Welcome User!
Case Study

Ileo-Caecal Koch's With Sub-Acute Intestinal Obstruction
Dr Anand R Kapse

A Surgeon, treating the patient for Ileo-caecal Koch's for 2yrs, now suspected sub-acute intestinal obstruction and referred him. This is the MDR-TB case

Name Mr L D Date 19/8/95 
Date Of Birth: 27/02/65 Education: SSC
Status: Married; Religion: Christian; Diet: Non-vegetarian
Occupation: Business-Electric Fitting Contracts.
Spouse: works as a packer
Father: Expired In 1978 Mother: 50 Brother: 28, 26, 21. Sister: 18.

Chief Complaints:


Sensations and Pathology



GIT: Abd since 2 years; OD for 3hrs

Pain - burning continuously


< Eating after
< After 6 PM 
< While sitting
< Fermented food
< Milk 

Lt sided headache

Giddiness-since 2 years

Revolving Vision hazy



Eyes I/2 hour
Chest since 2 years

Weakness Bitter taste

< Milk products
< Eggs
> Empty stomach 

Cannot work

Rectum -alternate days for 6 months

Constipation, stool



Abdomen/ stomach 8/10 stools a day- for 8 months

Diarrhoea watery -twisting sensation in the abdomen

< Eating after

Strain3 then weakness. Vomiting

Rt side since2yrs

Generalized numbness-

Before abdominal pain
< Sleep during
< Pressure


Nose: Since childhood

Cold and sneezing

< Dust


The patient was on AKT for 2 years without improving and was unable to work.

Patient As A Person
Wt 41.5 Kg; H/o Wt Loss +; Lean ++ Halitosis 
General heat as well as burning < evening. Partial - Palms and soles. 
Since 2 Years- uncovers feet.
Perspiration - excessive; especially chest, abdomen; Odour+; Stains - fast 
Appetite: N; Eructations < 6 p m < dinner after. Flatulence c/c Hunger can tolerate 
Cravings: Sweets 
Sex: No sexual activity since 2 Yr.

Life Space Investigation
Pt is a 30-year-old Christian male, coming from lower middle class, joint family. He stays with his wife and mother, 3 younger brothers and 1 younger sister in the railway quarters. He works as a mechanic of TV and electronic appliances. Earlier he was a sub-contractor for electrical fitting for big companies or buildings. He has stopped his contract job for 2 years due to illness. Now just does nominal work in the house.

His fathers was a railway guard and mother a teacher and lived as a nuclear family. He described his father as a calm, quiet and loving person while Mother was irritable. When pt was 11 years old, his father had an accident while on duty and suffered a head injury. For 1 year he was in hospital; first 2 months in coma, then left with residual behavioral problems - he would run around the house as if a train was coming; for breakfast, he would butter his head, and so on. One year later he expired. During illness, railway supported them financially. Later they offered a job to his mother. So they did not face any severe financial problems and there was no lasting impact on pt.

After father's death, mother put all children in a convent boarding school, where they also received occupational training. Pt learned electrical fitting and repairing of appliances. After SSC, he came back to support the family. He joined a company, but it closed down after 2 years. Then followed 2-3 small jobs. Later he joined a contractor doing electrical fittings for big companies and became a sub-contractor with 2-3 workers of his own. Conscientious, he was always very keen to complete the contract in time. Contractor paid him in installments, while he paid his workers on daily basis! His work took him outside Mumbai too; one Aurangabad project took 2 years, for which contractor still owes him Rs 60000. As contractor has not got money from the company, he says he can't say anything to him, but this makes him tense many times.

While in Aurangabad, he fell in love with a girl and proposed to her. Both sides agreed and they got married 3 years back. Pt got ileo-caecal Koch's in 1993. Since then he is not working and his family also tells him not to work, but he feels very bad about it since he is the eldest. Now his wife has joined as a packer in an Ulhasnagar company. Pt describes her as calm and cool-minded. She encourages him when he is depressed. Earlier pt had fear of transmitting disease to wife by physical contact. Even after clarification from the doctor, they abstain from physical relations completely. Wife cooperates very well.

Pt described his family as a close-knit, caring and helpful one. He said that any member's problem is solved by sitting together. Once when his friends was removed from his chawl few months after marriage, Pt kept him and his family in his house till they got another place.

As a child he was shy, non-mixing and anxious, especially before exams, though did well. He helped backstage with drawing, crafts and decoration work etc. At home he was extremely irritable and when angry he would shout and throw things. But his nature changed after the stint at boarding school, as Principal-Father explained how anger harms a person. Father also taught him to be helpful to others. His angry outbursts reduced, and he became very helpful. He can't bear insults to self or others. If contractor insulted any worker, he would tell him to talk properly. But later, he carries no grudge.

This illness has depressed him a lot; he wonders whether he will ever come out of it. If not, what will happen to his wife? He likes to be alone and brood. He feels his illness is a punishment for the anger and violence in childhood.
The little work he does at home, keeps him occupied.

Other Tension: To find a bigger house as mother is retiring in 3-4 yrs and they will have to vacate railway quarters.
Sleep: disturbed due to distention.
Dreams: Snakes 2/yr. Snakes come to bite him. Dreams of falling in a pit last month.

Reaction - Physical Factors
Sun < weakness. Likes winter. FAN: Full always
COVERS only abdomen with chaddar. Feet uncovers in summer and winter
Never wears Woolen. BATH: cold h/o in summer and tepid in winter till illness. Now since 2 yrs tepid always, never hot. CH4
Fasting no <. Eggs < Gases. Fried no <. Milk < vomiting
Sweets < Nausea Tea < eructation

Past History: 
Smoking -- 5 Filtered/Day; Jaundice; Knee Operation
Family History: Head Injury - Father
Headaches: Migraine - Mother
Hypertension - Mother
Hypothyroid - Maternal Grandfather

Physical Examination:
Blood Pressure - 120/ 90; Weight 41.5 Kg; Tongue thick yellow coating
Per Abd.- Tenderness ++ In Rt Lumbar Region.





























Mantoux Test 9/12/93 - Induration 14 mm x 13 mm
X Ray Chest 7/12/93 - Active Koch's infiltration in Lt lung with cavity in mid zone. KUB - No calculus. NAD.
Barium Meal Follow Through
18/8/94 - Ileo-caecal Koch's.
8/3/95 - Ileo-caecal Koch's. Compared to previous X-Ray- distension of distal ileum not seen now.
USG Abdomen - NAD.
Endoscopy - 8/8/94 - Intestines congested ++. Peritoneum and intestinal surface did not show evidence of Koch's. Ileocaecal region ?pulled up. Appendix retrocaecal. No local congestion. Because of position appendix could not be seen well.
Opinion -? Ileocaecal Koch's

Remedy Selected: Fer-iod
Reasons For Selection:
Study of the evolution of the disease brought out the following pathological and miasmatic co-relations.

Patient presented with sub-acute intestinal obstruction due to Koch's. 3 yrs back - vomiting and diarrhoea, since then constipation for 6mths. The disease had healed with fibrosis, but his generals had not improved. Food modalities showed psoric / tubercular dimension, the current state of debility indicated the tubercular zone.

Pronounced weakness and multiple food aggravations were marked features of the chief complaint. This suggested Ferrum. Hot lean patient with intense burnings and chronic tubercular inflammation with fibrosis producing sub-acute intestinal obstruction suggested Iodum. Thus Fer-iod was selected as a synthetic prescription. Calc-iod and Lyco came up for differentiation.

The interesting aspect was that, at first glance, the mental state looked more like Calc mind rather than the Ferrum mind. Patient was polite, calm and quiet. He had overcome his irritability on the advice of father at boarding school. On deeper reflection it became apparent that his original irritable disposition was being suppressed. He was not able to express his anger towards the contractor who was yet to pay him Rs 60000/-. Did this suppressed anger play any role in his breakdown? This cause-effect relationship could not be directly established. But transformation of an irritable, excitable person into a debilitated person fitted with Ferrum evolution.

Management: Low susceptibility, lowered vitality (broken down system) with high sensitivity lead to choice of 30 potency. Initially given OD and later BD. Treatment was started on 25/9/95. Within 2½ months patient improved 50 - 60 % and was able to work for 4 -5 hours at home. Later potency was raised to 200 as symptoms relapsed. This was gradually raised to daily repetition, once he could tolerate it. It is found that in this kind of pathology, repetition is necessary to revert the pathology. Within 3 more months, the patient was able to resume out door work, had put on 2.5 kg and his GIT complaints had settled. At this stage, his antikoch's was stopped in consultation with referring surgeon. Fer-iod 200 was continued for 3 more months. 1 dose of Tub-bov 1M was interpolated when loose stools episode came up. He was kept on placebo from 17/5/96. After 12/8/96, he was asked to report SOS. Patient is healthy till date.

Acknowledgement: The case was managed in coordination with Dr C B Jain, Hon Asst Director (Clinical Research) I C R who is in charge of the Tuberculosis Research Project of I C R. I am indebted to him for his advice.