International Journal of Scientific & Engineering Research, Volume 5, Issue 7, July-2014 543
ISSN 2229-5518
Clinical Study of Abdominal
Tuberculosis
Dr Jitendra Sankpal, Dr Spoorthy Shetty, Dr Manjiri Sankpal, Dr Vivek Tilwani, Dr Vijay Nikale, Dr Ashish Hatkar
Abstract— This is clinical study of 101 cases of abdominal tuberculosis admitted to tertiary care hospital during May 2010-November
2013. Majority of abdominal tuberculosis patients presented in 21-30yrs age and 11-20yrs age groups which were 34.65% and 21.78% respectively.Majority patients were females, which found to be 62(61.39%) patients, while male were 39(38.61%) patients. Ratio of male to female was 1: 1.59.Majority pateints were from lower socioeconomic group i.e. 66(65.35%) patients.Most common complaint was abdominal pain, which in all i.e.100% patients. Followed by next complains were loss of weight and loss of appetite which were present in
77.23% and 73.27% patients. Past history of tuberculosis present in 8.91% patients.Most common sign was pallor which was present in
67.33 patients and abdominal tenderness, which was a present in 39.60% of patients.Anaemia, was found 69.31% patients. Mantoux test was positive in 25.74% patients and ESR was raised in 67.33% patients.X ray chest showed positive finding of tuberculosis in 24.25% of patients. HIV was reactive in 4.95% of patients. Biopsy and CT abdomen pelvis has maximum sensivityof100%. In all ascites patients Ascites ADA level was increased. Surgical Management was done in 66.34% patients and 33.66% managed with chemotherapy alone.Most common surgical procedure was resection and anastomosis done in 26.87% of patients, followed by right hemicolectomy done in 23.88% patients. Diagnostic laparoscopy was done in 16.42% of patients.Most common operative finding was Ileocaecal mass .Most common complication was wound infection. Mortality occured in 1.49% of patients.In follow up 80% patients completed 6 months of AKT and 20% were on AKT.
Index Terms— Minimum Abdominal kochs, intestinal obstruction, strictures, hemicolectomy, diagnostic laproscopy,
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Uberculosis caused by Mycobacterium tuberculosis is a disease of great antiquity and for a long time it has main- tained its evil reputation and being one of the greatest killer diseases of the mankind. Tuberculosis detected as far back as 10000 BC, still remain a major public health problem
worldwide1.
Tuberculosis causes ill health among millions of people each
year and rank second leading cause of death from infectious
diseases worldwide, after human immunodeficiency virus
(HIV). According to WHO in 2011, there were estimated 8.7
million new cases of tuberculosis and 1.4 million people died
from tuberculosis worldwide2.India alone contributes 26% of this new TB cases. Because of the growing burden of TB, and the recognition that it is one of the most neglected health prob- lems worldwide, in 1993 the WHO declared TB as ‘A global
health emergency’. Indeed, although the metaphor of TB as
“ The Captain of all men of death ” was thought to be
reaching obsolescence, we are currently in a period of resur-
gence of the disease. The incidence of TB cases which was on a
steady decline since last 50 years, especially in the developed
nations, has seen increases since early 1990s. This has been
largely attributed to the emerging HIV epidemic, although
MDR tuberculosis, neglect of control programs, immigration
and other social changes has been important factors2. Tuberculosis is a chronic granulomatous infectious disease, commonly affecting the lungs. However it is a systemic infec- tion and may involve other extrapulmonary site. Abdominal
tuberculosis is 6th commonest form of extrapulmonary in- volvement. Its nonspecific and protean clinical manifestations cause intestinal tuberculosis to be confused with many other diseases especially Crohn’s disease and intestinal neoplasms.
The symptoms and signs often quite vague and laboratory investigations and radiological findings are sometimes non- conclusive. There is no single feature which is diagnostic for abdominal tuberculosis. In case of any localized involvement of the structures of the abdomen the presenting clinical picture will mimic the disease of that organ only. It continues to chal- lenge the diagnostic acumen and therapeutic skills of the pre- sent day surgeon.
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 complica- tions such as obstruction, perforation, fistula, or a mass which does not resolve with medical therapy 3. In most cases a trial of medical therapy should be undertaken prior to surgical inter- vention3. However complications can be fatal and may occur after initiation of antituberculous medications3. Many author advocate surgical management in intestinal obstruction due to TB as the obstructed lesion is often hypertrophic. This form according to many authors, often responds badly to medical management .4
The Surgical treatment of intestinal tuberculosis too has passed through many phases, from the bypass procedures of the pre- antibiotic era to the radical surgeries such as hemi- colectomy and wide resection, followed by the more recent and more conservative, modified surgical procedures such as limited ileocaecal resection, and stricturoplasties. 5
Against this backdrop of persistent prevalence of disease, di- agnostic challenges it pose & changing role for therapeutic management, that why surgeon called upon today in this dis- ease. Hence, this study aims at a fresh look into abdominal tuberculosis and at a better understanding of its clinical mani-
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festations, diagnostic modalities, management and its compli-
cations.
[2]Aim & Objectives
A.To study & analyse clinical presentation of cases of ab-
dominal tuberculosis.
b. To study& analyse various diagnostic modalities for con- firmation of
Abdominal tuberculosis
c. To study & analyse management of abdominal tuberculosis.
d. To study and analyse complication of abdominal tuberculo-
sis.
Study of patients admitted in tertiary care hospital during
May 2010 to Nov.2013.
All suspected and confirmed cases of abdominal tuberculosis.
Cases having evidence of genitourinary tuderculosis. Cases having active pulmonary tuberculosis
Patients detail history, clinical examination carried out Routine investigations carried out in all patients as follows Haemoglobin test
Complete blood count Liver Function tests Renal Function Tests Mantoux test
Erythrocyte Sedimentation Rate
X ray Chesst PA Veiw
X ray Abdomen Erect
These investigations are done for doubtful diagnosis to con- firm or support diagnosis.
ELISA Ig
Ascites fluid routine microscopy
Ascites fluid AFB staining
Acites fluid ADA level
USG (Abdomen + Pelvis)
Computed tomography of Abdomen + Pelvis( plain and con-
trast.)
Colonoscopy
Barium meal follow through
Biopsy
All patient received AKT as per DOTS.
Conservative management was done for uncomplicated ab-
dominal tuberculosis.
Operative management was done for complications of ab-
dominal tuberculosis and when diagnosis was in doubt.
Patient’s study of post op complications, mortality, and follow
up was carried out after 2 and 6 months.
Out of 101cases studied, 39(38.61%) were male and 62(61.39%) female cases were female. Female cases more observed than female. Male to female ratio was ratio found to be 1:1.6. In male as well as female maximum patients were observed in
21-30 yrs age group.
In present study majority pateints were from lower socioeco- nomic group i.e. 66(65.35%) patients consistent with studies done by Naseer Ahmed et al (2008)6 and Muhammad Saaiq et al (2012)7
Abdominal pain was observed in 100(100%) patients which was major symptom. After pain in abdomen second major symptom was found to be loss of weight 78(77.23%) followed by loss of appetite which observed in 74(73.27%) of patients. Past h/o tuberculosis observed in least no of patients i.e.
9(8.91%).Rest symptoms observed were vomiting
59(58.42%)patients, constipation 43(42.57%) patients), diar- rhoea 12(11.88%), nausea 55(54.45%), Abdominal distension
43(42.57%), Night sweats 44(43.56%).,fever49(48.51%). Most common clinical sign observed in this study was pallor
68(67.33%), which followed by Abdominal tenderness
40(39.60%).Least observed clinical sign was lymphadenopathy
18(17.82%).Rest clinical signs were Ascites 36(35.84%), lump in
abdomen 25(24.75%), Abdominal guarding32(31.68%), Ab-
dominal Rigidity 22(21.78%).
In present study 70(69.31%) patients had low haemoglobin.
Lymphocyte count predominance was found in 31(30.69%)
patients. Liver function test, renal function test found derange
in 15(14.85%) and 10(9.90%) patients respectively. ESR was raised in 68(%) patients and Mantoux test was positive in
26(25.74%) patients. Muneef et al (2001)8 found positive man- toux test in 27% of patients.
In this study chest x ray abnormal findings were present in
25(24.75%) patients and x ray abdomen erect abnormal find-
ings present in 60(59.41%) patients. Out of 101 patients
5(4.95%) were HIV Positive.
In this study, Ultrasonography and CECT Abdomen pelvis were done in 95(94.06%) patients. Biopsy, ELISA Ig, BMFT, colonoscopy were done in 49(48.51%), 35(34.65%), 29(28.71%),
17(16.83%) patients respectively. In CECT abdomen pelvis done in all 95(100%) patient had some positive feature. All
49(100%) biopsy done patients had tuberculosis in biopsy re- port. Out of 95 Ultrasonography patients 79(83.16%) patients had some positive features. In Barium meal follow through done patients, 29 patients out of 19(65.52) patients had some positive features. 16(94.12%) patients had positive finding out of 17 patients in colonoscopy test. CT scan, USG abdomen, Biopsy, ELISA Ig, BMFT, colonoscopy were not done in
6(5.94%), 6(5.94%), 52(51.49%), 66(64.35%), 72(71.29%),
84(83.17%) patients respectively. Thus, CT scan and Biopsy had 100% sensivity. Colonoscopy, USG, ELISA Ig, BMFT were having sensivity of 94.12%, 83.16%, 77.14%, 65.52% respective- ly. According to Ashraf Muhammad et al (2010)9 maximum
sensitive tests was Biopsy, which was 97% sensitive. Next sen-
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sitive test was ELISA Ig which about 80% sensitive.According to Rustam Khan et al (2006)10 maximum sensitive tests was Biopsy, which was 100% sensitive. Next sensitive test was USG (A+B) which was 88% sensitive
Mean cell count in present study was 550.28+351.26. Maxi- mum cell count was 1360 and minimum cell count was
160.Lymphocytes were predominant in all ascites fluids. Ac- cording to M.P. Sharma et al (2004) total count of ascites fluid is 150-4000/micro litre and predominantly consist of lympho- cytes (>70%).Mean protein level was 3.97+0.66. Maximum protein level was 5.3 and minimum protein level was 3.1 as compared to to M.P. Sharma et al (2004)11
Mean sugar level was76+10.90.Maximum sugar level was 98 and minimum sugar level was 60.
In present study all ascetic fluid was negative for AFB bacilli. According to M.P. Sharma et al (2004)11 staining for acid fast bacilli are positive in less than 3% of cases.In present study all patients with ascites had increased ADA level.According to Dwivedi et al (1990)12 ascites fluid ADA level has 100% sensiv- ity.
In this study out of 101 patients 34(33.66%) patients managed conservatively and 67(66.34%) patients managed by surgically. In Muhammad Ashraf et al (2010)9 study 88% patients man- aged surgically and Shabana Jamal et al (2011)13 study 95.6% patients were managed surgically.In present study Resection and anastomosis was most common i.e. in 26.875 patients, which followed by right hemi colectomy in 23.88% patients. Adhesiolysis was done in 22.39% patients. Diagnostic laparos- copy was performed in 16.42% patients.
According to Muhammad Asharaf et al (2010)9 right hemi- colectomy was the most common procedure performed. Ad- hesiolysis was done 17% patients.According to Taj Moham- mad Khan et al 14 most common procedure done was resection and anastomosis. In present study, ileocaecal mass was found in 21(32.84%) patients, which is most common operative find- ing. Strictures were found in 17(25.37%) patients .Adhesions was found in 15(22.39%) patients. Ascites was found in
12(17.91%) patients. Enlarged mesenteric lymph nodes were found in 7(10.45%) patients. Perforations and military tubercle were present in 6(8.96%), 5(7.46) patients respectively(table 1). According to Taj Mohammad khan et al14 adhesions was most common finding and Naseer Ahmed et al 6 strictures were most common intraoperative finding.
In present study most common site was intestine i.e.in 60.39% patients followed by peritoneum in 42% patients. Mesenteric lymph node and solid organ involved in 7% and 6% patients respectively consistent to Rustam et al (2006)10
In intestine ileum is most common part involved i.e. in
33(32.67%) patients. In intestine rest parts jejunum, ileocaecal region, appendix were involved in 4(3.96%), 22(21.78%),
2(1.98%) patients respectively. In post-operative patients,
8(11.94%) patients were developed wound infection. Septi-
caemia and anastomosis leak developed in 2(2.99%) patients.
TABLE NO.1: DISTRIBUTION OF SAMPLE BY OPERATIVE FIND-
INGS
Operative Findings | frequency | Percentage |
Ileocaecal Mass | 22 | 32.84 |
Strictures | 17 | 25.37 |
Adhesions | 15 | 22.39 |
Ascites | 12 | 17.91 |
Mesenteric Lymph Nodes | 7 | 10.45 |
Perforations | 6 | 8.96 |
Miliary tubercles | 5 | 7.46 |
Pulmonary complications developed in 5(7.46%) patients. One (1.49%) patients died postoperatively. Arshad Abro et al (2010)15most common post-operative complication was wound infection and Muhammad-ul-din et al (2012)16most common post op complication was respiratory infection. During follow up 80% patients completed 6 months of AKT and 20% were still on AKT. Nausea and vomiting occurred in 4% patients.
2% developed jaundice. Rests of the Patients were asympto- matic.
Abdominal tuberculosis is one of common cause of chronic abdominal pain and incidence being common in lower socio- economic status. The History of tuberculosis is as old as the history of mankind. Possible routes of abdominal tuberculosis include Ingestion of tubercle bacilli, Haematogenous seeding, Transport via infected bile, and Extension from adjacent dis- eased organs or tissues. There is no single feature which is diagnostic of abdominal tuberculosis. Tuberculosis has been known for its protean manifestations and often referred to as the ‘Great Mimic’. It can present with various symptoms ranging from chronic grumbling pain abdomen to acute perfo- ration; from mild fever to meningitis as a result of miliary tu- berculosis. To diagnose Tuberculosis high degree of suspicion is the prime need. This study thus gives a basic outline of presentation diagnosis and management of abdominal tuber- culosis in developing country.
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