CLINICAL PRESENTATION: Abdominal tuberculosis
Author?
HISTORY
A 12 year old girl first presented with acute abdominal pain and vomiting for a day For 4 months she had had
severe weight loss (from 35kg to 24kg) Loss of appetite Intermittent lower abdominal pain Low grade fever
DURING THIS PERIOD,
INVESTIGATED 3 TIMES IN HOSPITAL
INVESTIGATIONS
Chest X -Ray Ultrasound of abdomen Barium meal and follow through CT of abdomen Gastroscopy, biopsies Liver biopsy Bone marrow biopsy
This was the chest X-ray What does it show?
CT ABDOMEN
Hepatomegaly with fatty infiltration Ascites No lymph nodes Cannot exclude terminal ileum wall thickening due to ascites No masses or omental calcification No definitive features of abdominal TB
INVESTIGATIONS
Bloods hematology,biochemistry,immunology, microbiology Urine Liver biopsy Duodenal biopsy Bone marrow biopsy Sputums Stools
POSITIVE FINDINGS:
Raised CRP Fe deficient anaemia Ulcerating Mantoux Hypo-albuminaemia
Bone marrow : Granulomas and acid-fast bacilli seen
TREATMENT
She was started on treatment for disseminated tuberculosis, December 2002 Rifafour , with Prednisone, for the inflammatory response High calorie, high protein diet
TREATMENT
Tb treatment 18/12/2002 Prednisone started – inflammatory response Diet
PRESENT ADMISSION (FEBRUARY 2003)
EXAMINATION wasted tachycardia acute abdomen
Maximally tender right iliac fossa mass palpable
INVESTIGATIONS
WCC 34 X 10^9/L ALBUMIN 29 G/DL Abdominal X Ray
TREATMENT
Prepared for theatre
IV fluids , antibiotics
OPERATIVE FINDINGS
Fixed mass in right iliac fossa , matted bowel Sealed off with omentum Granulomas Multiple perforations
These are the operative findings
PROCEDURE
Resection of affected bowel
Primary anastomosis Left with 233 cm jejunum, 20 cm terminal ileum
HISTOLOGY
Matted bowel ,multiple perforations , multiple circumferential ulcers seen Focal caseating granulomas Focal sloughing of mucosa , areas of transmural necrosis Resection lines showed no granulomas
POST OPERATIVE COURSE
TB treatment continued
Hyperalimentation for one week Discharged Day 9
At follow-up - gained 2 kg
HOW DOES ABDOMINAL TB COME ABOUT?
HOW ABDOMINAL TB COMES ABOUT
Along lymphatics from mediastinal nodes to abdominal nodes Blood spread Possibly from swallowed sputum -> ileum Rarely, primary in bowel from M bovis
ABDOMINAL TUBERCULOSIS
Increased incidence of pulmonary TB has led to a corresponding increase in abdominal TB. Extremely difficult disease to diagnose outside operating room 50% of patients are HIV positive
SYMPTOMS
Abdominal pain Fever Significant weight loss Nausea, vomiting Abdominal distention Long duration of symptoms
PHYSICAL EXAMINATION
ABDOMINAL TENDERNESS PALPABLE MASS ASCITES, or DOUGHY ABDOMEN
SPECIAL INVESTIGATIONS
CXR AXR CONTRAST ENEMAS CT ABDOMEN : Thickening parietal/visceral peritoneum, bowel wall thickening, irregularity,mesenteric lymphadenopathy
LAPAROSCOPY : FINDINGS
PERITONEAL STUDDING WHITISHYELLOW PLAQUES MATTING OF THICKENED BOWEL WALLS WITH DENSE ADHESIONS PUNCTATE LESIONS OF CASEATING GRANULATION TISSUE PERITONEAL/RETROPERITONEAL LYMPHADENOPATHY WITH FLUCTUANCE AND CENTRAL NECROSIS
DIAGNOSIS
ACID FAST BACILLI STAIN AND /OR, POSITIVE CULTURE RESULTS ? PLACE FOR FINE NEEDLE ASPIRATION
TREATMENT
Four drug regimen Isoniazid,rifampin,pyrazinamide, either ethambutol or streptomycin Corticosteroid administration to reduce complications with peritoneal tuberculosis Surgery reserved for complications
ABDOMINAL TB
Non-specific presentation delays diagnosis Diagnosis intraoperatively start treatment promptly Appropriate surgical operations and prompt initiation of treatment successfully treats abdominal TB
THE END