management of abdominal tuberculosis joint hospital surgical grand round dr shirley y.w. liu...
TRANSCRIPT
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Management of Abdominal
Tuberculosis
Joint Hospital Surgical Grand Round
Dr Shirley Y.W. LiuDepartment of SurgeryNorth District Hospital
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• Tuberculosis in the Globe •
Pulmonary TBExtrapulmonary TB
87.5%10%
2.5%
Abdominal tuberculosis(~11-16% of extrapulomnary TB)
Aston NO. World J Surg 1997;21:492-499Singhal A, et al. Eur J Gastroenterol Hepatol 2005; 17:967-971
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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
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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]
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Mode of infectionSwallowing of
infected sputum
Hematogenous spreadfrom pulmonary focus
Ingestion of contaminatedmilk products
Direct spread from adjacent organs
Pathogenesis of abdominal TB
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Intestinal49%
Peritoneal42%
Nodal4%
Solid visceral5%
Abdominal tuberculosis
Khan R, et al. World J Gastroenterol 2006;12(39):6371-6375
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1. Intestinal tuberculosis
Ileocaecalregion
Small bowel& colon
Niall O, et al. World J Surg 1997;21:492-499
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1. Intestinal tuberculosis
Ulcerative typeFormation of mucosal ulcers
• Bleeding• Perforation• Fistulation• Stricture
Hyperplastic typeExtensive inflammatory changes
• Obstruction• Mass
Aston NO. World J Surg 1997;21:492-499
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2. Peritoneal Tuberculosis
Acute form Chronic form
AsciticClear straw-coloured ascitic fluid
FibrousIntestines and viscera mattedtogether causing obstruction
EncystedMatted intestines enclosing aloculation of serous fluid
PurulentPurulent 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
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3. Nodal/ Glandular tuberculosis
• Less common
• Enlargement of– Mesenteric lymph nodes– Retroperitoneal lymph nodes
• Complications– Abscess formation
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4. Solid visceral tuberculosis
USG showing tuberculous nodules in spleen
Intraabdominal viscera:• Liver• Kidney• Spleen• Pancreas
CT scan showing tuberculous nodules inliver and spleen
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To 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/ maleGood past health
2 months
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To 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)
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To start with…• Differential diagnosis
– Abdominal tuberculosis– Malignancy– Lymphoma– Inflammatory disease
(Continued)
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How would you investigate & manage
him?
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To diagnose abdominal tuberculosis…
Clinicalpresentation
ConcomitantPTB
Blood tests
Tuberculin test
Radiological test
Microbiology& histology
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Clinical presentation
Acute form41%
Chronic form50%
Combined form9%
• Peritonitis• Intestinal obstruction• Perforation• GI bleeding
• Chronic pain• Ascites• Weight loss• Vomiting• Diarrhea• Fever• MassLeung VKS, et al. Hong Kong Med J 2006;12:264-271
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Clinical Presentation
Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700
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Clinical Presentation
• Non-specific symptoms & signs– High index of suspicion – More liberal use of investigations
• Differential diagnosis– Malignancy– Lymphoma– Inflammatory bowel disease– Infective disease
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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;93:692-696Faylona JM, et al. Ann Coll Surg 1993;3:65-70
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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]
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Tuberculin test
• High specificity• Low sensitivity• Low positive predictive
value 50-67%
Huebner, et al. Clin Infect Dis 1993; 17:968-75
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Radiological tests
• No diagnostic feature available
• Imaging guided peritoneal biopsy– Limited diagnostic sensitivity
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USG abdomen
Ascites Right lower quadrant massconsisting of matted bowel
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Computer tomography scan
Loculated ascites
Gross ascites Thickened omentum Loculated ascites
Thickened ileocaecal bowel Enlarged paraaortic LN Tubercles in spleen & liver
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Contrast study
Stricture in ileocaecal region Stricture in descending colon
• Good for intestinal tuberculosis affecting small or large bowel
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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
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Tissue Biopsy• Peritoneal tapping• Endoscopic biopsy• Laparoscopy• Laparotomy
Histologicalexam
Microbiological Smear & culture
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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):3647-3549Tzoanopoulos, et al. Eur J Intern Med 2003;14:367-371
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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
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Colonoscopy
Mucosalulceration
Mucosal nodules
Deformed Ileocaecal valve
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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
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Laparoscopy
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Summary of diagnostic tests
Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700
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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
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Retrospective review of abdominal TB in NDH
23 patientsMale: female = 11:12
Median age = 48 (Range: 8 - 83)
Histology or microbiology provenabdominal TB
13 patients
Not proven10 patients
SuspectedAbdominal TB
6 patients
Other pathology4 patients
Peritoneal TB53.8%
Intestinal TB46.2%
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Clinical presentation No of patients (%)
Abdominal pain 77% Ascites 38% Vomiting 38% Weight loss 30% Fever 30% Cough 30% Peritonism 26% Obstruction 13% Mass 4%
Duration of presentation: 1 day to 2 years
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Diagnostic tools No of patients
(%)
Diagnosis*
Confirmed (%)
Concomitant PTB 30 NA Abnormal CXR 26 NA Positive ultrasound features 38 NA Positive CT scan features 46 NA Colonoscopy 46 83 Surgery 73 41 Laparoscopy 26 66 Laparotomy 47 27
Total number of patients: 23
*Diagnosis confirmation by positive histology, smear or culture for AFB
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Comparison of diagnostic sensitivity
Diagnostic tests
Sensitivity in literarture (%)
Sensitivity in NDH series
(%)Peritoneal
tapping34 0
colonoscopy 66 82
Laparosocpy 92 66
Leung VKS, et al. Hong Kong Med J 2006;12:264-271
Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700
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Treatment• Mainstay of treatment
– Anti-tuberculous chemotherapy– Duration for 6-12 months– Response to treatment
• Resolution of symptoms within 3 months of treatment
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Role of Surgery• Indications of surgery
– Diagnostic uncertainty• Diagnostic laparoscopy in particular
– Complications• Obstruction• Perforation• Hemorrhage• Fistulation
• Conservative surgical approach should be adopted
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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
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Summary
High index of suspicion
More liberal use of invasive investigations
Mainstay of treatment by anti-TB drugs
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Thank you