Management of

Abdominal Tuberculosis
• Tuberculosis in the Globe •

Pulmonary TB
Extrapulmonary TB
87.5%
10%

2.5%

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

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

Singhal A, et al. Eur J Gastroenterol Hepatol 2005; 17:967-971
 Tuberculosis

• 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]
 Pathogenesis of abdominal TB
Ingestion of contaminated Hematogenous spread
milk products from pulmonary focus

Mode of infection
Direct spread from Swallowing of
adjacent organs infected sputum
 Abdominal tuberculosis

Intestinal Peritoneal Nodal Solid visceral

49% 42% 4% 5%

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

 1. Intestinal tuberculosis

Small bowel
& colon
Ileocaecal
region

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

 1. Intestinal tuberculosis

Ulcerative type Hyperplastic type

Formation of mucosal ulcers Extensive inflammatory changes
• Bleeding • Obstruction
• Perforation • Mass
• Fistulation
• Stricture

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

 2. Peritoneal Tuberculosis

Acute form Chronic form

Ascitic
Clear straw-coloured ascitic fluid

Tuberculous peritonitis Fibrous

Intestines and viscera matted
• Acute abdomen together causing obstruction
• Exploratory laparotomy
 ascitic fluid Encysted
 thickened omentum Matted intestines enclosing a
 scattered tubercles loculation of serous fluid

Purulent
Purulent ascitic fluid
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
Intraabdominal viscera:
• Liver
• Kidney
• Spleen
• Pancreas

CT scan showing tuberculous nodules in

liver and spleen

USG showing tuberculous nodules in spleen

To start with…
24/ male • Complained of
Good past health – Diffuse abdominal pain
– Abdominal distension 2 months
– Weight loss

• Physical exam
– Gross ascites
– No peritonism or mass

• Blood tests
– All normal except elevated
ESR
To start with…
(Continued) • Plain X-ray
– Normal

• USG abdomen
– Gross ascites only

• CT abdomen
– Gross ascites
– Small bowel matted together
in central abdomen
– Enlarged mesenteric lymph
nodes
To start with…
(Continued) • Differential diagnosis
– Abdominal tuberculosis
– Malignancy
– Lymphoma
– Inflammatory disease
 How would you
investigate & manage him?
To diagnose abdominal tuberculosis…
Concomitant
PTB
Clinical Blood tests
presentation

Tuberculin Microbiology
test & histology
Radiological
test
 Clinical presentation

Acute form Combined form Chronic form

41% 9% 50%

• Peritonitis • Chronic pain

• Intestinal obstruction • Ascites
• Perforation • Weight loss
• GI bleeding • Vomiting
• Diarrhea
• Fever
Leung VKS, et al. Hong Kong Med J 2006;12:264-271 • Mass
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%
Marshall JB, et al. Am J Gastroenterol 1993;88:989-999 – Average = 38%
Horvath KD, et al. Am J Gastroenterol 1998;93:692-696
Faylona 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 mass

consisting of matted bowel
 Computer tomography scan

Gross ascites Thickened omentum Loculated ascites

Loculated ascites

Thickened ileocaecal bowel Enlarged paraaortic LN Tubercles in spleen & liver

 Contrast study
• Good for intestinal tuberculosis affecting small or large bowel

Stricture in ileocaecal region Stricture in descending colon

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

Histological Microbiological
exam 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):3647-3549

Tzoanopoulos, 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

Mucosal Mucosal Deformed

ulceration nodules 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 patients
Male: female = 11:12
Median age = 48 (Range: 8 - 83)

Histology or microbiology proven Not proven

abdominal TB 10 patients
13 patients

Suspected Other pathology

Peritoneal TB Intestinal TB
Abdominal TB 4 patients
53.8% 46.2%
6 patients
Duration of presentation: 1 day to 2 years
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%
Total number of patients: 23

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

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

 Comparison of diagnostic
sensitivity
Diagnostic Sensitivity in Sensitivity in
tests literarture (%) NDH series (%)

Peritoneal 34 0
tapping
colonoscopy 66 82

Laparosocpy 92 66

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

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