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Abdominal tuberculosis: an easily forgotten diagnosis
Abdominal tuberculosis (TB) is an uncommon condition in Australia. Diagnosis can be delayed because of its atypical presentation.
We report two patients with atypical abdominal pain who turned out
to have abdominal TB presenting to our institution within a month.
The first, a 34-year-old Indian male living in Australia for 3 years
and no recent travel history, presented to emergency department with
a 2-month history of central abdominal pain, which had increased in
the last week and localized to the right side. He had previously been
fit and well. Clinically he was afebrile and haemodynamically stable
with normal blood parameters other than a raised C-reactive protein
(CRP) of 44 (normal < 10). He was markedly tender in his right iliac
fossa with no other abnormal findings. A computed tomography
(CT) scan of his abdomen and pelvis demonstrated a 5 ¥ 5 ¥ 5 cm
rim-enhancing collection around the caecal pole communicating
with a 10 ¥ 7 ¥ 5 cm pelvic collection (Fig. 1).
The provisional diagnosis of an appendiceal abscess was made
and laparoscopy was arranged. However, at the time of laparoscopy,
the intra-abdominal fluid was found to be a serous exudate, with
diffuse multiple peritoneal nodules present in all quadrants of the
abdominal wall (Fig. 2). Biopsies were taken with histopathology
showing necrotizing granulomatous inflammation consistent with
disseminated intra-abdominal TB (Fig. 3). He was subsequently
treated with anti-TB treatment.
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559..560
The second patient, a 41-year-old female originally from Indonesia, who has been living in Australia for 8 years with no recent travel
history, was admitted to the medical high dependency unit of the
hospital with dyspnoea, malaise and diarrhoea. She was being
treated empirically for atypical pneumonia, based on CT findings
prior to ascitic tap, which was done for diagnostic reasons because of
ongoing abdominal symptoms. It showed acid-fast bacilli a week
later. During the second week of her admission, she developed acute
abdominal pain with peritonism, associated with an increase in
Fig. 2. Intra-operative view of the 34-year-old male patient with atypical
right iliac fossa pain, showing multiple diffuse peritoneal nodules throughout the abdomen.
Fig. 1. Forty-one-year-old female with abdominal ascites and thickened
proximal small bowel on a computed tomography scan of the abdomen
and pelvis.
© 2011 The Authors
ANZ Journal of Surgery © 2011 Royal Australasian College of Surgeons
Fig. 3. Histopathology image of the peritoneal nodule from the 34-yearold male with abdominal pain, showing necrotizing granulomatous
inflammation.
ANZ J Surg 81 (2011) 559–560
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white blood cell count and CRP. A repeat CT demonstrated some
free fluid and skip lesions of her proximal small and large bowel and
associated fat stranding.
She proceeded on to a laparotomy which demonstrated a perforation to her ileum 35 cm proximal to the ileocaecal junction. A
small bowel resection of the affected segment was performed, with
the ends brought out as a double barrel ileostomy. Pathology on the
specimen showed granulomatous enteritis, with mycobacterial
organisms seen in the specimen. She was subsequently treated with
standard TB regimen.
TB is an uncommon disease in Australia. TB notifications in 2005
showed an incidence of 5.3/100 000, which have remained stable
since 1985.1 The incidence is much higher in overseas born and
indigenous populations compared with non-indigenous Australian
born population (20.6 versus 5.9 versus 0.8 per 100 000).1 This is
similar to other western nations with a high immigration, for
example, UK.2
Incidence of abdominal TB is increasing worldwide as a result of
multi-drug resistant TB and concurrent HIV infection, and because
of this incidence, diagnostic dilemmas and management of complications are becoming more common.
Clinical presentation of these patients depends on the predominant system affected, which may include peritoneum, gastrointestinal tract, lymphatics, spleen, liver and pancreas. The most common
organs affected include the peritoneum and ileocaecal junction. Presenting symptoms may range from localized or general ascites and
abdominal distension to abdominal pain, diarrhoea, fever, weight
loss, malaena and anaemia.
There is a high correlation of abdominal TB with pulmonary TB,
with 80% of patients dying of pulmonary TB found to have abdominal involvement on post-mortem studies.3 Abdominal TB tends to
affect a population between 20 and 45 years of age, with infection
via a haematogenous route from a primary lung focus or military TB,
via lymphatics from infected nodes, direct ingestion of bacilli from
sputum or infected sources, or by direct spread from adjacent
organs.4
Common presentations in the gastrointestinal tract include an
ulcerative process that may bleed, perforate or form fistulas; or a
hyperplastic reaction that may cause obstruction or present as a
mass.5 The classic histological findings include a caseating granulomas and acid-fast bacilli on Ziehl–Neelsen-stained specimens.
Mycobacterium bovis infections have been all but eliminated by
public health measures, and are only a rare cause of presentation of
intestinal TB secondary to direct ingestion of infected material.
Almost all cases of abdominal TB in western countries are caused by
Mycobacterium tuberculosis, but an increasing incidence of infection with Mycobacterium intracellulare is noted in association with
HIV infection.5
Clinical diagnosis is difficult and relies on a combination of
imaging and pathological techniques including ultrasound, CT scan,
endoscopy, colonoscopy and laparoscopy with biopsies of suspi-
Images for surgeons
cious granulomas. Analysis of ascitic fluid, skin-prick testing and
microbiological confirmation with or without polymerase chain
reaction for testing of biopsy tissue and culture may also be useful in
establishing diagnosis.6 Interestingly, only 15 to 20% of patients
with abdominal TB have radiographic evidence of active pulmonary
TB on a chest X-ray, and therefore a high index of suspicion in a low
prevalence population is required.7
Treatment includes a similar approach as for pulmonary TB with
6–9 months of directly observed treatment, short course combination drug treatment.8 However, sometimes patients will present with
acute complications of their abdominal TB and will require emergent laparotomy to manage ulcers, perforations, adhesions, obstructions, bleeding, fistulae formation and stenosis.
Corticosteroids have a role in the management of systemic symptoms and local pressure effects, but their use is controversial and
uncertain, but may be of benefit in established intestinal strictures.9
In conclusion, abdominal TB is a non-specific disease that may
present with a wide variety of symptoms and complications. High
index of suspicion is required in particular in low volume populations such as Australia.
Medical treatment is the mainstay of therapy; however, surgical
involvement may be needed for diagnosis and management of acute
complications.
References
1. Roche P, Bastian I, Krause V et al. Tuberculosis notifications in Australia.
Commun. Dis. Intell. 2007; 31: 71–80.
2. Bennet D, Watson JM, Jenkins PA, McGuirk S. The UK mycobacterium
network 1994. Tuber. Lung Dis. 1995; 76: 99–109.
3. Sculley RE, Galdabini JJ, McNeely BU. Case records of Massachusetts
General Hospital. N. Engl. J. Med. 1980; 303: 445–57.
4. Lazarus AA, Thilagar B. Abdominal tuberculosis. Dis. Mon. 2007; 53:
32–8.
5. Aston NO, Chir MA. Abdominal tuberculosis. World J. Surg. 1997; 21:
492–9.
6. Radzi M et al. Diagnostic challenge of GI TB: a report of 34 cases and an
overview of literature. Southeast Asian J. Trop. Med. Public Health 2009;
40: 505–9.
7. Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum.
Am. J. Gastroenterol. 1993; 88: 989–99.
8. Blumberg HM, Leonard MK, Jasmer RM. Update on the treatment of
tuberculosis and latent tuberculosis infection. JAMA 2005; 293: 2776–84.
9. Allen MB, Cooke NJ. Corticosteroids and tuberculosis. BMJ 1991; 303:
871–2.
Michael Yunaev, MBBS
Andrew Ling, MBBS
Saleh Abbas, FRACS
Michael Suen, FRACS
Henry Pleass, FRACS
Surgery, Westmead Hospital, Sydney, New South Wales, Australia
doi: 10.1111/j.1445-2197.2011.05801.x
© 2011 The Authors
ANZ Journal of Surgery © 2011 Royal Australasian College of Surgeons