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Table of Content - Volume 19 Issue 2- August 2021
Study of abdominal tuberculosis at a tertiary hospital
Pandit Shamarao Powar
Associate Professor, Department of Surgery, BKL Walawalkar Rural Medical College, Kasarwadi, Savarde, Chiplun, Ratanagiri, Maharashtra, INDIA. Email: panditpowar90@gmail.com
Abstract Background: Gastrointestinal TB is a 6th most common form of extrapulmonary, localized manifestation of this infectious disease. Diagnosis of abdominal tuberculosis is an ongoing challenge, difficulty in diagnosis is due to subtle clinical presentation with vague symptoms and non-specific signs, it mimics many other pathologies like Crohn's disease, malignancies, lymphomas etc. and very low yield of Mycobacterium tuberculosis on microscopy or culture. In present study we studied confirmed or strongly suspected cases of abdominal tuberculosis presenting in surgery department at a tertiary hospital. Material and Methods: Present study was a prospective, observational study conducted in suspected and confirmed cases of abdominal tuberculosis. Results: During study period 72 patients, confirmed or strongly suspected cases of abdominal tuberculosis were treated at our center. Mean age of patients was 33.6 ± 7.5 years. Male to female ratio was 1.8:1. 13% patients had previous history of TB while 8% had family history of TB. Abdominal X‑ray erect and USG abdomen + pelvis were done in all patients. Common X-ray findings were multiple air‑fluid level (44%), ground glass appearance (15%), gas under diaphragm (13%) and calcification (8%). While common USG abdomen + pelvis findings were ascites (36%), mesenteric lymphadenitis (29%), dilated bowel loop (22%) and bowel wall thickening (21%). In present study, 17 patients (24%) were managed conservatively. Remaining 76% patients underwent surgical interventions. In operative cases bands and adhesions (53%), strictures (42%), peritonitis, omental thickening (33%) and gross adhesions (18%) were common findings. In 55 patients who underwent laparotomy, common postoperative complications were surgical site infections (13%), paralytic ileus (9%) and enterocutaneous fistula (7%). Postoperative peritonitis and burst abdomen was noted in 4% patients. Conclusion: Abdominal tuberculosis is a surgical dilemma, a high degree of clinical suspicion is required to make a diagnosis of TB. Various imaging features and radiological signs are useful in making a diagnosis of abdominal TB. Keywords: abdominal tuberculosis, Mycobacterium tuberculosis, strictures, mesenteric lymphadenitis
INTRODUCTION Tuberculosis (TB) is a common and major health problem, especially in developing countries like India, where poverty, malnutrition and overcrowding prevail, tuberculosis continues to be one of the important causes of morbidity, mortality and loss of working man hours. It has been declared a global emergency by the World Health Organization (WHO) and is the most important communicable disease worldwide.1 The abdominal TB, which is not so commonly seen as pulmonary TB, can be a source of significant morbidity and mortality and is usually diagnosed late due to its nonspecific clinical presentation.2 Gastrointestinal TB is a 6th most common form of extrapulmonary, localized manifestation of this infectious disease.1 In the abdomen, tuberculosis may affect the gastro-intestinal tract, peritoneum, lymph nodes, and solid viscera. Approximately 1-3% of total TB cases are extra pulmonary of these abdominal tuberculosis (ATB) accounts for 11%-16% .3 There are three ways in which the tubercle bacilli can infect the abdomen through ingestion of infected sputum or milk, through hematogenous or lymphatic spread and through direct spread into the peritoneum from the fallopian tubes.4,5 Diagnosis of abdominal tuberculosis is an ongoing challenge, difficulty in diagnosis is due to subtle clinical presentation with vague symptoms and non-specific signs, it mimics many other pathologies like Crohn's disease, malignancies, lymphomas etc. and very low yield of Mycobacterium tuberculosis on microscopy or culture.6 In present study we studied confirmed or strongly suspected cases of abdominal tuberculosis presenting in surgery department at a tertiary hospital.
MATERIAL AND METHODS Present study was a prospective, observational study conducted in department of general surgery with department of chest and tuberculosis, department of microbiology. Study duration was of 2 years (May 2018 to August 2020). Institutional ethical committee permission was obtained. Inclusion Criteria - All suspected and confirmed cases of abdominal tuberculosis. Exclusion Criteria • Patients with evidence of genitourinary tuberculosis. • Patients with active pulmonary. A written informed consent was taken from patients/relatives. Patients detail history (demographic, past and medical) was taken and clinical examination was carried out. Routine investigations (complete blood count, liver function tests, renal function test, mantoux test, erythrocyte sedimentation rate, X ray Chest PA View, X ray abdomen erect) and special Investigations for doubtful diagnosis to confirm or support diagnosis (ELISA IgG, ascites fluid routine microscopy/AFB staining/ADA level, USG-abdomen + pelvis, computed tomography of abdomen + pelvis plain and contrast, colonoscopy, barium meal follow through, biopsy) were done. After clinical, laboratory and radiological evaluation management was decided. Conservative management done for uncomplicated abdominal tuberculosis. Operative management done for complications of abdominal tuberculosis and when diagnosis in doubt. All patient received AKT as per DOTS. Follow up Carried out after 2 and 6 months. Patients clinical details were entered in proforma and analysed with regard to various clinical presentation, management, complications and follow-up. Statistical analysis was done using descriptive statistics. RESULTS During study period 72 patients, confirmed or strongly suspected cases of abdominal tuberculosis were treated at our center. Mean age of patients was 33.6 ± 7.5 years. Male to female ratio was 1.8:1. 13% patients had previous history of TB while 8% had family history of TB.
Table 1: General characteristics
Abdominal X‑ray erect and USG abdomen + pelvis were done in all patients. Common X-ray findings were multiple air‑fluid level (44%), ground glass appearance (15%), gas under diaphragm (13%) and calcification (8%). While common USG abdomen + pelvis findings were ascites (36%), mesenteric lymphadenitis (29%), dilated bowel loop (22%) and bowel wall thickening (21%). Abdominal CT scan was done in 30 patients, ascites (53%), bowel wall thickening (37%), lymph nodes (30%) and mesenteric thickening (17%) were common findings. Bowel contrast study was done in 14 patients. Table 2: Radiological investigations
In present study, 17 patients (24%) were managed conservatively. Remaining 76% patients underwent surgical interventions. In operative cases bands and adhesions (53%), strictures (42%), peritonitis, omental thickening (33%) and gross adhesions (18%) were common findings. Table 3: Operative findings
In 55 patients who underwent laparotomy, common postoperative complications were surgical site infections (13%), paralytic ileus (9%) and enterocutaneous fistula (7%). Postoperative peritonitis and burst abdomen was noted in 4% patients. Table 4: Postoperative complications
DISCUSSION Abdominal TB can present itself as, chronic, acute, and acute-on-chronic, or may be an incidental finding at laparotomy for other diseases.7 Abdominal Tuberculosis can affect any age group but is more common in young people at the peak of their productive life. In a study done by Awasthi et al.8 and Badkur M. et al.,9 most affected patients were between 21–40 years, similar findings were noted in present study. Neither clinical signs, laboratory, radiological and endoscopic methods nor bacteriological and histopathological findings provide a gold standard by themselves in the diagnosis of abdominal TB.10 Radiological investigation is the mainstay in making presumptive diagnosis of abdominal TB, this include chest x-rays, ultrasound or CT scan of the abdomen and barium studies.11 Symmetric circumferential thickening of the terminal ileum and caecum accompanied with alteration of ileocecal valve, thickening of valve, adherent loops, and mesenteric lymphadenopathy with central necrosis are common findings noted in CT scan. The present study we noted that the ileocecal region is most often affected in gastrointestinal TB (GITB). This is probably because it is an area of physiological stasis, is a site of avid water and electrolyte absorption, and has relatively little digestive capacity. These factors permit prolonged contact between bacilli and mucosa.12 Differential diagnosis of Crohn’s disease (CD) and GITB is becoming increasingly important. If patients are misdiagnosed with GITB, toxicity may result from unnecessary anti-TB therapy (ATT) and treatment of the primary disease (ie, CD) gets delayed. Conversely, the administration of steroids alone for CD treatment in the event where GITB is overlooked can be highly detrimental to patients.13 If dilemma persists; it is always better to give an empirical trial of ATT first in a country like India, rather than giving immune suppressants therapy.14 The Management abdominal tuberculosis is still controversial. Surgical intervention which was frequently used in the past for diagnosis is not necessary and is reserved for complications such as obstruction, perforation, fistula, or a mass which does not resolve with medical therapy. In most cases a trial of medical therapy should be undertaken prior to surgical intervention. The treatment of abdominal tuberculosis is mainly conservative (non-operatively) with anti-tuberculous therapy and surgical treatment is reserved for those with acute surgical complications including free perforation, confined perforation with abscess or fistula, massive bleeding, complete obstruction, or obstruction not responding to medical management.15 In this study, 24% patients were treated conservatively and 76% required surgical treatment, most common operative finding is ascites, adhesions, stricture, and lump. Shukla and Kumar noted similar observations.16 In our study adhesiolysis, resection, ileostomy, and primary anastomosis were the most frequent surgical procedure which is similar to other studies.17 Postoperative complications include anastomotic leak, faecal fistula, peritonitis, intra-abdominal sepsis, persistent obstruction, wound infection and dehiscence. A recent Indian study has shown that around 40% of intestinal tuberculosis [ITB] had stricturing disease and only one-fourth of strictures show resolution following ATT. The resolution of strictures is dependent on disease location, duration and severity of stricture.18 In study by Keshri A et al.,19 intestinal obstruction (sub-acute/acute) due to bands/ adhesions or bowel strictures was the commonest etiology among the operated patients (35%) followed by ileal/jejunal perforations either by itself or proximal to luminal obstruction (21.3%), abdominal lump/omental cocoon formation (17.5%) and appendicular/terminal-ileal abscess in relation to appendicular/terminal ileal lymph nodes or bowel perforation or mesenteric lymph nodes (16.3%). In study by Weledji EP,20 about 24% of patients were managed conservatively and responded to anti-tuberculous therapy, 76 % needed surgery among which 20% were operated as emergency. Adhesiolysis of gut (47.3%), strictureplasty (10.5%), resection anastomosis (5.2%), right hemicolectomy (5.2%), and ileo-transverse anastomosis (7.8%) were performed and peritoneal biopsy and lymph node biopsy in 21% of patients. The tuberculous bowel perforations were usually treated with resection of involved segments with primary anastomosis. Govind K. et al.,21 in study for intermittent directly observed therapy for abdominal tuberculosis noted that there was no difference in the complete response, partial response, or mucosal healing rate between the 6 months and 9 months of antituberculosis regimens in treatment of GI and peritoneal tuberculosis, antituberculosis drugs given intermittently using the DOTs strategy were efficacious and there was no difference in the recurrence of tuberculosis after 1 year of follow-up. Chronic abdominal pain, palpable abdominal lump, with other non-specific and protean manifestations make an early diagnosis difficult; added, the difficulty in obtaining appropriate and adequate tissue material for analysis and the tedious detection methods available, prompting clinicians/surgeons to administer anti tubercular therapy (ATT) in microbiologically confirmed as well as clinically diagnosed cases of tuberculosis for treatment.19 Xpert MTB/RIF has a role in diagnosis of abdominal tuberculosis. Study by Kumar S. et al.,22 showed that Xpert MTB/RIF had a poor sensitivity but a high specificity in diagnosing abdominal TB and therefore can serve as an important tool in clinical practice where a positive test for TB may confirm ITB and rule out CD.
CONCLUSION Abdominal tuberculosis is a surgical dilemma, a high degree of clinical suspicion is required to make a diagnosis of TB. Various imaging features and radiological signs are useful in making a diagnosis of abdominal TB. With the help of colonoscopy and biopsy and newer molecular methods, early treatment can be initiated and patients can be managed conservatively even with sub acute intestinal obstruction.
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