Management of Abdominal

Tuberculosis

Joint Hospital Surgical Grand Round

Dr Shirley Y.W. LiuDepartment of SurgeryNorth District Hospital

• Tuberculosis in the Globe •

Pulmonary TBExtrapulmonary TB

87.5%10%

2.5%

Abdominal tuberculosis(~11-16% of extrapulomnary TB)

Aston NO. World J Surg 1997;21:492-499Singhal A, et al. Eur J Gastroenterol Hepatol 2005; 17:967-971

Tuberculosis• Incidence in Hong Kong (year 2005)

– 90 new cases per 100 000 persons [http://www.info.gov.hk/dh/publicat/web/tb/tb2005e.htm]

• Recent global resurgence of tuberculosis– HIV infection– Aging population– Widespread use of immunosuppresive agents

[Horvath, et al. Am J Gastroenterol 1998;93:692-6]

• Abdominal tuberculosis– Common surgical differential diagnosis in our daily practice

Abdominal tuberculosis

• Epidemiology:– Both gender: equally affected– Most common age: 35-45 years [Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700]

• Risk factors– Alcoholic liver disease– HIV infection

• 9% of all new TB cases are related to HIV

– Advanced age– Low socioeconomic status

[Corbett, et al. Arch Intern Med 2003;163:1009-21]

Mode of infectionSwallowing of

infected sputum

Hematogenous spreadfrom pulmonary focus

Ingestion of contaminatedmilk products

Direct spread from adjacent organs

Pathogenesis of abdominal TB

Intestinal49%

Peritoneal42%

Nodal4%

Solid visceral5%

Abdominal tuberculosis

Khan R, et al. World J Gastroenterol 2006;12(39):6371-6375

1. Intestinal tuberculosis

Ileocaecalregion

Small bowel& colon

Niall O, et al. World J Surg 1997;21:492-499

1. Intestinal tuberculosis

Ulcerative typeFormation of mucosal ulcers

• Bleeding• Perforation• Fistulation• Stricture

Hyperplastic typeExtensive inflammatory changes

• Obstruction• Mass

Aston NO. World J Surg 1997;21:492-499

2. Peritoneal Tuberculosis

Acute form Chronic form

AsciticClear straw-coloured ascitic fluid

FibrousIntestines and viscera mattedtogether causing obstruction

EncystedMatted intestines enclosing aloculation of serous fluid

PurulentPurulent ascitic fluid

Tuberculous peritonitis

• Acute abdomen• Exploratory laparotomy

ascitic fluid thickened omentum scattered tubercles

Ahmed ME, et al. Ann R coll Surg Engl 1994;76:75-79

3. Nodal/ Glandular tuberculosis

• Less common

• Enlargement of– Mesenteric lymph nodes– Retroperitoneal lymph nodes

• Complications– Abscess formation

4. Solid visceral tuberculosis

USG showing tuberculous nodules in spleen

Intraabdominal viscera:• Liver• Kidney• Spleen• Pancreas

CT scan showing tuberculous nodules inliver and spleen

To start with…• Complained of

– Diffuse abdominal pain– Abdominal distension– Weight loss

• Physical exam– Gross ascites– No peritonism or mass

• Blood tests– All normal except elevated

ESR

24/ maleGood past health

2 months

To start with…• Plain X-ray

– Normal

• USG abdomen– Gross ascites only

• CT abdomen– Gross ascites– Small bowel matted together

in central abdomen– Enlarged mesenteric lymph

nodes

(Continued)

To start with…• Differential diagnosis

– Abdominal tuberculosis– Malignancy– Lymphoma– Inflammatory disease

(Continued)

How would you investigate & manage

him?

To diagnose abdominal tuberculosis…

Clinicalpresentation

ConcomitantPTB

Blood tests

Tuberculin test

Radiological test

Microbiology& histology

Clinical presentation

Acute form41%

Chronic form50%

Combined form9%

• Peritonitis• Intestinal obstruction• Perforation• GI bleeding

• Chronic pain• Ascites• Weight loss• Vomiting• Diarrhea• Fever• MassLeung VKS, et al. Hong Kong Med J 2006;12:264-271

Clinical Presentation

Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700

Clinical Presentation

• Non-specific symptoms & signs– High index of suspicion – More liberal use of investigations

• Differential diagnosis– Malignancy– Lymphoma– Inflammatory bowel disease– Infective disease

Concomitant PTB• Concomitant PTB

– Present in 15-25% only

• Sputum smear and culture for AFB:– Low diagnostic yield

• Abnormal CXR:– 19-83%– Average = 38%Marshall JB, et al. Am J Gastroenterol 1993;88:989-999

Horvath KD, et al. Am J Gastroenterol 1998;93:692-696Faylona JM, et al. Ann Coll Surg 1993;3:65-70

Blood tests

• No specific diagnostic blood tests available

• Common blood parameters:– Elevated ESR

• Almost always raised but not exceed 60 mm/hr [Manohar, et al. Gut 1990;31:1130-2]

– Mild anemia • normochromic/ normocytic

[Marshall JB, et al. Am J Gastroenterol 1993;88:989-999]

– Mild leukocytosis [Manohar, et al. Gut 1990;31:1130-2]

Tuberculin test

• High specificity• Low sensitivity• Low positive predictive

value 50-67%

Huebner, et al. Clin Infect Dis 1993; 17:968-75

Radiological tests

• No diagnostic feature available

• Imaging guided peritoneal biopsy– Limited diagnostic sensitivity

USG abdomen

Ascites Right lower quadrant massconsisting of matted bowel

Computer tomography scan

Loculated ascites

Gross ascites Thickened omentum Loculated ascites

Thickened ileocaecal bowel Enlarged paraaortic LN Tubercles in spleen & liver

Contrast study

Stricture in ileocaecal region Stricture in descending colon

• Good for intestinal tuberculosis affecting small or large bowel

Microbiology and histology exam

Definitive diagnosis:

– 1950 Hoon, et al:• Ziehl-Neelsen stain for

AFB• Tissue culture for

mycobacteria• Caseating granulomas

on histology

Hoon JR, et al. Int Abstr Surg 1950;91:417-40

Tissue Biopsy• Peritoneal tapping• Endoscopic biopsy• Laparoscopy• Laparotomy

Histologicalexam

Microbiological Smear & culture

Molecular Methods

• Polymerase chain reaction (PCR)– PCR analysis for Mycobacterium

tuberculosis complex in tissues– Reported as 100% sensitivity in some

series

Uzunkoy, et al. World J Gastroenterol 2004;10(24):3647-3549Tzoanopoulos, et al. Eur J Intern Med 2003;14:367-371

Peritoneal tapping

• Ziehl-Neelsen stain: 3% positive– At least 5000 bacteria/ ml is required

• Culture for AFB: 35% positive– At least 10 bacteria is required– 66-83% positive if 1L of ascitic fluid is cultured after

centrifugation

Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700

Colonoscopy

Mucosalulceration

Mucosal nodules

Deformed Ileocaecal valve

Laparoscopy

• Highest diagnostic yield– Macroscopic appearance 93%– Peritoneal biopsy for ZN stain 3-25%– Peritoneal biopsy for culture 38-92%– Histology 93%

• Low complication rates

Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700

Laparoscopy

Summary of diagnostic tests

Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700

Retrospective review of abdominal TB in NDH

• Method:– Retrospective review of medical records– Between January 2001 to December 2006

(six years inclusive)– With diagnosis of abdominal tuberculosis

Retrospective review of abdominal TB in NDH

23 patientsMale: female = 11:12

Median age = 48 (Range: 8 - 83)

Histology or microbiology provenabdominal TB

13 patients

Not proven10 patients

SuspectedAbdominal TB

6 patients

Other pathology4 patients

Peritoneal TB53.8%

Intestinal TB46.2%

Clinical presentation No of patients (%)

Abdominal pain 77% Ascites 38% Vomiting 38% Weight loss 30% Fever 30% Cough 30% Peritonism 26% Obstruction 13% Mass 4%

Duration of presentation: 1 day to 2 years

Diagnostic tools No of patients

(%)

Diagnosis*

Confirmed (%)

Concomitant PTB 30 NA Abnormal CXR 26 NA Positive ultrasound features 38 NA Positive CT scan features 46 NA Colonoscopy 46 83 Surgery 73 41 Laparoscopy 26 66 Laparotomy 47 27

Total number of patients: 23

*Diagnosis confirmation by positive histology, smear or culture for AFB

Comparison of diagnostic sensitivity

Diagnostic tests

Sensitivity in literarture (%)

Sensitivity in NDH series

(%)Peritoneal

tapping34 0

colonoscopy 66 82

Laparosocpy 92 66

Leung VKS, et al. Hong Kong Med J 2006;12:264-271

Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700

Treatment• Mainstay of treatment

– Anti-tuberculous chemotherapy– Duration for 6-12 months– Response to treatment

• Resolution of symptoms within 3 months of treatment

Role of Surgery• Indications of surgery

– Diagnostic uncertainty• Diagnostic laparoscopy in particular

– Complications• Obstruction• Perforation• Hemorrhage• Fistulation

• Conservative surgical approach should be adopted

Conclusion• Remains a diagnostic challenge to

surgeons– Vague and non-specific clinical features– Low yield of mycobacterium culture or

smear– Invasive investigations are required for

obtaining tissue for histopathology/ culture

Summary

High index of suspicion

More liberal use of invasive investigations

Mainstay of treatment by anti-TB drugs

Thank you