International Surgery Journal

Krishnaswamy J et al. Int Surg J. 2017 Oct;4(10):3423-3426

http://www.ijsurgery.com pISSN 2349-3305 | eISSN 2349-2902

DOI: http://dx.doi.org/10.18203/2349-2902.isj20174509
Original Research Article

Abdominal tuberculosis: a clinical study in a tertiary care hospital

Jawahar Krishnaswamy, Khalilur Rahaman*, Reshma S., Bharath N.

Department of General Surgery, Saveetha Medical College, Chennai, Tamil Nadu, India

Received: 26 June 2017

Accepted: 20 August 2017

*Correspondence:
Dr. Khalilur Rahaman,
E-mail: khalil_rahman96@yahoo.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Abdominal tuberculosis is the sixth most common form of extrapulmonary site of infection after
lymphatic, genitourinary, bone and joint, miliary and meningeal TB with a rising incidence in recent years.
Tuberculosis can affect any part of the gastro-intestinal (GI) tract including anus, peritoneum and hepato-biliary
system. The clinical manifestations of abdominal tuberculosis are non-specific and mimic various GI disorders and
cause delay in diagnosis and management. The aim of this study is to study the incidence of abdominal tuberculosis,
percentage of acute presentation, to study and analyse clinical presentation, various diagnostic modalities, role of
surgery and to evaluate the spectrum of surgeries done for abdominal tuberculosis
Methods: Study was done by analyzing 108 cases in our tertiary care hospital, Chennai, India, during the period of
June 2015 to January 2016. All suspected and diagnosed cases of abdominal tuberculosis were included in the study.
The relevant clinical information, laboratory results, microbiological and radiological investigations were recorded.
Histopathological examination of all the resected or excised specimens was done to detect tuberculosis in all the
cases.
Results: Out of 108 cases with abdominal tuberculosis, the average age of presentation was between 21 and 40 years
with a slight male predominance (male:female = 1.1:1). Abdominal pain (92%) was the most common presenting
symptom followed by anorexia (70%), loss of weight (70%), and intestinal obstruction (13%). 29 cases underwent
surgical management. All patients were put on anti-tubercular treatment and majority showed good response to
therapy.
Conclusions: Abdominal tuberculosis should be considered as a differential diagnosis in patients with vague GI
symptoms. To diagnose abdominal tuberculosis, high degree of suspicion is needed, and its incidence being common
in people with lower socioeconomic status. This study gives a basic outline of presentation, diagnosis and
management of abdominal tuberculosis in developing country.

Keywords: Abdominal tuberculosis, Abdominal pain, Gastrointestinal, Radiological investigations

INTRODUCTION part of the body can be involved by the disease.1,2

Abdominal tuberculosis (TB) constitutes a major public
Tuberculosis is a chronic granulomatous disease caused health problem in developing countries and associated
by an aerobic bacteria Mycobacterium tuberculosis. It with significant morbidity and mortality.3,4 It is the 6th
remains the world-wide problem despite the discovery of most frequent site for the extra pulmonary involvement
the causative organism for more than a century ago. and it can involve any part of the gastrointestinal tract,
Infections with atypical mycobacteria usually occur in peritoneum and hepatobiliary system. The
immunocompromised hosts due to host immunity and mycobacterium reaches the gastrointestinal tract via
resistance factors. Pulmonary tuberculosis is the most hematogenous spread, ingestion of infected sputum or
common form and it primarily involves the lung but any direct spread from infected contiguous lymph nodes and

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fallopian tubes.5-9 The clinical manifestations of RESULTS

abdominal tuberculosis can mimic many other disease
process, causing delay in diagnosis.10 The most common During the study period total 108 patients were diagnosed
site of predilection is the ileocaecal region, attributed to as a case of abdominal tuberculosis with a slight male
the minimal digestive activity, relatively increased predominance of male:female ratio 1.1 :1. These patients
physiological stasis, higher rate of fluid and electrolyte presented a wide age group of distribution 11 to 60 years
absorption and more lymphoid tissue at this site.5,8,11 with maximum number of cases presenting between 21 to
Peritoneal involvement may occur due to spread of the 40 years Table 1.
bacilli from mesenteric lymph node. However, one third
of cases show abdominal lymph node and peritoneal Table 1: Distribution of cases according to age.
tuberculosis without any evidence of gastrointestinal
involvement.12 Grossly, the abdominal tuberculosis Age group (years) No. of cases %
presents in 3 morphological forms: ulcerative, < 20 years 17 16
hypertrophic and combination of both ulcero- 21-40 years 59 55
hypertrophic.6,11,13,14 Most common complication of 41-60 years 22 20
intestinal tuberculosis is intestinal obstruction attributed > 60 years 10 9
too strictures or by adhesions and in India approximately
Total 108 100
3-20% of all cases of bowel obstruction are due to the
tuberculosis.8,15,16 One of the serious complication of
abdominal tuberculosis is perforation, causing high Only 16 cases had the past history of pulmonary
morbidity and mortality and it accounts for 5-9% of small tuberculosis while family history of tuberculosis was
intestinal perforations in India.6,8,17 Scant literature is present in only 22 cases. The clinical manifestations of
available on the extra pulmonary tuberculosis in the patients are summarized in Table 2 which shows
reference to its incidence and bacteria positivity.18 abdominal pain as the most common presentation
Surgical intervention is reserved only for complications followed by anorexia, loss of weight, nausea/vomiting,
such as obstruction, perforation, fistula, or a mass which fever and intestinal obstruction.
does not resolve with medical therapy. In most cases a
trial of medical therapy should be undertaken prior to Table 2: Clinical presentations of patients.
surgical intervention.3 The surgical treatment of intestinal
tuberculosis too has passed through many phases, from Number Percentage
Clinical presentation
the bypass procedures of the pre-antibiotic era to the of cases (%)
radical surgeries such as hemicolectomy and wide- Abdominal pain 99 92
resection, followed by the more recent and more Anorexia 75 70
conservative, modified surgical procedures such as Loss of weight 76 70
limited ileocecal resection, and stricturoplasties.5 This Nausea and vomiting 68 63
study aims at a fresh look in to abdominal tuberculosis Fever 43 40
and at a better understanding of its clinical Intestinal obstruction 14 13
manifestations, diagnostic modalities, management and
its complications. The signs observed in the patients are summarized in
Table 3 which shows tenderness localized to the right
METHODS lower quadrant as the most common sign followed by
mass abdomen, ascites, visible intestinal peristalsis and
The study was carried out in our tertiary care hospital, doughy abdomen.
Chennai, India, during June 2015 to January 2016. The
study included 108 patients with all suspected and Table 3: Clinical signs of patients.
confirmed cases of abdominal tuberculosis.
Number of Percentage
The following methods were used for the study which Sign
cases (%)
includes, patients detail history, clinical examination, Tenderness 62 57
investigations carried out in all patients are as follows: Mass abdomen 29 27
Polymerase Chain Reaction (PCR), Mantoux test, Ascites 14 13
analysis of ascitic fluid, sputum AFB, X-ray chest PA
VIP 15 13
view, X-ray abdomen, ultrasound abdomen, Contrast CT
Doughy abdomen 11 10
abdomen and pelvis, endoscopy and biopsy, pathological
examination of specimen. All patients received anti-
tuberculous treatment as per DOTS. Conservative The laboratory findings are summarized in Table 4 which
management was done for uncomplicated abdominal revealed elevated ESR in 88 patients as the most common
tuberculosis. Operative management was done for laboratory abnormalities. Mantoux skin test was
complications of abdominal tuberculosis. performed in 93 cases and was found positive in 50 cases
only. All patients received plain film chest radiographs

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 Krishnaswamy J et al. Int Surg J. 2017 Oct;4(10):3423-3426

and 15 (14%) cases had abnormal radiological findings genitourinary, bone and joints, military and meningeal
including cavitatory lesions, pleural effusion and TB.11 The incidence of abdominal tuberculosis is rising
lymphadenopathies. all over the world however very scant literature and
knowledge has been updated. Abdominal TB can affect
Table 4: Investigations of patients. any age group. In a study conducted by Sharma MP et al,
19 most affected patients are between 21 to 45 years of
No. of patients age. This finding of involvement of slight younger
Investigations Percentage population was also seen in many other studies.20,21
Done Contributory Present study showed a slight male predominance than
(%)
ESR 93 88 95 females with abdominal tuberculosis and similar results
Mantoux 93 50 54 were seen in a study conducted by Rajput MJ et al.21
X-ray abdomen 108 44 41 Although Indian studies have suggested a slight female
Contrast CT predominance.6 The clinical manifestations of abdominal
abdomen and 95 95 100 tuberculosis are quite protean. Similar to the previous
reports abdominal pain (92%) was the most common
pelvis
clinical presentation in this study also, followed by
X-ray chest 108 15 14
anorexia (70%).19 In a study conducted by Sharma MP et
Laproscopy 15 13 86 al, fever was recorded in half of the patients and in the
Barium study 55 45 82 present study about 40% of cases presented with fever.19
USG abdomen 108 43 40 Routine laboratory tests have limited value in the
Colonoscopy 15 11 73 diagnosis of abdominal TB.22 In present study 15 cases
UGI scopy 47 - 0 were found to have abnormal findings on chest x-ray
(CXR). Arif Au et al and Rajput MJ et al, observed
Ultrasound abdomen done in all patients, 43 (40%) cases preexisting pulmonary tuberculosis in 20% and 33.95%
had abnormal findings. Laparoscopy showed 86% of of their patients respectively.20,21 Majority of abdominal
positive cases. All patients received plain film abdomen tuberculosis cases have been found in patients with
radiographs and 44 (41%) cases had abnormal HIV.25 In the present study we aimed to investigate the
radiological findings. Contrast CT abdomen and pelvis incidence of abdominal tuberculosis, percentage of acute
were done in 95 (88%) patients, all 95 (100%) patients presentation, to analyse the clinical presentation,
had some positive features. Intestinal resection and diagnostic modalities and role of surgery for abdominal
anastomosis was the most common surgical procedure tuberculosis. We conclude that the incidence of
performed in the cases of abdominal tuberculosis Table 5, abdominal TB is common among people with lower
followed by hemicolectomy, stricturoplasy, ileotransverse socioeconomic status.
colostomy and adhesiolysis. Out of 108 patients, 29
(27%) cases underwent surgical intervention, other cases CONCLUSION
were treated conservatively with anti-tubercular therapy.
All the cases responded well to therapy. Abdominal tuberculosis should be considered as a
differential diagnosis in patients with vague GI
Table 5: Type of surgical procedures done in patients. symptoms. To diagnose abdominal tuberculosis, high
degree of suspicion is needed, and its incidence being
No. of cases common in people with lower socioeconomic status. This
Type of surgery
Acute Chronic study gives a basic outline of presentation, diagnosis and
Laparotomy and closure 4 management of abdominal tuberculosis in developing
Resection and anastomosis country.
Perforation 2
Funding: No funding sources
Limited resection 3 6
Conflict of interest: None declared
Hemicolectomy 4 Ethical approval: The study was approved by the
Ileotransverse colostomy 3 institutional ethics committee
Stricturoplasty 4
Adhesiolysis 3 REFERENCES
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