Abdominal tuberculosis: an easily forgotten diagnosisans_5801 559..560

Abdominal tuberculosis (TB) is an uncommon condition in Austra-lia. Diagnosis can be delayed because of its atypical presentation.We report two patients with atypical abdominal pain who turned outto have abdominal TB presenting to our institution within a month.

The first, a 34-year-old Indian male living in Australia for 3 yearsand no recent travel history, presented to emergency department witha 2-month history of central abdominal pain, which had increased inthe last week and localized to the right side. He had previously beenfit and well. Clinically he was afebrile and haemodynamically stablewith normal blood parameters other than a raised C-reactive protein(CRP) of 44 (normal < 10). He was markedly tender in his right iliacfossa with no other abnormal findings. A computed tomography(CT) scan of his abdomen and pelvis demonstrated a 5 ¥ 5 ¥ 5 cmrim-enhancing collection around the caecal pole communicatingwith a 10 ¥ 7 ¥ 5 cm pelvic collection (Fig. 1).

The provisional diagnosis of an appendiceal abscess was madeand laparoscopy was arranged. However, at the time of laparoscopy,the intra-abdominal fluid was found to be a serous exudate, withdiffuse multiple peritoneal nodules present in all quadrants of theabdominal wall (Fig. 2). Biopsies were taken with histopathologyshowing necrotizing granulomatous inflammation consistent withdisseminated intra-abdominal TB (Fig. 3). He was subsequentlytreated with anti-TB treatment.

The second patient, a 41-year-old female originally from Indone-sia, who has been living in Australia for 8 years with no recent travelhistory, was admitted to the medical high dependency unit of thehospital with dyspnoea, malaise and diarrhoea. She was beingtreated empirically for atypical pneumonia, based on CT findingsprior to ascitic tap, which was done for diagnostic reasons because ofongoing abdominal symptoms. It showed acid-fast bacilli a weeklater. During the second week of her admission, she developed acuteabdominal pain with peritonism, associated with an increase in

Fig. 1. Forty-one-year-old female with abdominal ascites and thickenedproximal small bowel on a computed tomography scan of the abdomenand pelvis.

Fig. 2. Intra-operative view of the 34-year-old male patient with atypicalright iliac fossa pain, showing multiple diffuse peritoneal nodules through-out the abdomen.

Fig. 3. Histopathology image of the peritoneal nodule from the 34-year-old male with abdominal pain, showing necrotizing granulomatousinflammation.

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white blood cell count and CRP. A repeat CT demonstrated somefree fluid and skip lesions of her proximal small and large bowel andassociated fat stranding.

She proceeded on to a laparotomy which demonstrated a perfo-ration to her ileum 35 cm proximal to the ileocaecal junction. Asmall bowel resection of the affected segment was performed, withthe ends brought out as a double barrel ileostomy. Pathology on thespecimen showed granulomatous enteritis, with mycobacterialorganisms seen in the specimen. She was subsequently treated withstandard TB regimen.

TB is an uncommon disease in Australia. TB notifications in 2005showed an incidence of 5.3/100 000, which have remained stablesince 1985.1 The incidence is much higher in overseas born andindigenous populations compared with non-indigenous Australianborn population (20.6 versus 5.9 versus 0.8 per 100 000).1 This issimilar to other western nations with a high immigration, forexample, UK.2

Incidence of abdominal TB is increasing worldwide as a result ofmulti-drug resistant TB and concurrent HIV infection, and becauseof this incidence, diagnostic dilemmas and management of compli-cations are becoming more common.

Clinical presentation of these patients depends on the predomi-nant system affected, which may include peritoneum, gastrointesti-nal tract, lymphatics, spleen, liver and pancreas. The most commonorgans affected include the peritoneum and ileocaecal junction. Pre-senting symptoms may range from localized or general ascites andabdominal distension to abdominal pain, diarrhoea, fever, weightloss, 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 abdomi-nal involvement on post-mortem studies.3 Abdominal TB tends toaffect a population between 20 and 45 years of age, with infectionvia a haematogenous route from a primary lung focus or military TB,via lymphatics from infected nodes, direct ingestion of bacilli fromsputum or infected sources, or by direct spread from adjacentorgans.4

Common presentations in the gastrointestinal tract include anulcerative process that may bleed, perforate or form fistulas; or ahyperplastic reaction that may cause obstruction or present as amass.5 The classic histological findings include a caseating granu-lomas and acid-fast bacilli on Ziehl–Neelsen-stained specimens.

Mycobacterium bovis infections have been all but eliminated bypublic health measures, and are only a rare cause of presentation ofintestinal TB secondary to direct ingestion of infected material.Almost all cases of abdominal TB in western countries are caused byMycobacterium tuberculosis, but an increasing incidence of infec-tion with Mycobacterium intracellulare is noted in association withHIV infection.5

Clinical diagnosis is difficult and relies on a combination ofimaging and pathological techniques including ultrasound, CT scan,endoscopy, colonoscopy and laparoscopy with biopsies of suspi-

cious granulomas. Analysis of ascitic fluid, skin-prick testing andmicrobiological confirmation with or without polymerase chainreaction for testing of biopsy tissue and culture may also be useful inestablishing diagnosis.6 Interestingly, only 15 to 20% of patientswith abdominal TB have radiographic evidence of active pulmonaryTB on a chest X-ray, and therefore a high index of suspicion in a lowprevalence population is required.7

Treatment includes a similar approach as for pulmonary TB with6–9 months of directly observed treatment, short course combina-tion drug treatment.8 However, sometimes patients will present withacute complications of their abdominal TB and will require emer-gent laparotomy to manage ulcers, perforations, adhesions, obstruc-tions, bleeding, fistulae formation and stenosis.

Corticosteroids have a role in the management of systemic symp-toms and local pressure effects, but their use is controversial anduncertain, but may be of benefit in established intestinal strictures.9

In conclusion, abdominal TB is a non-specific disease that maypresent with a wide variety of symptoms and complications. Highindex of suspicion is required in particular in low volume popula-tions such as Australia.

Medical treatment is the mainstay of therapy; however, surgicalinvolvement may be needed for diagnosis and management of acutecomplications.

References1. 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 oftuberculosis and latent tuberculosis infection. JAMA 2005; 293: 2776–84.

9. Allen MB, Cooke NJ. Corticosteroids and tuberculosis. BMJ 1991; 303:871–2.

Michael Yunaev, MBBSAndrew Ling, MBBSSaleh Abbas, FRACS

Michael Suen, FRACSHenry Pleass, FRACS

Surgery, Westmead Hospital, Sydney, New South Wales, Australia

doi: 10.1111/j.1445-2197.2011.05801.x

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