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

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Presentation on theme: "Management of Abdominal Tuberculosis Joint Hospital Surgical Grand Round Dr Shirley Y.W. Liu Department of Surgery North District Hospital."— Presentation transcript:

1 Management of Abdominal Tuberculosis Joint 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: Singhal A, et al. Eur J Gastroenterol Hepatol 2005; 17:

3 Tuberculosis Incidence in Hong Kong (year 2005) –90 new cases per 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: years [Sanai, et al. Aliment Pharmacol Ther 2005;22: ] 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: ]

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

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

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

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:

9 2. Peritoneal Tuberculosis Acute formChronic 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 USG showing tuberculous nodules in spleen Intraabdominal viscera: Liver Kidney Spleen Pancreas CT scan showing tuberculous nodules in liver and spleen

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

13 T o start with… Plain X-ray –Normal USG abdomen –Gross ascites only CT abdomen –Gross ascites –Small bowel matted together in central abdomen –Enlarged mesenteric lymph nodes (Continued)

14 T o start with… Differential diagnosis –Abdominal tuberculosis –Malignancy –Lymphoma –Inflammatory disease (Continued)

15 H ow would you investigate & manage him?

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

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

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

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 –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: Horvath KD, et al. Am J Gastroenterol 1998;93: 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: ] –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 Ascites Right lower quadrant mass consisting of matted bowel

25 Computer tomography scan Loculated ascites Gross ascitesThickened omentum Loculated ascites Thickened ileocaecal bowelEnlarged paraaortic LN Tubercles in spleen & liver

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

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): Tzoanopoulos, et al. Eur J Intern Med 2003;14:

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:

31 Colonoscopy Mucosal ulceration Mucosal nodules Deformed Ileocaecal valve

32 Laparoscopy Highest diagnostic yield –Macroscopic appearance93% –Peritoneal biopsy for ZN stain 3-25% –Peritoneal biopsy for culture38-92% –Histology 93% Low complication rates Sanai, et al. Aliment Pharmacol Ther 2005;22:

33 Laparoscopy

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

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: ) 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 Clinical presentationNo of patients (%) Abdominal pain77% Ascites38% Vomiting38% Weight loss30% Fever30% Cough30% Peritonism26% Obstruction13% Mass4% Duration of presentation: 1 day to 2 years

38 Diagnostic tools No of patients (%) Diagnosis* Confirmed (%) Concomitant PTB30NA Abnormal CXR26NA Positive ultrasound features38NA Positive CT scan features46NA Colonoscopy4683 Surgery7341 Laparoscopy2666 Laparotomy4727 Total number of patients: 23 *Diagnosis confirmation by positive histology, smear or culture for AFB

39 Comparison of diagnostic sensitivity Diagnostic tests Sensitivity in literarture (%) Sensitivity in NDH series (%) Peritoneal tapping 340 colonoscopy6682 Laparosocpy9266 Leung VKS, et al. Hong Kong Med J 2006;12: Sanai, et al. Aliment Pharmacol Ther 2005;22:

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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