J,:lK SCIE!

"CE
ORIGINAL ARTICLE I
Abdominal Tuberculosis in Surgical Practice:
Analysis of 30 cases and Review of Literature
D. R. Thapa*, Meena Sidhu**, H. L. Goswamy*, Nasib C. Digray*, R. K. Kaehroo*,
R. K. Nargotra***
ABSTRACT
Thirty patients of abdominal tuberculosis in the age grClip of20-40 years were analyzed. Majority
ofthe cases had abdominal pain as the leading clinical presentation. A significant number of patients
also had abdominal lump. Intestinal obstruction! perforation was present in 10 patients requiring
surgical intervention. Barium studies (done on 27 occasions) had a positive rate of70%. All patients,
where diagnosis of tuberculosis was confirmed, received three-drug anti-tubercular regimen There
was no post-operative mortality.
Keywords:
Abdominal tuberculosis, Intestinal obstruction, Stricturoplasty.
Introduction
Abdominal tuberculosis continues to be a common
presentation of extrapulmonary form of tuberculosis
in developing countries. However, in developed
countries its incidence has become rare due to
increased standards of living (I). With the recent spurt
in Acquired Immunio-deficiency Syndrome (AIDS),
the incidence of tuberculosis in these countries may
rise (2!. Extrapulmonary form of tuberculosis is
difficult to diagnose and remains of grave concern for
human population (3). Abdominal tuberculosis 'has
bizarre, chronic and insiduous type of presentation and
difficult diagnosis. Furthermore, the investigations for
this, may be non-pathognomonic (4). Of late, due to
advent of laparoscopy, the diagnosis has been
possible laparotomy (4).Since there is diversity
in clinical presentation, difficulty in diagnosis and
widespread complications, often marked by prolonged
morbidity and mortality, we have analysed our patients
to highlightthe various aspects ofabdominal tuberculosis
seen in our set up.
Material and Methods
Thirty patients of abdominal tuberculosis managed
over a period of 15 months in a single surgical unit were
analyzed. The diagnosis in our patients was made by
clinical data and investigations. Two groups of patients
were seen and analyzed accordingly.
From the Departments of "'Surgery. -It .. Radio Diagnosis & Imaging. Govt. Medical College Jammu (J&K) and
""Department of Pathology, G.B. Pant Hospital, New Delhi.
Correspondence to: Dr. II. L. Goswamy. Prof. & Head Depll. of Surgery & Principal and Dean Gave Medical College. Jammu. J&K.
Vol. 2 No. I. January-March 2000 37
{",JK SCIENCE
.....
Group-I: Patients presenting with acute symptoms:
pain, vomiting, constipation signifying intestinal
obstruction/perforation requiring urgent surgical
intervention. Here the diagnosis was possible by
operative findings and histopathology of the biopsied
tissue.
Group-II: Patients presenting with chronic symptoms
(pain, fever, lump and/or distension abdomen, ascitis,
altered bowel habits, etc). The investigations in these
patients included complete haemogram, sputum for AFB,
x-rays (chest, abdomen), ultrasonography (USG), finc
needle aspiration cytology (FNAC), contrast gastro-
intestinal studies, pleuro/peritoneocentesis etc; wherever
indicated. Whenever, the diagnosis was doubtful, inspite
"f <leta'\eo tne 'Pat;e,.,t was aov;sed
surgical intervention. ELISA for tuberculosis and
Montoux test were done selectively.
After confirmation ofdiagnosis, all patients received
antitubercu lar treatment (ATT ) for a period of9 months
to one and halfyear. This regimen was modified in some
cases where streptomycin was given for initial two
months along with Isonizid (INH) and
Pyrazinamide.
Results
Majority of our patients were males in the age group
of 2nd to 4th decade. Male to female ratio WilS 2 : I. The
various clinical symptoms and signs are depicted in Table
I and II respectively.
Table-I
Symptoms at Presentation (n =30)
Symptoms No. of Cases Percentage
Fever 15 50.0
Weight loss 18 60.0
Anorexia 18 60.0
Abdominal pain 26 86.7
Vomiting 20 66.6
Abdominal distension 13 43.3
Constipation 13 43.3
Diarrhoea 03 10.0
Lump abdomen 16 53.3
38
Table-II
Various signs in patients presenting with abdominal
tuberculosis (n = 30)
Sign No. of PatienlS
Pallor 26 86.61
Lymphadenopathy 6 20.00
Fever 12 4000
Chest signs 7 23.33
Distension abdomen 12 4000
Abdominal tenderness 24 80.00
Lump abdomen 16 53.33
Ascites 3 1000
Duration of symptoms in present study varied [rom:
days to 3 years and majority ofour patients had symptom; I
of more than 6 months duration at the time of
presentation. Past history of pulmonary
positive in only 6 patients (20 per cent). Out ofthese.4
patients were on treatment with ATI while one had
already taken a complete course ofanti-tuberc';lar drugs.
the other one was a defaulter. Significant extra-abdominal
lymphadenopathy was recorded in 20 per cent of the
patients and in 1)1ajority of them only ccrvical lymph
glands were involved, whereas one patient had in
'.
addition, involvement of axillary lymph nodes. Most of
the patients were anaemic (93.3 percent) with ESR more
than 20 mm in 1st hr. (by Westergren's method).
Radiography of the chest showed evidence of healed or
active pulmonary tuberculosis in 23.3 per cent of patients.
Plain radiography of the abdomen revealed multiple
dilated loops of small gut with significant gas-fluj(j levels
in erect films in 9 patients. Free air under the dome
of diaphragm was seen in onc patient whereas in two
patients, there ·was radiological evidence of ascites.
Various radiological findings on barium contrast study
of abdomen in patients with tuberculosis in our study
are shown in Table III. Twelve patients needed surgery
for various indications as depicted in Table IV.
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"'1'1'
Diagnosis No. of patients
Table-III
Contrast Studies in Abdominal Tuberculosis
Table-IV
Indications for Surgery (n =12)
Discrepancy in number is due to multiple lesions in same
patient.
Pcritoncum Small Small & Largc Abd Multiple
only Inlestine Large Intcstinc lymph lesions
only Intestine only nodes
3 7 3 9 7
Laparotomy and biopsy ofmesen!ricl
retroperitoneal lymph nodes/omentum/
peritoneum 12
Stricturoplasty 2
Resection & anastomosis 5
Ileotransverse by-pass I
Local resection of transverse colon with end to
end anastomosis
Resection of Ileal stricture with lIeotransverse
bypass with resection of stricture sigmoid colon
with colostomy with closure of colostomy in
2nd stage
Gastrojejunostomy
Adhesiolysis 2
Table-VI
Surgical Procedures Done
Lesion Distribution in Abdominal Tuberculosis.
gastric outlet obstruction, was found on operation to be
having duodenal obstruction because of enlarged
tubercular lymph-nodes proved on histopathological
examination. Incidental evidence of tuberculosis was
found in one patient being operated for gall-stones.
Postoperative complications were seen in five patients
requiring no surgical intervention and were managed
conservatively. The site-wise distribution of disease,
surgical procedure and their compl ications are shown
Table V, VI & VII respectively.
TABLE-V
3
I
I
4
No" of Patients Findings
J Barium meal/foi!Olv-lhrollgh ( n ~ 13)
lleocaecal irregularity with pulled up
caecum 2
Strictures of terminal ileum 3
Dilated stomach with gastric outlet
obstruction
Multiple narrO\ved and dilated segments
of small gut 7
Normal study 5
B. Barium enema (n=8)
Filling defect of caecum with pulled up
caecum
Stricture transverse colon
Stricture sigmoid colon
Normal study
Intestinal obstruction 5
Suspected lump abdomen 2
PeritonitIS 2
Carcinoma colon 1
Stricture colon I
Chronic cholecystitis with cholelithiasis I
Total 12
At laparotomy, evidence of tuberculosis, in the form
of multiple tubercles in the peritoneum, involvement of
mesenteric lymph nodes and intestinal strictures, was
observed in 9 patients and was subsequently confirmed
on histopathological examination" The patient, who was
operated upon with the clinical diagnosis of carcinoma
colon, was histopathologically proved to be suffering
from tuberculosis of colon. Another patient who had
Discrepancy in number is due to multiple procedures in
same patient.
Table-VII
Post Operative Complications
S. No. Complication No. of Patients
I. Adhesion obstruction 2
2. Faecal fistula I
3. Minor wound infection 2
4. Deaths. Nil
Vol 2No" 1, January-March 2000 39
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Fig. 2. Barium follow through Sludy sllll\ illl! striClure Il'l"lIlillal ilrulll
with lIlultiple dilated 100Jls of small gut and Jlulled up caecum.
Fig. 3. Barium follon through stud) shoningstricture terminal ileum
with dilated loops of small gUI pruximal to slriclure and pulled
up caecum.
he classical doughy feel of abdomen which is
posed ta be indicativc of diffuse or extensivc intra-
,Ollnal tuberculosis (20, 21) was not seen in any of
'lJlicllts. Thecolllt11onest finding in our patients was
" mmartenderncss (80%) suggesting \\lo\ve.mcnt of
Ielill perl\onetlm. WO"'-CTI; _, 2"1)nmre maOc
mllar observations. Like other studies (8,23) right iliac
has becn a finding in significant number of
ur patients. CI inical evidence of ascites was observcd
In 10% of patients in our series, which is in conformity
Illth thc reports of other workers (14).
Barium studies of gastrointestinal tract have been
,\lnsidcrcd to be a great help as regards to diagnosis and
/\Ielll of abdominal tuberculosis (12, 23-26). Various
wnannalities which suggest the diagnosis ofabdominal
IUberculosis on bariulll contrast studies are: narrowing
and dilatation of intcsti naI lumen, stricture, fixity of loops
of sillall intestinc, change in ilcocaccal angle and
ileacaecal irregularit ics, pulled up caecum, fi II ing defect
nCaeClIl11 or involvement of large intestine. Patients may
,,'e isolated abnormality or a combination of above
"ndings (27,28). The samc findings have been present
ip aur cascs as sho\,_n in figures (Fig, I to 5),
Fig. I. LbnulIl follon through 5ho\ stricture terminal ileum
\ilh multiple dil:llcd loops of small gut proximal to strirlurr.
###BOT_TEXT###quot;lli. 2No.1. January-March 2000 41

lar drugs. involvement of axillary lymph nodes.3 Diarrhoea Lump abdomen 38 03 16 10.3 .~ positive in only 6 patients (20 per cent). the diagnosis was doubtful. whereas one patient had in '. Plain radiography of the abdomen revealed multiple dilated loops of small gut with significant gas-fluj(j levels in erect films in 9 patients. ultrasonography (USG).6 43.-----Group-I: Patients presenting with acute symptoms: pain. {". contrast gastrointestinal studies. After confirmation ofdiagnosis. The investigations in these patients included complete haemogram.. Table-I Symptoms at Presentation (n = 30) Symptoms No. ascitis. Here the diagnosis was possible by operative findings and histopathology of the biopsied tissue. of Cases Percentage Fever Weight loss Anorexia Abdominal pain Vomiting Abdominal distension Constipation 15 18 18 26 20 13 13 50. (by Westergren's method). Twelve patients needed surgery for various indications as depicted in Table IV.. I of more than 6 months duration at the time of presentation. etc).3 per cent of patients. ELISA for tuberculosis and Montoux test were done selectively. This regimen was modified in some cases where streptomycin was given for initial two months along with Isonizid (INH) and Pyrazinamide. Male to female ratio WilS 2 : I. Significant extra-abdominal lymphadenopathy was recorded in 20 per cent of the patients and in 1)1ajority of them only ccrvical lymph glands were involved.00 53.---------~ c~~... Free air under the ~ight dome of diaphragm was seen in onc patient whereas in two patients. altered bowel habits. Out ofthese. inspite "f <leta'\eo '\we~t'gatio..4 patients were on treatment with ATI while one had already taken a complete course ofanti-tuberc'.3 43. vomiting... Most of the patients were anaemic (93. Past history of pulmonary tuberculosis.00 4000 23.0 86. the other one was a defaulter. wherever indicated. fever. Majority of our patients were males in the age group of 2nd to 4th decade.t was aov. tne 'Pat.0 60. all patients received antitubercu lar treatment (ATT ) for a period of9 months to one and half year..sed surgical intervention.. lump and/or distension abdomen.33 1000 Table-II Various signs in patients presenting with abdominal tuberculosis (n = 30) Sign No. Results Etlial~butoll addition.3 percent) with ESR more than 20 mm in 1st hr. pleuro/peritoneocentesis etc. of PatienlS 26 6 12 7 12 24 16 3 Percen~ Pallor Lymphadenopathy Fever Group-II: Patients presenting with chronic symptoms (pain.JK SCIENCE . there ·was radiological evidence of ascites...0 60. abdomen). Chest signs Distension abdomen Abdominal tenderness Lump abdomen Ascites Duration of symptoms in present study varied [rom: days to 3 years and majority ofour patients had symptom. finc needle aspiration cytology (FNAC). x-rays (chest. constipation signifying intestinal obstruction/perforation requiring urgent surgical intervention.~. Radiography of the chest showed evidence of healed or active pulmonary tuberculosis in 23. 86.61 20..33 4000 80.0 53. Various radiological findings on barium contrast study of abdomen in patients with tuberculosis in our study are shown in Table III.7 66. Whenever..e... The various clinical symptoms and signs are depicted in Table I and II respectively. sputum for AFB.

Table-VI Surgical Procedures Done Laparotomy and biopsy ofmesen!ricl retroperitoneal lymph nodes/omentum/ peritoneum 12 Table-IV Indications for Surgery (n = 12) No. evidence of tuberculosis. Deaths. I. was histopathologically proved to be suffering from tuberculosis of colon. January-March 2000 Discrepancy in number is due to multiple procedures in same patient. Incidental evidence of tuberculosis was found in one patient being operated for gall-stones. TABLE-V Lesion Distribution in Abdominal Tuberculosis. 4. The site-wise distribution of disease. VI & VII respectively. surgical procedure and their compl ications are shown obstruction Multiple narrO\ved and dilated segments of small gut Normal study B. Filling defect of caecum with pulled up caecum Stricture transverse colon Stricture sigmoid colon Normal study 3 I I Pcritoncum only Small Small & Inlestine Large only Intestine Largc Intcstinc only Abd lymph nodes Multiple lesions 3 7 3 9 7 4 Discrepancy in number is due to multiple lesions in same patient. 2. who was operated upon with the clinical diagnosis of carcinoma colon. No" of Patients lleocaecal irregularity with pulled up caecum Strictures of terminal ileum Dilated stomach with gastric outlet 2 3 Postoperative complications were seen in five patients requiring no surgical intervention and were managed conservatively. Another patient who had Vol 2 No" 1. Complication Adhesion obstruction No.______________!"-!K "'1'1' SCIENCE Table-III Contrast Studies in Abdominal Tuberculosis Findings J Barium meal/foi!Olv-lhrollgh (n~ 13) gastric outlet obstruction. Nil 39 . in the form of multiple tubercles in the peritoneum. of Patients 2 Faecal fistula Minor wound infection I 2 3. Barium enema (n=8) 7 5 Table V. Table-VII Post Operative Complications S. involvement of mesenteric lymph nodes and intestinal strictures. No. was found on operation to be having duodenal obstruction because of enlarged tubercular lymph-nodes proved on histopathological examination. was observed in 9 patients and was subsequently confirmed on histopathological examination" The patient. of patients 5 2 2 1 Diagnosis Intestinal obstruction Suspected lump abdomen PeritonitIS Carcinoma colon Stricturoplasty Resection & anastomosis Ileotransverse by-pass Local resection of transverse colon with end to end anastomosis Resection of Ileal stricture with lIeotransverse bypass with resection of stricture sigmoid colon with colostomy with closure of colostomy in 2nd stage Gastrojejunostomy 2 5 I Stricture colon Chronic cholecystitis with cholelithiasis I I Total 12 Adhesiolysis 2 At laparotomy.

Fig. _. which is in conformity Illth thc reports of other workers (14). fixity of loops of sillall intestinc.____________ J:~JK SCIENCE he classical doughy feel of abdomen which is posed ta be indicativc of diffuse or extensivc intra. Patients may . 2"1) nmre maOc mllar observations. Ielill Barium studies of gastrointestinal tract have been . Various wnannalities which suggest the diagnosis ofabdominal IUberculosis on bariulll contrast studies are: narrowing and dilatation of intcsti na I lumen. Barium follon through stud) shoningstricture terminal ileum with dilated loops of small gUI pruximal to slriclure and pulled up caecum. pulled up caecum. January-March 2000 41 . fi II ing defect nCaeClIl11 or involvement of large intestine. The samc findings have been present ip aur cascs as sho\. 2No. ~ncT WO"'-CTI.28). I. Thecolllt11onest finding in our patients was " mmartenderncss (80%) suggesting \\lo\ve.Ollnal tuberculosis (20. 23-26). change in ilcocaccal angle and ileacaecal irregularit ics. stricture. Like other studies (8. Barium follow through Sludy sllll\ illl! striClure Il'l"lIlillal ilrulll with lIlultiple dilated 100Jls of small gut and Jlulled up caecum.mcnt of perl\onetlm. 3. 2.23) right iliac 's~11ul11p has becn a finding in significant number of ur patients. ###BOT_TEXT###quot;lli. 21) was not seen in any of 'lJlicllts._n in figures (Fig. CI inical evidence of ascites was observcd In 10% of patients in our series. LbnulIl follon through 311Hj~ 5ho\ ill~ stricture terminal ileum \ilh multiple dil:llcd loops of small gut proximal to strirlurr. Fig.1.. I to 5). Fig.\lnsidcrcd to be a great help as regards to diagnosis and /\Ielll of abdominal tuberculosis (12.'e isolated abnormality or a combination of above "ndings (27.