|Year : 2019 | Volume
| Issue : 4 | Page : 144-147
Abdominal tuberculosis: An old disease surprising young surgeons
Royson Jerome Dsouza, Vijay Abraham, S Suraj, Myla Yacob
Division of Surgery, Christian Medical College Hospital, Vellore, Tamil Nadu, India
|Date of Submission||15-Oct-2019|
|Date of Decision||24-Nov-2019|
|Date of Acceptance||26-Nov-2019|
|Date of Web Publication||12-Dec-2019|
Dr. Vijay Abraham
General Surgery Unit 3, Christian Medical College Hospital, Vellore, Tamil Nadu
Source of Support: None, Conflict of Interest: None
A 21-year-old male with no prior illnesses presented to the emergency department with features of small bowel obstruction. Contrast-enhanced computed tomography of the abdomen showed features of ileal obstruction and contained perforation secondary to probable Crohn's disease. However, on exploratory laparotomy, he underwent adhesiolysis, terminal ileal resection, and end ileostomy. The biopsy showed multiple tubercles and other pathognomic characteristics of tuberculosis (TB). The findings were conclusive of abdominal TB involving the peritoneum and terminal ileum. On initiation of antitubercular therapy, his condition improved symptomatically, and he was subsequently discharged. Although the prevalence of TB has been declining in recent times, it still remains a major public health problem in our country. Abdominal TB is known to mimic multiple other conditions, and a high index of suspicion is needed to initiate appropriate therapy, thereby preventing morbidity and mortality. It is therefore crucial that young surgeons familiarize themselves with all the different manifestations of abdominal TB.
Keywords: Abdominal tuberculosis, Crohn's disease, intestinal obstruction secondary to abdominal tuberculosis, surgery for abdominal tuberculosis
|How to cite this article:|
Dsouza RJ, Abraham V, Suraj S, Yacob M. Abdominal tuberculosis: An old disease surprising young surgeons. Curr Med Issues 2019;17:144-7
| Introduction|| |
Tuberculosis (TB) in all its forms still poses to be a life-threatening disease in our country. According to the WHO, the burden of TB is nearly 12 million globally of which India shares 26% of the cases, making it the largest contributor. Of 0.45 million new cases of multidrug-resistant TB detected worldwide in 2012, more than half were in India. Although the lung is the primary organ to be infected, the bacilli can disseminate into almost every other organ in the body. Extrapulmonary TB is difficult to diagnose due to its nonspecific clinical and radiological features. The abdomen is involved concomitantly with the lung in only up to 25% of patients. The presentation is normally with a chronic abdominal pain and fever. However, acute presentation in terms of intestinal obstruction and perforation is uncommon, and its diagnosis is difficult and often delayed. It is also prudent that abdominal TB is distinguished from Crohn's disease histologically, as it shares similar clinical and radiological features. In our report, we present a young male with no prior illnesses who presented to us with features of intestinal perforation while being evaluated for suspected Crohn's disease. His clinical features, relevant investigations, and diagnostic considerations before arriving at the final diagnosis of abdominal TB have been discussed with a review of the literature.
| Case Report|| |
A 21-year-old student presented with complaints of abdominal pain for 2 months, which was insidious in onset and confined to the lower quadrant. It was associated with low-grade fever and abdominal distention. He had a significant loss of weight and appetite. He did not have any history of similar complaints in the past, he did not have any history of abdominal operation, pulmonary TB, or other comorbid illnesses. He was being evaluated in our outpatient clinic for suspected Crohn's disease. Meanwhile, due to acute worsening of symptoms, he presented to the emergency department with severe abdominal pain of 4 days associated with multiple episodes of bilious vomiting, constipation, and obstipation.
On examination, he was emaciated and in acute distress due to pain. His pulse rate was 110/min, blood pressure was 90/60 mmHg, and respiratory rate was 30/min. His abdomen was grossly distended, showing visible intestinal peristalsis. There was tenderness in the right lower quadrant but no features of peritonitis. The bowel sounds were exaggerated. On the digital rectal examination, the rectum was empty.
His baseline blood evaluation revealed a normal leukocyte and differential counts [Table 1]. His chest X-ray [Figure 1] showed no pneumoperitoneum and X-ray of the abdomen [Figure 2] revealed multiple dilated bowel loops with air–fluid levels. After an initial resuscitation with intravenous fluids, nasogastric aspiration, and broad-spectrum antibiotics, a contrast-enhanced computed tomography scan of the abdomen was done [Figure 3]. This was suggestive of a chronic inflammatory pathology with intermittent thickening of jejunal and ileal segments, mesenteric hypervascularity, omental thickening, and features of contained perforation at the terminal ileum. These findings were more in favor of inflammatory bowel disease, likely Crohn's disease.
|Figure 1: Chest X-ray showing dilated colonic loops under the diaphragm – Chilaiditi sign.|
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|Figure 2: X-ray of the abdomen showing multiple dilated small bowel loops.|
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|Figure 3: Contrast-enhanced computed tomography of the abdomen showing omental thickenings (blue arrow head), mesenteric hypervascularity (green arrow head), and thickened walls of the small bowel (red arrow head) with ascites.|
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He underwent an emergency exploratory laparotomy which revealed an abdominal cocoon with encysted and loculated pyoperitoneum. The omentum, peritoneum, mesentery, and bowel wall were studded with multiple tubercles [Figure 4]. There was also a thickening of the terminal ileum with a contained perforation which was adherent to the dome of the bladder. Adhesiolysis followed by terminal ileal resection and an end ileostomy was performed. The abdomen was closed after a thorough peritoneal lavage and placement of drains. The intraoperative findings were suggestive of abdominal TB with peritoneal and terminal ileal involvement.
|Figure 4: Intraoperative findings – multiple tubercles over the small bowel (black arrow head) and contained perforation at the terminal ileum (white arrow head).|
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The biopsies from the resected bowel, omentum, and peritoneum were reported to be necrotizing granulomatous inflammation with caseation and other features consistent with the histopathological diagnosis of intestinal TB. He was then initiated on antitubercular therapy with isoniazid, rifampicin, pyrazinamide, and ethambutol. Following this, he improved symptomatically. He was discharged on the 7th postoperative day. At discharge, he was afebrile with a healthy, functioning stoma.
| Discussion|| |
TB of the abdomen can mimic many other diseases due to its vague, nonspecific presentations and laboratory and radiological examinations. Crohn's disease is the main differential diagnosis to be considered and has to be ruled out before initiating a definitive therapy. Crohn's is a disease of younger age group peaking in the 20–40 range, whereas TB is seen in the 5th–7th decade. There is a considerable overlap in the clinical presentation and laboratory, radiological, and the histopathological findings between these two. Both the diseases involve the terminal ileum; however, isolated involvement of the ileum is common in Crohn's disease, whereas ileocecal segment involvement is more common in TB. The extrapulmonary manifestations of TB can resemble the extraintestinal manifestations of Crohn's such as reactive arthritis, erythema nodosum, and uveitis. Our patient was initially suspected to have a fistulating Crohn's disease and was being evaluated for the same until he had to undergo an emergency laparotomy. In these clinical scenarios, the other differentials to be considered are intestinal lymphoma, Yersinia More Details infections, carcinoma cecum, and peritoneal carcinomatosis.
Surgery for abdominal TB is reserved for emergencies such as intestinal perforation, contained perforation with intra-abdominal sepsis, fistula formation, massive hemorrhage, complete obstruction, or obstruction unresponsive to conservative treatment. About 20%–40% of patients with abdominal TB can present with acute abdomen, the most common being intestinal obstruction due to multiple strictures or healing by cicatrization on initiation of antitubercular therapy. Since TB is a systemic disease, the extent of resection should be conservative. Long segment resections and multiple anastomoses should be avoided since the patients are nutritionally deprived putting them at a higher risk of anastomotic leak.
There are essentially three types of operations performed in abdominal TB. The first type is done to bypass the affected segments of the bowel where an ileostomy or a colostomy is done. The second type is a segmental resection such as limited ileocecal resection or terminal ileal resection. The complications are common in these procedures and include anastomotic leak, fecal fistula, peritonitis, intra-abdominal sepsis, wound dehiscence, and wound infection. This is due to the poor surgical profile of the patients secondary to chronic malnutrition. The third type of operation is bowel conserving strictureplasty for stenosing and obstructive lesions. This procedure is superior to multiple resections and anastomoses, as it does not sacrifice the length of the bowel and avoids the risk of anastomotic leak, short bowel, and blind loop syndromes. However, thickened bowel and hard tissues make execution a challenging proposition.
| Conclusion|| |
Abdominal TB can be of different types such as peritoneal TB, gastrointestinal TB, TB lymphadenitis, and visceral TB. It may often present with acute abdomen, necessitating an emergency exploratory laparotomy. The preoperative diagnosis in an emergency setting is challenging, as it can mimic various other conditions due to its nonspecific laboratory and radiological findings. Therefore, it is important for young surgeons to understand the wide spectrum of manifestations of abdominal TB and wisely choose the appropriate surgical procedures that can be safely performed in this challenging condition.
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Conflicts of interest
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]