Accepted Manuscript

Title: Clinical and laboratory presentation of abdominal

tuberculosis in Shillong, Meghalaya: experience from
Northeast India

Authors: Bhupen Barman, Arvind Nongpiur, Kaustubh Bora,

Evangelyne Synrem, Pranjal Phukan, Kalyan Sarma

PII: S0976-2884(17)30060-7
DOI: http://dx.doi.org/doi:10.1016/j.injms.2017.06.002
Reference: INJMS 135

To appear in:

Received date: 5-5-2017

Revised date: 4-6-2017
Accepted date: 6-6-2017

Please cite this article as: Bhupen Barman, Arvind Nongpiur, Kaustubh Bora,
Evangelyne Synrem, Pranjal Phukan, Kalyan Sarma, Clinical and laboratory
presentation of abdominal tuberculosis in Shillong, Meghalaya: experience from
Northeast India (2010), http://dx.doi.org/10.1016/j.injms.2017.06.002

This is a PDF file of an unedited manuscript that has been accepted for publication.
As a service to our customers we are providing this early version of the manuscript.
The manuscript will undergo copyediting, typesetting, and review of the resulting proof
before it is published in its final form. Please note that during the production process
errors may be discovered which could affect the content, and all legal disclaimers that
apply to the journal pertain.
Title: Clinical and laboratory presentation of abdominal tuberculosis in Shillong, Meghalaya:
experience from Northeast India

Full length Article

Title: Clinical and laboratory presentation of abdominal tuberculosis in Shillong, Meghalaya:
experience from Northeast India
Author details:
Dr Bhupen Barman, MD ( Medicine), Associate Professor, Department of General
Medicine, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences
(NEIGRIHMS), Shillong, Meghalaya, India, 793018
Dr Arvind Nongpiur, Assistant Professor, Department of Psychiatry, North Eastern Indira
Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong,
Meghalaya, India, 793018. arvindnongpiur@gmail.com
Dr Kaustubh Bora, Regional Medical Research Centre, N.E.Region (Indian Council of
Medical Research), Dibrufarh, assam. Kaustubhbora1@gmail.com
Dr Evangelyne Synrem, Senior Resident, Department of General Medicine, North Eastern
Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong,
Meghalaya, India, 793018. evansynrem@gmail.com
Dr Pranjal Phukan , Associate Professor, Department of Radiology, North Eastern Indira
Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong,
Meghalaya, India, 793018. pphukan10@gmail.com
Dr Kalyan Sarma, Senior Resident, Department of Radiology, North Eastern Indira Gandhi
Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, Meghalaya,
India, 793018. sarmakalyan@ymail.com

Corresponding author:
Dr Bhupen Barman, MD ( Medicine), Associate Professor, Department of General
Medicine, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences
(NEIGRIHMS), Shillong, Meghalaya, India, 793018. Phone: 09485190835 , Mail
id: drbhupenb@gmail.com

ABSTRACT:

Objective: Tuberculosis is an immense health problem in the developing countries.

Diagnosis of abdominal tuberculosis is often difficult because of its protean manifestations.
Our objective was to evaluate the various clinical and laboratory presentation of abdominal
tuberculosis from a tertiary care setup.
Materials and methods: We reviewed the clinical and laboratory features of patients
presenting with abdominal tuberculosis through retrospective analysis from January 2016
to December 2016 from a tertiary care hospital in Northeast India.
Results: Of the 42 adult patients with abdominal tuberculosis who were part of the study,
22 (52.4%) were males and 20 (47.6%) females. The mean age was 34.6 years. Fever
(93%) was the most common presenting symptom followed by pain abdomen (74%), loss
of appetite (71%), weight loss (67%) and nausea/vomiting (45%). The main organs
involved were the mesenteric lymph nodes (n = 19, 45.2%), the peritoneum (n = 6, 14.3%),
and gastrointestinal (n = 5, 11.9%). Pulmonary tuberculosis was apparent in 4 (9.5%)
patients.
Conclusion: Abdominal tuberculosis presents with varied symptomatology. A high degree of
suspicion along with meticulous history and clinical examination corroborated with
laboratory investigation is required for its diagnosis

Key words: Abdominal tuberculosis, Lymphadenopathy, Gastrointestinal, Ascites,

Northeast India

Introduction:

Despite the discovery of the causative organism for more than a century ago and being
100% curable, tuberculosis (TB) remains a major health public problem. It is the second
leading cause of death among infectious diseases worldwide, with extra-pulmonary
tuberculosis becoming increasingly common.1 The estimated prevalence of tuberculosis is
10.4 million globally which leads to 1.8 million annual deaths.2 The primary site of TB is
lung; although virtually all organ system may be affected. Extra pulmonary tuberculosis
constitutes about 15 to 20 per cent of all cases of tuberculosis and accounts for more than
50 per cent of the cases in individuals positive for Human Immuno Deficiency (HIV) virus.3
Abdominal tuberculosis is not a very common form of extra-pulmonary tuberculosis. It
contributes to around 3.5 to 16% of TB cases.4-5 Abdominal tuberculosis is the sixth most
frequent form of extrapulmonary tuberculosis after lymphatic, genitourinary, bone and joint,
miliary and meningeal tuberculosis.6 Abdominal TB may manifest in different forms, with
gastro-intestinal (GI) tuberculosis being the most common, followed by TB of peritoneum
and abdominal lymph nodes. Although any part of the GI tract can be affected, ileocecal
region is the most commonly involved site. The diagnosis of abdominal TB is often difficult
because of its non-specific clinical manifestations mimicking several other diseases. A high
index of clinical suspicion, especially in the high-risk population is required for early
diagnosis.
The South-East Asian and Western Pacific regions represented 60% of the global TB
burden, with India alone sheltering one-fourth of the cases. Though India is the second-
most populous country in the world, one fourth of the global incident TB cases occur in
India annually. As per WHO Global TB Report 2016 (WHO, 2016), out of the estimated
global annual incidence of 10.4 million TB cases, 2.2 million were estimated to have
occurred in India.2
Meghalaya in northeast India is predominantly inhabited by hill tribes belonging to the
Austro-Asiatic and Tibetan-Burmese stock. Ensuring quality medical care and healthcare
infrastructure in the northeastern states of India has been a challenge due to the peculiar
problems of the region, viz. remoteness and tough terrain, difficult transportation and
communication, economic backwardness, shortage of trained medical manpower,
ineffective utilization of existing facilities, ethnic violence, insurgent extortion networks,
porous international border facilitating illicit drug trade, etc.7 There are few studies on
prevalence of pulmonary and extra-pulmonary tuberculosis from Meghalaya and the
adjoining northeastern states of Assam, Arunachal Pradesh, Nagaland, Mizoram, and
Manipur, which point towards a substantial burden of tuberculosis.8-11 The current study
was conducted with the aim to evaluate the clinico-laboratory profile of abdominal TB
patients diagnosed in our centre.

Materials and methods:

Study design and participants:
We carried out a retrospective study of patients who were admitted from January 2016 to
December 2016 at the Department of General Medicine, North Eastern Indira Gandhi
Regional Institute of Health and Medical Sciences (NEIGRIHMS) which is a tertiary care
hospital in Shillong, Meghalaya. The study was approved by the Institutional Ethics
Committee. All the cases diagnosed as abdominal TB, including gastrointestinal tract,
peritoneum, mesenteric lymph nodes or other intra-abdominal solid organs were
considered. Data collected from the records of these patients included clinical
manifestations, results of laboratory tests (such as sonography of abdomen, contrast
enhanced computed tomography abdomen, hematology, biochemistry and histopathology,
when available).
The diagnosis of abdominal TB was made in all the cases fulfilling the following criteria:
Acid fast stain positivity for M. tuberculosis in ascites fluid/biopsy specimens.
Exudative ascites fluid with high adenosine deaminase (ADA) activity
Identification of caseating granulomas on histological examination of biopsy
specimens from lymph node of abdomen.
Radiological features compatible with TB on ultrasound or contrast enhanced
computed tomography(CECT) scan of the abdomen,
Patients with a high index of clinical suspicion and negative diagnostic workup but
who showed a good response to anti-TB therapy.

Statistical analysis:
The statistical analyses were performed in SPSS 17.0 (Chicago, USA). The categorical
data were tabulated as counts and percentages, along with 95% confidence intervals (CIs).

Results:
A total of 42 patients were diagnosed with abdominal tuberculosis from January 2016 to
December 2016. Of these, 22 (52.4%) were males and 20 (47.6%) were females (male:
female ratio = 1.1:1). The age of the patients ranged from 19 to 67 years (mean age = 34.6
years). Most of the patients (35.7%) were in the age group of 31 to 40 years.

The most common symptomatic presentation among our patients was low grade fever with
evening rise of temperature (93%). Although a wide index of suspicion is required to
diagnose abdominal TB in time, yet, a constellation of presentation such as low grade fever
(93%), pain abdomen (74%), loss of appetite (71%), weight loss (67%), nausea and/or
vomiting (45%), diarrhoea alternating with constipation (36%) and distension of abdomen
(33%) were found to be useful indicators of abdominal tuberculosis (Table 1). Most
common signs observed in this study were anemia (76%), abdominal tenderness (74%),
doughy abdomen (40.5%) and malnutrition (50%).

Depending upon the anatomical involvement, we classified the patients as peritoneal TB,
gastro-intestinal TB, tubercular lymphadenopathy and visceral TB (Table 2). We found that
tubercular mesenteric lymphadenopathy with or without involvement of other abdominal
organs was the most common type of abdominal TB in our study sample (n = 19, 45.2%).
Peritoneal involvement and gastro-intestinal TB were detected in 14.3% and 11.9% of the
patients, respectively. Mixed involvement (i.e. peritoneal TB and tubercular
lymphadenopathy present concurrently) was also common (23.8%). Two patients had
involvement of the viscera (one in liver and the other in psoas muscle) (Table 2 and Table
3). Among the patients with gastro-intestinal TB, ileocaecal region was the most common
site of involvement (n=4, 10%). One patient had duodenal involvement. Extra-abdominal
TB was observed in six patients (14.3%), four of whom had sputum positive pulmonary
tuberculosis (9.5%). Other sites involved were cervical lymph nodes (n=1; 2.4%) and
meninges (n=1; 2.4%).

Ultrasonography of abdomen was done in all patients (Table 4). The most common
sonographic findings were mesenteric lymphadenopathy (n=19, 45.2%, 95% CI: 31.2 -
60.1) followed by hepatomegaly (n=9, 21.4%, 95% CI: 11.7 - 35.9), and ascites (n=6,
14.3%, 95% CI: 6.7 - 27.8). Splenic enlargement and intestinal thickening were noted in 4
patients each (9.5%, 95% CI: 3.8 - 22.1).

On the other hand, reports of CECT scan of the abdomen were present for 24 patients
(Table 5). Mesenteric lymphadenopathy (70.8%, 95% CI: 50.8 - 85.1) and intestinal
thickening (45.8%, 95% CI: 27.9 - 64.9) accounted for the bulk of the tomographic findings
in our patients. Ascites was found in 8 patients (33.3%, 95% CI: 17.9 - 53.3), whereas
hepatic and splenic enlargement was present in 4 (16.7%) and 2 (8.3%) patients
respectively. Further, uncommon presentations like psoas abscess and splenic abscess
were detected in 1(2.4%) patient each. Subacute intestinal duodenal obstruction secondary
to duodenal TB was present in 1(2.4%) patient.

Ascitic fluid analysis was done in 16 cases. Ascitic fluid was exudative in nature with high
protein content and lymphocytic pleocytosis in all these cases. Besides, the ADA activity in
these samples were elevated (Average=86 U/l) along with raised lactate dehydrogenase
level. None of these fluid samples were positive when stained for acid fast bacilli (AFB).

Mantoux skin test was positive in 8 (19%) patients. Majority of the patients were anaemic
(average haemoglobin = 9.9 g/dL) and had raised ESR (average ESR = 63.9 mm AEFH).
Raised serum globulin (mean = 4.6.g/dL) with diminished albumin levels (mean = 3.01
g/dL) leading to altered albumin:globulin ratio was very common. Two patients (8.3%) were
positive for HIV and both had mixed involvement of peritoneum and lymph node.

Discussion:

Abdominal TB is the sixth most common site for extra pulmonary involvement after lymph
node, genitourinary, bone and joint, miliary and meningeal tuberculosis.6 Abdominal TB
usually occurs in four forms: tuberculous lymphadenopathy, peritoneal tuberculosis,
gastrointestinal tuberculosis and visceral tuberculosis involving solid organs. All these
varieties were found in our study. Combination of these varieties also exists. 12 We found 10
such cases where lymph node involvement and peritoneal involvement were concurrently
present. The tubercle bacilli may reach the gastrointestinal tract via direct contact through
the ingested food, swallowing infected sputum in patients with active pulmonary TB,
haematogenous spread from active pulmonary or miliary TB, or may spread from infected
adjacent lymph nodes and viscera such as fallopian tubes, adnexa.13

Abdominal tuberculosis can occur at any age group, but commonly prevalent in young
people at the peak of their productive life. This is reflected in this study as majority of our
patients were in the third and fourth decades of life, which is consistent with other
studies.14-16 The presentation of abdominal tuberculosis in this productive age group has
important economic implications since these are people in their most productive years and
this disease imposes a considerable burden on their families and the society as a whole.

In our study, the gender distribution was almost equal with slight male preponderance
which is similar to previous studies.15,17-18 However, some Indian studies have suggested a
slight female predominance.19-20

We observed the most frequently occurring symptoms were fever (ranging from low to high
grade), abdominal pain, weight loss, loss of appetite and altered bowel habit. Most
commonly observed physical findings were anemia, malnutrition, abdominal tenderness
and doughy feeling of abdomen but, none of the signs except for doughy feeling of
abdomen, were suggestive of abdominal TB. In view of the nonspecificity of signs and
symptoms diagnosis of abdominal TB requires a high level of suspicion (especially in
endemic areas) with a careful history taking and physical examination.

The reported incidence of coexistence of abdominal with pulmonary tuberculosis varies

from 5% to 36%.17, 21-22 We found concomitant pulmonary tuberculosis in approximately
10% (4 patients) of the sample, although one patient had complaints suggestive of the
same. Therefore, sputum for AFB, chest Xray or chest CT should be performed routinely in
patients with diagnosis of abdominal TB. Further, evidence of active pulmonary TB will also
help in the diagnosis of abdominal TB.

Tuberculosis virtually can affect any organ or tissue in the abdomen, and can be mistaken
for other inflammatory or neoplastic conditions because of nonspecific clinical
manifestations. In this study we found mesenteric lymph node as the most frequently
involved site in cases of abdominal tuberculosis. Classically the most common sites of
tuberculosis in the abdomen include gastrointestinal tract, peritoneal cavity and lymph
node.23 Our findings were in accordance with some of the previously published literature.24
Within the gastrointestinal tract, the ileocecal area is the most common site of involvement.

USG of abdomen is very useful in diagnosis of abdominal TB and is characterised by (i)

free and loculated ascites, (ii) localized ascites ('Club Sandwich sign'), (iii) adhesions, (iv)
peritoneal thickening, (v) peritoneal nodules, (vi) lymphadenopathy (mesenteric, peri-
pancreatic, periportal and para-aortic groups) and (vii) bowel wall thickening (15 mm or
more), especially involving ileocaecal region. Of these, the presence of fine fibrinous
strands in the ascitic fluid, localized ascites and mesenteric thickening, with enhanced
mesenteric echogenicity along with lymphadenopathy were highly suspicious of a diagnosis
of TB in appropriate clinical settings.25-26 In the present study USG abdomen was done in
all patients and showed mesenteric lymphadenopathy (45%) with or without intestinal and
omental thickening in most cases followed by ascites (14%) compared to ascites in 79%
and enlarged lymph nodes in 35% of the patients by Uygur-Bayramili et al and 43% and
29.5% of the patients respectively by Shreshtha S et al.27-28

CT scan of abdomen provides a comprehensive overview of abdominal structures and

hence is the imaging modality of choice for evaluation of undiagnosed cases, but bearing
strong clinical suspicion. It is also helpful for detecting mixed variety of cases as well as
cases with atypical presentation (e.g. splenic abscess). The varied presentations in CT
abdomen specific for tuberculosis that are reported in the literature are: lymph node with
low density centres with calcification, high density (25-45 HU) ascites, omental abnormality
(smudged, omental cake and omental line), adherent bowel loop and ileocecal
thickening.29-30 Our experience shows that in addition to detecting the usual presentations
of abdominal TB, such as lymphadenopathy (70%) followed by intestinal thickening (46%)
and ascites (33%), CT scan of the abdomen is useful for diagnosing cases with atypical
presentation (e.g. splenic abscess) as well.

Ascitic fluid examination in abdominal TB is typically characterised by straw coloured fluid

with high protein (>2.5 g/dl), serum-ascites albumin gradient <1.1 g/dl, cells >1000/mm3
with predominantly lymphocytes (>70%) and adenosine deaminase (ADA) levels >33 U/l. A
smear for acid-fast bacilli (AFB) has a sensitivity of only 0 to 3%, and a culture increases
the sensitivity for diagnosis to 35 to 50%. Ascitic fluid ADA activity has been proposed as a
useful diagnostic test for abdominal TB, and our finding corroborates the same. In countries
with a high incidence of TB and in high risk patients, measurement of ADA in ascitic fluid
might be a useful screening test.31-32 In the present study ascitic fluid analysis was done in
16 cases and characterized by lymphocytic pleocytosis with high protein and high ADA and
high lactate dehydrogenase (LDH) level with none of the case was positive for AFB.

The conventional methods of diagnosing TB, such as microscopy detection of AFB and
culture have shortcomings the former has low sensitivity (~53.3%), and the latter is very
time-consuming. Since abdominal TB is paucibacillary, the diagnosis is even more
challenging. Often, the yield of organisms is low (under 50%) and characteristic histological
changes are considered diagnostic. In comparison, molecular methods like multiplex
polymerase chain reaction (PCR) test has a superior sensitivity (93.7%) and specificity
(97.3%) in AFB smear positive samples.33 For diagnosing extra-pulmonary TB too, PCR-
based methods with multiple targets (e.g. IS6110 and MPT64 genes) appear promising.34-35
The only drawback is lack of trained manpower and cost-issues in resource poor settings.

The recommended treatment for abdominal TB is anti-TB therapy for a minimum of 6

months including ethambutol, rifampicin and isoniazid for 3 months followed by rifampicin
and isoniazid for 6 months or pyrazinamide, ethambutol, rifampicin and isoniazid for 2
months followed by rifampicin and isoniazid for 4 months.36 It is important to administer a
correct and complete course, as inadequate drugs, dose or duration is the most important
cause of emergence of multi-drug resistant tuberculosis. Some patients may require
extension of the continuation phase of ATT, and this must be assessed by the treating
clinician, further research is required to establish the optimum treatment duration in these
forms of abdominal TB. Sometimes surgical interventions are of value in establishing
diagnosis (via exploratory laparotomy) and for managing complications of abdominal TB.

To conclude, we catalogue the clinical and laboratory presentation of abdominal TB cases

diagnosed in our set-up over a period of one year. Abdominal TB is a major public health
problem, more so in developing countries. A high degree of clinical suspicion is necessary
for its diagnosis and subsequent management. History of the patient and meticulous clinical
examination can provide valuable pointers towards its diagnosis, especially when
corroborated with biochemical, microbiological and pathological tests. However, clinical
presentation alone is often inadequate to establish the diagnosis definitively. This is
because presentation of the patients are varied and often non-specific. Thus, the role of
imaging modalities like ultrasonography and computed tomography of the abdomen as
components of the work-up up such patients has become indispensable. These modalities
are not only helpful for diagnosing the usual cases of abdominal TB, but are also helpful for
detecting the atypical cases.

References:
1. Frieden TR, Brudney KF, Harries AD. Global tuberculosis: perspectives,
prospects, and priorities. JAMA. 2014;312(14):1393-4
2. World Health Organization. Tuberculosis. Global Tuberculosis Report 2016
http://www.who.int/tb/en/ accessed on 5th May 2017
3. Sharma SK, Mohan A. Extrapulmonary tuberculosis. Indian J Med Res.
2004;120(4):316-53
4. al Karawi MA, Mohamed AE, Yasawy MI, Graham DY, Shariq S, Ahmed AM, al
Jumah A, Ghandour Z. Protean manifestation of gastrointestinal tuberculosis: report
on 130 patients. J Clin Gastroenterol. 1995;20(3):225-32
5. Kapoor VK. Abdominal tuberculosis. Postgrad Med J. 1998;74(874):459-67
6. Paustian FF, Marshall JB. Intestinal tuberculosis. In: Berk JE, editor. Bockus
Gastroenterology. 4th ed. Philadelphia: WB Saunders: 1985. p. 2018-36
7. Prakash A, Saxena A. Health in north-east region of India The new focus of
attention (editorial). Indian J Med Spec 2016; 7: 9394
8. Bhattacharya PK, Jami Md, Lyngdoh M, Akhtar H, Roy A, Talukdar KK. Spectrum of
Pulmonary and Extra-Pulmonary Tuberculosis: A Retrospective Study from North
East India. National J of Laboratory Medicine. 2016; 4(5): IO06-IO10
9. Synmon B, Das M, Kayal AK, Goswami M, Sarma J, Basumatary L, Bhowmick S.
Clinical and radiological spectrum of intracranial tuberculosis: A hospital based
study in Northeast India. Indian J Tuberc. 2017;64(2):109-118
10. Bhuyan M, Dutta A, Dutta D. Management of spinal tuberculosis in the north-
eastern region of India. Int J Health Sci Res. 2017; 7(2):31-36
11. Devi SB, Naorem S, Singh TJ, Singh KB, Prasad L, Devi TS. HIV and TB Co-
infection (A Study from RIMS Hospital, Manipur).JIACM 2005; 6(3): 220-3
12. Debi U, Ravisankar V, Prasad KK, Sinha SK, Sharma AK. Abdominal tuberculosis
of the gastrointestinal tract: revisited. World J Gastroenterol. 2014;20(40):14831-40
13. Horvath KD, Whelan RL. Intestinal tuberculosis: return of an old disease. Am J
Gastroenterol. 1998;93:692696
14. Baloch NA, Anees S, Baber M, et al. Abdominal tuberculosis: a review of 68 cases.
J Surg Pak. 2002;7:1214
15. Awasthi S, Saxena M, Ahmad F, Kumar A, Dutta S. Abdominal Tuberculosis: A
Diagnostic Dilemma. J Clin Diagn Res. 2015;9(5):EC01-3
16. Sharma MP, Bhatia V. Abdominal tuberculosis. Indian J Med Res. 2004;120(4):305-
15
17. Rajput MJ, Memon AS, Rani S, Memon AH. Clinicopathological profile and surgical
management outcomes in patients suffering from intestinal tuberculosis. JLUMHS
2005; 4: 113-8
18. Chaudhary P, Kumar R, Ahirwar N, Nabi I, Gautam S, Munjewar C, Kumar A. A
retrospective cohort study of 756 cases of abdominal tuberculosis: Two decades
single centre experience. Indian J Tuberc. 2016;63(4):245-250
19. Jain M, Baijal R, Kumar P, Gupta D. Profile of patients with gastrointestinal TB at a
tertiary care centre in western India. Trop Doct. 2011;41(4):242-3
20. Das P, Shukla HS. Clinical diagnosis of abdominal tuberculosis. Br J Surg.
1976;63(12):941-6
21. Arif AU, Shah LA, Ullah A, Sadiq MuD. The frequency and management of intestinal
tuberculosis; a hospital based study. J Postgrad Med Instit 2008; 22
22. Sircar S, Taneja VA, Kansra U. Epidemiology and clinical presentation of abdominal
tuberculosis--a retrospective study. J Indian Med Assoc 1996; 94: 342-4
23. Rathi P, Gambhire P. Abdominal Tuberculosis. J Assoc Physicians India.
2016;64(2):38-47
24. Debi U, Ravisankar V, Prasad KK, Sinha SK, Sharma AK. Abdominal tuberculosis
of the gastrointestinal tract: Revisited. World J Gastroenterol 2014; 20(40): 14831-
14840
25. Kedar RP, Shah PP, Shivde RS, Malde HM. Sonographic findings in
gastrointestinal and peritoneal tuberculosis. Clin Radiol. 1994;49(1):24-9
26. Jain R, Sawhney S, Bhargava DK, Berry M. Diagnosis of abdominal tuberculosis:
sonographic findings in patients with early disease. AJR Am J Roentgenol.
1995;165(6):1391-5
27. Uygur-Bayramili O, Dabak G, Dabak R. A clinical dilemma: abdominal
tuberculosis. World J Gastroenterol. 2003;9(5):1098 1101
28. Shreshtha S, Ghuliani D. Abdominal tuberculosis: A retrospective analysis of
45 cases. Indian J Tuberc. 2016;63(4):219-224
29. Suri S, Gupta S, Suri R. Computed tomography in abdominal tuberculosis. Br J
Radiol. 1999;72(853):92-8
30. Ha HK, Jung JI, Lee MS, Choi BG, Lee MG, Kim YH, Kim PN, Auh YH. CT
differentiation of tuberculous peritonitis and peritoneal carcinomatosis. AJR Am
J Roentgenol. 1996;167(3):743-8
31. Voigt MD, Kalvaria I, Trey C, Berman P, Lombard C, Kirsch RE. Diagnostic value
of ascites adenosine deaminase in tuberculous peritonitis. Lancet. 1989
8;1(8641):751-4
32. Dwivedi M, Misra SP, Misra V, Kumar R. Value of adenosine deaminase estimation
in the diagnosis of tuberculous ascites. Am J Gastroenterol. 1990;85(9):1123-5
33. Chong VH. Differences in patient profiles of abdominal and pulmonary tuberculosis:
a comparative study. Med J Malays. 2011;66 (4):318321
34. Kaur IR, Kashyap B, Goel N, Avasthi R,Vaid N, Arora V, Singh NP. Utility of PCR
targeting IS6110 and MPT64 genes in the diagnosis of extrapulmonary tuberculosis.
Indian J Med Spec 2017 (Available online 18 May 2017)
https://doi.org/10.1016/j.injms.2017.05.002
35. Dayal R, Agarwal D, Pathak H, Feroz S, Kumar M, Chauhan DS, Bhatia R. PCR
targeting IS6110 in diagnosing tuberculosis in children in comparison to MGIT
culture. Indian J Tuberc. 2016;63(3):154-157
36. Chaudhuri AD. Recent changes in technical and operational guidelines for
tuberculosis control programme in India - 2016: A paradigm shift in tuberculosis
control. J Assoc Chest Physicians 2017;5:1-9.
Table 1. Clinical presentation of the patients (N = 42).

Clinical Presentation n Percentage (95% CI)

Abdominal distension 14 33.3 (21 - 48.5)
Abdominal pain/tenderness 31 73.8 (58.9 - 84.7)
Abdominal rigidity 3 7.1 (2.5 - 19)
Doughy feeling of abdomen 17 40.5 (27 - 55.5)
Weight loss 28 66.7 (51.6 - 78.9)
Malnutrition 21 50 (35.5 - 64.5)
Anaemia 32 76.2 (61.5 - 86.5)
Fever 39 92.9 (80.9 - 97.5)
Nausea/vomiting 19 45.2 (31.2 - 60.1)
Loss of appetite 30 71.4 (56.4 - 82.8)
Diarrhoea 7 16.7 (8.3 - 30.6)
Constipation 2 4.8 (1.3 - 15.8)
Diarrhoea alternating with constipation 15 35.7 (22.9 - 50.8)
Table 2. Classification of the patients (N = 42)

Classification of the cases N Percentage (95% CI)

Peritoneal tuberculosis 6 14.3 (6.7 - 27.8)
Gastro-intestinal tuberculosis 5 11.9 (5.2 - 25)
Tubercular lymphadenopathy 19 45.2 (31.2 - 60.1)
Visceral tuberculosis 2 4.8 (1.3 - 15.8)
Mixed (Peritoneal and lymphadenopathy) 10 23.8 (13.5 - 38.5)
Table 3. Sites of involvement

Site of involvement n Percentage (95% CI)

Peritoneum 6 14.3 (6.7 - 27.8)
Lymph nodes 19 45.2 (31.2 - 60.1)
Duodenum 1 2.4 (0.4 - 12.3)
Ileo-caecum 4 9.5 (3.8 - 22.1)
Psoas muscle 1 2.4 (0.4 - 12.3)
Liver 1 2.4 (0.4 - 12.3)
Mixed 10 23.8 (13.5 - 38.5)
Table 4. Ultrasonography findings (available for all patients, N = 42)

Sonography findings n Percentage (95% CI)

Ascites 6 14.3 (6.7 - 27.8)
Mesenteric lymphadenopathy 19 45.2 (31.2 - 60.1)
Intestinal thickening 4 9.5 (3.8 - 22.1)
Splenic enlargement 4 9.5 (3.8 - 22.1)
Hepatic enlargement 9 21.4 (11.7 - 35.9)
Psoas abscess 1 2.4 (0.4 - 12.3)
Normal 1 2.4 (0.4 - 12.3)
Table 5. Computed tomography findings (available in 24 patients).

Computed tomography findings n Percentage (95% CI)

Ascites 8 33.3 (17.9 - 53.3)
Mesenteric lymphadenopathy 17 70.8 (50.8 - 85.1)
Intestinal thickening 11 45.8 (27.9 - 64.9)
Splenic enlargement 2 8.3 (2.3 - 25.9)
Hepatic enlargement 4 16.7 (6.7 - 35.9)
Psoas abscess 1 4.2 (0.7 - 20.2)
Splenic abscess 1 4.2 (0.7 - 20.2)
Sub-acute intestinal obstruction 1 4.2 (0.7 - 20.2)