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Management of Abdominal Tuberculosis Joint Hospital Surgical Grand Round

Management of Abdominal Tuberculosis Joint Hospital Surgical Grand Round. Dr Shirley Y.W. Liu Department of Surgery North District Hospital. • Tuberculosis in the Globe •. Pulmonary TB. Extrapulmonary TB. 87.5%. 10%. 2.5%. Abdominal tuberculosis (~11-16% of extrapulomnary TB).

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Management of Abdominal Tuberculosis Joint Hospital Surgical Grand Round

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  1. Management of Abdominal TuberculosisJoint Hospital Surgical Grand Round Dr Shirley Y.W. Liu Department of Surgery North District Hospital

  2. • 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

  3. Tuberculosis • Incidence in Hong Kong (year 2005) • 90 new cases per 100 000 persons [http://www.info.gov.hk/dh/publicat/web/tb/tb2005e.htm] • 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

  4. 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]

  5. Pathogenesis of abdominal TB Ingestion of contaminated milk products Hematogenous spread from pulmonary focus Mode of infection Direct spread from adjacent organs Swallowing of infected sputum

  6. Abdominal tuberculosis Intestinal 49% Solid visceral 5% Peritoneal 42% Nodal 4% Khan R, et al. World J Gastroenterol 2006;12(39):6371-6375

  7. 1. Intestinal tuberculosis Small bowel & colon Ileocaecal region Niall O, et al. World J Surg 1997;21:492-499

  8. 1. Intestinal tuberculosis • Ulcerative type • Formation of mucosal ulcers • Bleeding • Perforation • Fistulation • Stricture • Hyperplastic type • Extensive inflammatory changes • Obstruction • Mass Aston NO. World J Surg 1997;21:492-499

  9. 2. Peritoneal Tuberculosis Acute form Chronic form Ascitic Clear straw-coloured ascitic fluid Fibrous Intestines and viscera matted together causing obstruction Encysted Matted intestines enclosing a loculation of serous fluid Purulent Purulent ascitic fluid Tuberculous peritonitis • Acute abdomen • Exploratory laparotomy • ascitic fluid • thickened omentum • scattered tubercles Ahmed ME, et al. Ann R coll Surg Engl 1994;76:75-79

  10. 3. Nodal/ Glandular tuberculosis • Less common • Enlargement of • Mesenteric lymph nodes • Retroperitoneal lymph nodes • Complications • Abscess formation

  11. 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

  12. To start with… 24/ male Good past health • Complained of • Diffuse abdominal pain • Abdominal distension • Weight loss • Physical exam • Gross ascites • No peritonism or mass • Blood tests • All normal except elevated ESR 2 months

  13. 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

  14. To start with… (Continued) • Differential diagnosis • Abdominal tuberculosis • Malignancy • Lymphoma • Inflammatory disease

  15. How would you investigate & manage him?

  16. To diagnose abdominal tuberculosis… Concomitant PTB Clinical presentation Blood tests Tuberculin test Microbiology & histology Radiological test

  17. Clinical presentation Acute form 41% Chronic form 50% Combined form 9% • Chronic pain • Ascites • Weight loss • Vomiting • Diarrhea • Fever • Mass • Peritonitis • Intestinal obstruction • Perforation • GI bleeding Leung VKS, et al. Hong Kong Med J 2006;12:264-271

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

  19. Clinical Presentation • Non-specific symptoms & signs • High index of suspicion • More liberal use of investigations • Differential diagnosis • Malignancy • Lymphoma • Inflammatory bowel disease • Infective disease

  20. Concomitant PTB • Concomitant PTB • Present in 15-25% only • Sputum smear and culture for AFB: • Low diagnostic yield • Abnormal CXR: • 19-83% • Average = 38% • Marshall JB, et al. Am J Gastroenterol 1993;88:989-999 • Horvath KD, et al. Am J Gastroenterol 1998;93:692-696 • Faylona JM, et al. Ann Coll Surg 1993;3:65-70

  21. 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]

  22. Tuberculin test • High specificity • Low sensitivity • Low positive predictive value 50-67% Huebner, et al. Clin Infect Dis 1993; 17:968-75

  23. Radiological tests • No diagnostic feature available • Imaging guided peritoneal biopsy • Limited diagnostic sensitivity

  24. USG abdomen Right lower quadrant mass consisting of matted bowel Ascites

  25. Computer tomography scan Loculated ascites Gross ascites Thickened omentum Loculated ascites Tubercles in spleen & liver Thickened ileocaecal bowel Enlarged paraaortic LN

  26. Contrast study • Good for intestinal tuberculosis affecting small or large bowel Stricture in descending colon Stricture in ileocaecal region

  27. 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

  28. Tissue Biopsy • Peritoneal tapping • Endoscopic biopsy • Laparoscopy • Laparotomy Histological exam Microbiological Smear & culture

  29. 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

  30. 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

  31. Colonoscopy Mucosal nodules Mucosal ulceration Deformed Ileocaecal valve

  32. 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

  33. Laparoscopy

  34. Summary of diagnostic tests Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700

  35. 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

  36. Retrospective review of abdominal TB in NDH • 23 patients • Male: female = 11:12 • Median age = 48 (Range: 8 - 83) Histology or microbiology proven abdominal TB 13 patients Not proven 10 patients Suspected Abdominal TB 6 patients Other pathology 4 patients Peritoneal TB 53.8% Intestinal TB 46.2%

  37. Duration of presentation: 1 day to 2 years

  38. Total number of patients: 23 *Diagnosis confirmation by positive histology, smear or culture for AFB

  39. Comparison of diagnostic sensitivity Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700 Leung VKS, et al. Hong Kong Med J 2006;12:264-271

  40. Treatment • Mainstay of treatment • Anti-tuberculous chemotherapy • Duration for 6-12 months • Response to treatment • Resolution of symptoms within 3 months of treatment

  41. Role of Surgery • Indications of surgery • Diagnostic uncertainty • Diagnostic laparoscopy in particular • Complications • Obstruction • Perforation • Hemorrhage • Fistulation • Conservative surgical approach should be adopted

  42. 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

  43. Summary High index of suspicion More liberal use of invasive investigations Mainstay of treatment by anti-TB drugs

  44. Thank you

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