentation to a hospital [1, 2, 41].
In agreement with other studies [16, 36, 49], the ileocaecal region was the most common site of the bowel affected. This is in sharp contrast to other authors who reported the terminal ileum as the most common site of involvement [10, 39]. Many studies have been reported that the most common site of involvement of intestinal TB is the ileocaecal region, possibly because of the increased physiological stasis, increased rate of fluid and electrolyte absorption, minimal digestive activity and an abundance of lymphoid tissue at this site . It has been shown that the M cells associated with Peyer’s patches can phagocytes BCG bacilli . The frequency of bowel involvement declines as one proceeds both proximally and distally from the ileocaecal region . In this study, the main lesion causing obstruction was intestinal tuberculosis in the hypertrophic form which is in agreement with Nguyen  in Vietnam.
In the present study, the right hemicolectomy with ileo-transverse anastomosis was the most common surgical procedure performed in 55.9% of the patients. This was followed by segmental bowel resection with end to end anastomosis, release of adhesions, bypass surgery, ileostomy and stricturoplasty. Similar surgical treatment pattern was reported by other writers also [15, 52, 53]. In our study, stricturoplasty was performed in only one patient. This is in contrast to that reported by Akbar et al who reported stricturoplasty as the most common surgical procedure performed. Stricturoplasty is a simple procedure originally described by Katariya and his colleagues in Chandigarh India in 1977 . The procedure has become widely popular and is being practiced all over the world. It has also been tried in Crohn’s disease, with the same usefulness . The procedure is simple, quicker, less traumatic and applicable anywhere from pylorus to ileocaecal junction. The procedure can also be undertaken in active lesions . However, this procedure was not popular in our study because the majority of our patients had very extensive local disease with long and multiple strictures and only option was either right hemicolectomy with ileo-transverse anastomosis or by segmental bowel resection with end to end anastomosis. Anti-tuberculous therapy was prescribed in all the tubercular patients postoperatively.
The presence of complications has an impact on the final outcome of patients presenting with tuberculous intestinal obstruction. In keeping with other studies [32, 36], surgical site infection was the most common postoperative complications in the present study. High rate of surgical site infection in the present study may be attributed to HIV seropositivity and low CD 4 count.
The overall median duration of hospital stay in the present study was 24 days which is higher than that reported by other authors [20, 25, 35, 36]. This can be explained by the presence of large number of patients with postoperative complications in our study. However, due to the poor socio-economic conditions in Tanzania, the duration of inpatient stay for our patients may be longer than expected.
The overall mortality rate in this study was 22.7% and it was significantly associated with delayed presentation, HIV positivity, low CD 4 count, high ASA class and presence of complications. Addressing these factors responsible for high mortality in our patients is mandatory to be able to reduce mortality associated with this disease.
Self discharge by patient against medical advice is a recognized problem in our setting. Similarly, poor follow up visits after discharge from hospitals remain a cause for concern. These issues are often the results of poverty, long distance from the hospitals and ignorance. Delayed presentation, delayed histopathological confirmation of tuberculous bowel obstruction and the large number of loss to follow up were the major limitations in this study.
However, despite these limitations, the study has provided local data that can be utilized by health care providers to plan for preventive strategies as well as establishment of management guidelines for these patients. The challenges identified in the management of patients with tuberculous bowel obstruction in our environment need to be addressed, in order to deliver optimal care for these patients.