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Abdominal tuberculosis
Infection
Abdominal tuberculosis
large immigrant population, the incidence of TB was almost equal to that of Crohn’s disease. The immigrants may have acquired TB in their country of origin; the disease may remain quiescent for years, becoming reactivated later when the host defence mechanisms are suppressed as a result of factors such as old age, poor nutrition, diabetes, alcoholism and corticosteroids or other immunosuppressive drugs. Patients receiving continuous ambulatory peritoneal dialysis are at greater risk of peritoneal TB. TB and AIDS – TB was on the verge of disappearance, but has reappeared in association with the spread of HIV and has been declared a worldwide emergency. It may precede AIDS by several months, and extrapulmonary involvement is more common in HIV-positive patients. In sub-Saharan Africa, 60–90% of patients with extrapulmonary TB are HIV positive. Evidence for TB should be sought in patients with AIDS, and HIV infection should be sought in patients with TB. In the presence of HIV, TB is rapidly progressive, but HIV-positive TB patients are treated in the same manner as HIV-negative patients.
V K Kapoor
Abstract Tuberculosis (TB) is common in both underdeveloped and developing countries and, as a result of HIV, is increasingly seen in the developed world also. The lungs are the most common site of involvement in TB, but the abdomen is a common site of extrapulmonary involvement. Abdominal TB includes involvement of the gastrointestinal tract, peritoneum and lymph nodes. Most patients have a chronic presentation but it may be interspersed with acute attacks caused by complications. It often presents with subacute intestinal obstruction and a palpable lump. Symptoms of other organ (e.g. lungs, genital tract) involvement and general symptoms of TB may also be present. Microbiological diagnosis is difficult in abdominal TB; histology and radiology are the mainstay of diagnosis. In the western world, abdominal TB may mimic the more common Crohn’s disease; malignancy (carcinoma and lymphoma) is also an important differential diagnosis. Most patients with abdominal TB can be treated with antitubercular therapy alone but some may require surgery, mainly for complications such as obstruction and perforation, and sometimes for confirmation of diagnosis. Surgical procedures in abdominal TB are conservative.
Clinical features Abdominal TB is commonly seen in young adults, but can occur at any age. In children, peritoneal and lymph node involvement is more common than gastrointestinal disease. TB has an insidious onset and most patients have had symptoms for months or even years. In about one-third of patients, this chronic course is interrupted by acute attacks, which may lead to presentation. The symptoms and signs of abdominal involvement vary with the site of involvement, the type of lesion and the mode of presentation (Table 1). Subacute intestinal obstruction is characterized by attacks of incomplete obstruction that resolve spontaneously. The mass caused by abdominal TB is firm, mobile and mildly tender. It is commonly caused by a hypertrophic ileocaecal lesion and is palpable in the right iliac fossa. It may result from enlarged mesenteric lymph nodes, in which case it is palpable in the central abdomen. Ascitic peritoneal TB causes a distended, tender abdomen. Tubercular involvement of other organs mimics common diseases at these sites; for example: • oesophagus – cancer • gastroduodenal area – peptic ulcer disease, gastric outlet obstruction • anorectal area – fistula in ano. The symptoms and signs of tuberculous involvement may be present in the lungs, pleura, genital tract or peripheral lymph nodes. Patients may also have general symptoms such as fever, anorexia, weight loss or pyrexia of unknown origin. In patients with miliary TB, features of tubercular toxaemia such as highgrade fever, tachycardia and leucocytosis may be present. TB should be considered in patients with chronic unexplained abdominal symptoms, intestinal obstruction, peritonitis, an abdominal mass, ascites or fever of unknown origin, and in children who fail to thrive.
Keywords gastrointestinal; lymph node; tuberculosis; tuberculous peritonitis
Abdominal tuberculosis (TB) can affect the gastrointestinal tract, the peritoneum, lymph nodes of the small bowel mesentery or the solid viscera (e.g. liver, spleen, pancreas). The gastrointestinal tract is involved in 66–75% of patients with abdominal TB; the terminal ileum and the ileocaecal region are the most common sites, followed by the jejunum and colon. Multiple sites are common, and most patients with gastrointestinal lesions also have peritoneum and lymph node involvement. The term ‘miliary TB’ denotes generalized involvement of multiple organs or systems.
Epidemiology In the UK, the annual incidence of abdominal TB in migrants from the Indian subcontinent is 9/100,000. In one area of the UK with a
V K Kapoor MS DNB FRCS FACS FICS FACG FAMS is Professor and Head of the Department of Surgical Gastroenterology at the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. He qualified from the All India Institute of Medical Sciences, New Delhi, India. His current research interests include gall-bladder cancer and bile duct injuries. Competing interests: none declared.
MEDICINE 35:5
Investigations Microbiology – definitive diagnosis of TB is made by demonstra tion of the presence of acid-fast bacilli; these are easily found in 257
© 2007 Published by Elsevier Ltd.
Infection
Clinical features of abdominal tuberculosis Site of involvement
Type of lesion
Mode of presentation
Clinical features
Small intestine
Ulcerative
Chronic
Diarrhoea, malabsorption, malnutrition, lower gastrointestinal bleeding, fever Intestinal perforation and peritonitis Intestinal obstruction Intestinal obstruction Intestinal obstruction Mass, intestinal obstruction Intestinal obstruction Intestinal obstruction Lower gastrointestinal bleeding, fever Pain, ascites, fever Tuberculous peritonitis Intestinal obstruction Intestinal obstruction Intestinal obstruction
Stricture
Ileocaecum and large intestine
Hypertrophic
Peritoneum
Ulcerohypertrophic Ascitic Adhesive
Acute Chronic Acute-on-chronic Acute Chronic Acute-on-chronic Acute Chronic Chronic Acute Chronic Acute-on-chronic Acute
Table 1
ascitic fluid, but are difficult to demonstrate in gastrointestinal and lymph node tissue. Acid fast bacilli can be demonstrated by PCR techniques also. Histology – the histological picture includes epithelioid cell granulomata with a peripheral rim of lymphocytes and plasma cells, Langhans’ giant cells and central caseating necrosis; fibrosis and calcification are seen in healing lesions. Tissue for histological examination can be obtained by: • ultrasound-guided or CT-guided biopsy from an abdominal mass or enlarged lymph nodes • colonoscopic biopsy from colonic and ileocaecal lesions (the ileum can also be entered retrogradely) • laparoscopic biopsy of the parietal peritoneum (in patients with ascites). Imaging – chest radiography is usually normal, but evidence of pulmonary TB supports the diagnosis. Radiographs of the abdomen are useful in patients with intestinal obstruction and perforation. Barium studies (follow-through – Figure 1, entero clysis and double-contrast enema) demonstrate lesions in the intestine. Ultrasonography and CT (particularly when combined with enteroclysis) may demonstrate ascites, enlarged lymph nodes, thickened bowel loops, strictures or hypertrophic masses.
aseating necrosis, which is characteristic of tubercular granuloC mata, is absent in Crohn’s disease.
Management Antitubercular therapy for abdominal TB is the same as that for pulmonary TB. Short-course chemotherapy (6–9 months) including pyrazinamide, ethambutol, rifampicin and isoniazid is recommended. Inadequate and incomplete ATT is responsible for emergence of multi-drug resistant (MDR) and extremely drugresistant (XDR) tuberculosis. Surgery Indications – in many patients, there is strong clinical and radiological suspicion of TB but tissue cannot be obtained for microbiological or histological examination; this is more
Differential diagnosis Abdominal TB mimics many abdominal conditions (Tables 2 and 3). Crohn’s disease resembles abdominal TB in clinical presentation, radiological features, operative findings and histology (epithelioid cell granulomata). It is important to distinguish the two conditions – corticosteroids are the mainstay of treatment in Crohn’s disease, but may activate a relapse of TB if administered without antitubercular therapy. The diagnosis of Crohn’s disease is indicated in patients with extra-intestinal manifestations in the skin, eyes and joints, and perianal fissures and abscesses.
MEDICINE 35:5
Figure 1 Barium follow-through study showing distal ileal stricture (a) with proximal dilatation (b).
258
© 2007 Published by Elsevier Ltd.
Infection
Differential diagnosis of abdominal tuberculosis Symptom
Differential diagnosis
• Malabsorption
Coeliac disease Lymphoma Caecal carcinoma Appendicular mass Crohn’s disease Cardiac disease Renal disease Hepatic disease Malignancy
• Mass
• Ascites
Figure 2 Small intestinal stricture and enlarged mesenteric lymph nodes.
Table 2
c ommon in those with ulcerative intestinal or adhesive peritoneal TB. Some authors advocate a therapeutic trial of empirical antitubercular therapy, but it is better to perform diagnostic laparotomy to exclude more serious conditions (e.g. malignancy). Operative findings of clear, straw-coloured ascites, peritoneal tubercles, adhesions, enlarged mesenteric lymph nodes (Figure 2), hypertrophic ileocaecal and colonic lesions or short, fibrotic small intestinal strictures suggest the diagnosis of abdominal TB. Peritoneal tuberculosis may result in encapsulation of bowel. One of the enlarged lymph nodes should be removed and bisected – caseation strongly supports abdominal TB (Figure 3). If malignancy is suspected, frozen sections should be obtained for analysis. Patients with an acute abdomen require emergency laparotomy. Patients with acute-on-chronic intestinal obstruction respond to conservative management; they are investigated using radiological studies and treated according to the results. Patients with intestinal obstruction who have gastrointestinal lesions (e.g. ileocaecal or colonic hypertrophic masses, small intestinal strictures) usually require surgery, though some reports advocate
antitubercular therapy. It is unnecessary to give a preoperative course of antitubercular therapy, except in patients with tuber cular toxaemia and in those with open (cavitating) pulmonary TB. Procedures – when the diagnosis of abdominal TB is certain, conservative surgical procedures are recommended. Some of these procedures may be performed with the assistance of laparoscopy. • Limited segmental ileocaecal resection is performed in patients with an ileocaecal lesion. • Strictureplasty is preferred for small intestinal strictures, but resection is performed in patients with tight fibrotic strictures that almost totally obliterate the lumen (Figure 3) or multiple strictures in a short segment. Soft strictures causing only minimal restriction of the lumen may be left alone or dilated via enterotomy. • In patients with extensive peritoneal TB with dense adhesions resulting in matting of bowel loops, biopsy alone should be per formed and antitubercular therapy given; addition of cortico steroids for 6–12 weeks may reduce the risk of adhesive intestinal obstruction. • Patients with peritoneal or lymph node involvement alone, or with ulcerative intestinal lesions, are treated using antitubercular therapy; surgery is indicated only for complications (e.g. perforation, peritonitis).
Diagnostic dilemmas in abdominal tuberculosis Radiology • Distinguishing tuberculous strictures from those caused by Crohn’s disease, ischaemia or malignancy Ultrasonography • Distinguishing tuberculous lymph nodes from lymphoma Endoscopy • Distinguishing colonoscopic findings of tuberculosis (ulcer, nodules, strictures, polyps) from those of malignancy Operative • Distinguishing hypertrophic ileocaecal mass from carcinoma of the caecum • Distinguishing miliary peritoneal tuberculosis from carcinomatosis peritonei
Figure 3 Limited resection of a small intestinal stricture. Open intestinal specimen shows ulceration. Bisected mesenteric lymph node shows caseation.
Table 3
MEDICINE 35:5
259
© 2007 Published by Elsevier Ltd.
Infection
(Describes in detail the pathology of abdominal TB and its differentiation from Crohn’s disease.) Tandon RK, Sarin SK, Bose SL, et al. A clinico-radiological reappraisal of intestinal tuberculosis – changing profile? Gastroenterol Jap 1986; 21: 17–22. (A medical series of 186 patients.)
Prognosis The prognosis in patients with abdominal TB has improved markedly as a result of advances in diagnostic methods, better antitubercular drugs and safer surgical procedures. However, TB is associated with significant mortality (5–10%) and morbidity (anastomotic leak and fistula), and recurrence is a problem. ◆
Practice points
Further reading Anand BS, Nanda R, Sachdev K. Response of tuberculous strictures to antituberculous treatment. Gut 1988; 29: 62–9. (Reports successful management of obstructing intestinal lesions with antituberculous therapy.) Bhansali SK. Abdominal tuberculosis. Experiences with 300 cases. Am J Gastroenterol 1977; 67: 324–37. (A study of 300 patients managed surgically.) Kapoor VK. Abdominal tuberculosis. Postgrad Med J 1998; 74: 459–67. (Abdominal TB revisited – a review with 115 references.) Tandon HD, Prakash A. Pathology of intestinal tuberculosis and its distinction from Crohn’s disease. Gut 1972; 13: 260–9.
MEDICINE 35:5
• Abdominal tuberculosis should be considered as a possible differential diagnosis in many conditions • Definitive diagnosis requires histological examination • Tuberculosis should be looked for in patients with HIV • Diagnostic laparotomy is frequently required • All patients should receive antitubercular therapy; surgery is commonly required for complications • Inadequate and incomplete anti-tubercular therapy may lead to emergence of multi-drug resistant tuberculosis
260
© 2007 Published by Elsevier Ltd.
Abdominal tuberculosis
large immigrant population, the incidence of TB was almost equal to that of Crohn’s disease. The immigrants may have acquired TB in their country of origin; the disease may remain quiescent for years, becoming reactivated later when the host defence mechanisms are suppressed as a result of factors such as old age, poor nutrition, diabetes, alcoholism and corticosteroids or other immunosuppressive drugs. Patients receiving continuous ambulatory peritoneal dialysis are at greater risk of peritoneal TB. TB and AIDS – TB was on the verge of disappearance, but has reappeared in association with the spread of HIV and has been declared a worldwide emergency. It may precede AIDS by several months, and extrapulmonary involvement is more common in HIV-positive patients. In sub-Saharan Africa, 60–90% of patients with extrapulmonary TB are HIV positive. Evidence for TB should be sought in patients with AIDS, and HIV infection should be sought in patients with TB. In the presence of HIV, TB is rapidly progressive, but HIV-positive TB patients are treated in the same manner as HIV-negative patients.
V K Kapoor
Abstract Tuberculosis (TB) is common in both underdeveloped and developing countries and, as a result of HIV, is increasingly seen in the developed world also. The lungs are the most common site of involvement in TB, but the abdomen is a common site of extrapulmonary involvement. Abdominal TB includes involvement of the gastrointestinal tract, peritoneum and lymph nodes. Most patients have a chronic presentation but it may be interspersed with acute attacks caused by complications. It often presents with subacute intestinal obstruction and a palpable lump. Symptoms of other organ (e.g. lungs, genital tract) involvement and general symptoms of TB may also be present. Microbiological diagnosis is difficult in abdominal TB; histology and radiology are the mainstay of diagnosis. In the western world, abdominal TB may mimic the more common Crohn’s disease; malignancy (carcinoma and lymphoma) is also an important differential diagnosis. Most patients with abdominal TB can be treated with antitubercular therapy alone but some may require surgery, mainly for complications such as obstruction and perforation, and sometimes for confirmation of diagnosis. Surgical procedures in abdominal TB are conservative.
Clinical features Abdominal TB is commonly seen in young adults, but can occur at any age. In children, peritoneal and lymph node involvement is more common than gastrointestinal disease. TB has an insidious onset and most patients have had symptoms for months or even years. In about one-third of patients, this chronic course is interrupted by acute attacks, which may lead to presentation. The symptoms and signs of abdominal involvement vary with the site of involvement, the type of lesion and the mode of presentation (Table 1). Subacute intestinal obstruction is characterized by attacks of incomplete obstruction that resolve spontaneously. The mass caused by abdominal TB is firm, mobile and mildly tender. It is commonly caused by a hypertrophic ileocaecal lesion and is palpable in the right iliac fossa. It may result from enlarged mesenteric lymph nodes, in which case it is palpable in the central abdomen. Ascitic peritoneal TB causes a distended, tender abdomen. Tubercular involvement of other organs mimics common diseases at these sites; for example: • oesophagus – cancer • gastroduodenal area – peptic ulcer disease, gastric outlet obstruction • anorectal area – fistula in ano. The symptoms and signs of tuberculous involvement may be present in the lungs, pleura, genital tract or peripheral lymph nodes. Patients may also have general symptoms such as fever, anorexia, weight loss or pyrexia of unknown origin. In patients with miliary TB, features of tubercular toxaemia such as highgrade fever, tachycardia and leucocytosis may be present. TB should be considered in patients with chronic unexplained abdominal symptoms, intestinal obstruction, peritonitis, an abdominal mass, ascites or fever of unknown origin, and in children who fail to thrive.
Keywords gastrointestinal; lymph node; tuberculosis; tuberculous peritonitis
Abdominal tuberculosis (TB) can affect the gastrointestinal tract, the peritoneum, lymph nodes of the small bowel mesentery or the solid viscera (e.g. liver, spleen, pancreas). The gastrointestinal tract is involved in 66–75% of patients with abdominal TB; the terminal ileum and the ileocaecal region are the most common sites, followed by the jejunum and colon. Multiple sites are common, and most patients with gastrointestinal lesions also have peritoneum and lymph node involvement. The term ‘miliary TB’ denotes generalized involvement of multiple organs or systems.
Epidemiology In the UK, the annual incidence of abdominal TB in migrants from the Indian subcontinent is 9/100,000. In one area of the UK with a
V K Kapoor MS DNB FRCS FACS FICS FACG FAMS is Professor and Head of the Department of Surgical Gastroenterology at the Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. He qualified from the All India Institute of Medical Sciences, New Delhi, India. His current research interests include gall-bladder cancer and bile duct injuries. Competing interests: none declared.
MEDICINE 35:5
Investigations Microbiology – definitive diagnosis of TB is made by demonstra tion of the presence of acid-fast bacilli; these are easily found in 257
© 2007 Published by Elsevier Ltd.
Infection
Clinical features of abdominal tuberculosis Site of involvement
Type of lesion
Mode of presentation
Clinical features
Small intestine
Ulcerative
Chronic
Diarrhoea, malabsorption, malnutrition, lower gastrointestinal bleeding, fever Intestinal perforation and peritonitis Intestinal obstruction Intestinal obstruction Intestinal obstruction Mass, intestinal obstruction Intestinal obstruction Intestinal obstruction Lower gastrointestinal bleeding, fever Pain, ascites, fever Tuberculous peritonitis Intestinal obstruction Intestinal obstruction Intestinal obstruction
Stricture
Ileocaecum and large intestine
Hypertrophic
Peritoneum
Ulcerohypertrophic Ascitic Adhesive
Acute Chronic Acute-on-chronic Acute Chronic Acute-on-chronic Acute Chronic Chronic Acute Chronic Acute-on-chronic Acute
Table 1
ascitic fluid, but are difficult to demonstrate in gastrointestinal and lymph node tissue. Acid fast bacilli can be demonstrated by PCR techniques also. Histology – the histological picture includes epithelioid cell granulomata with a peripheral rim of lymphocytes and plasma cells, Langhans’ giant cells and central caseating necrosis; fibrosis and calcification are seen in healing lesions. Tissue for histological examination can be obtained by: • ultrasound-guided or CT-guided biopsy from an abdominal mass or enlarged lymph nodes • colonoscopic biopsy from colonic and ileocaecal lesions (the ileum can also be entered retrogradely) • laparoscopic biopsy of the parietal peritoneum (in patients with ascites). Imaging – chest radiography is usually normal, but evidence of pulmonary TB supports the diagnosis. Radiographs of the abdomen are useful in patients with intestinal obstruction and perforation. Barium studies (follow-through – Figure 1, entero clysis and double-contrast enema) demonstrate lesions in the intestine. Ultrasonography and CT (particularly when combined with enteroclysis) may demonstrate ascites, enlarged lymph nodes, thickened bowel loops, strictures or hypertrophic masses.
aseating necrosis, which is characteristic of tubercular granuloC mata, is absent in Crohn’s disease.
Management Antitubercular therapy for abdominal TB is the same as that for pulmonary TB. Short-course chemotherapy (6–9 months) including pyrazinamide, ethambutol, rifampicin and isoniazid is recommended. Inadequate and incomplete ATT is responsible for emergence of multi-drug resistant (MDR) and extremely drugresistant (XDR) tuberculosis. Surgery Indications – in many patients, there is strong clinical and radiological suspicion of TB but tissue cannot be obtained for microbiological or histological examination; this is more
Differential diagnosis Abdominal TB mimics many abdominal conditions (Tables 2 and 3). Crohn’s disease resembles abdominal TB in clinical presentation, radiological features, operative findings and histology (epithelioid cell granulomata). It is important to distinguish the two conditions – corticosteroids are the mainstay of treatment in Crohn’s disease, but may activate a relapse of TB if administered without antitubercular therapy. The diagnosis of Crohn’s disease is indicated in patients with extra-intestinal manifestations in the skin, eyes and joints, and perianal fissures and abscesses.
MEDICINE 35:5
Figure 1 Barium follow-through study showing distal ileal stricture (a) with proximal dilatation (b).
258
© 2007 Published by Elsevier Ltd.
Infection
Differential diagnosis of abdominal tuberculosis Symptom
Differential diagnosis
• Malabsorption
Coeliac disease Lymphoma Caecal carcinoma Appendicular mass Crohn’s disease Cardiac disease Renal disease Hepatic disease Malignancy
• Mass
• Ascites
Figure 2 Small intestinal stricture and enlarged mesenteric lymph nodes.
Table 2
c ommon in those with ulcerative intestinal or adhesive peritoneal TB. Some authors advocate a therapeutic trial of empirical antitubercular therapy, but it is better to perform diagnostic laparotomy to exclude more serious conditions (e.g. malignancy). Operative findings of clear, straw-coloured ascites, peritoneal tubercles, adhesions, enlarged mesenteric lymph nodes (Figure 2), hypertrophic ileocaecal and colonic lesions or short, fibrotic small intestinal strictures suggest the diagnosis of abdominal TB. Peritoneal tuberculosis may result in encapsulation of bowel. One of the enlarged lymph nodes should be removed and bisected – caseation strongly supports abdominal TB (Figure 3). If malignancy is suspected, frozen sections should be obtained for analysis. Patients with an acute abdomen require emergency laparotomy. Patients with acute-on-chronic intestinal obstruction respond to conservative management; they are investigated using radiological studies and treated according to the results. Patients with intestinal obstruction who have gastrointestinal lesions (e.g. ileocaecal or colonic hypertrophic masses, small intestinal strictures) usually require surgery, though some reports advocate
antitubercular therapy. It is unnecessary to give a preoperative course of antitubercular therapy, except in patients with tuber cular toxaemia and in those with open (cavitating) pulmonary TB. Procedures – when the diagnosis of abdominal TB is certain, conservative surgical procedures are recommended. Some of these procedures may be performed with the assistance of laparoscopy. • Limited segmental ileocaecal resection is performed in patients with an ileocaecal lesion. • Strictureplasty is preferred for small intestinal strictures, but resection is performed in patients with tight fibrotic strictures that almost totally obliterate the lumen (Figure 3) or multiple strictures in a short segment. Soft strictures causing only minimal restriction of the lumen may be left alone or dilated via enterotomy. • In patients with extensive peritoneal TB with dense adhesions resulting in matting of bowel loops, biopsy alone should be per formed and antitubercular therapy given; addition of cortico steroids for 6–12 weeks may reduce the risk of adhesive intestinal obstruction. • Patients with peritoneal or lymph node involvement alone, or with ulcerative intestinal lesions, are treated using antitubercular therapy; surgery is indicated only for complications (e.g. perforation, peritonitis).
Diagnostic dilemmas in abdominal tuberculosis Radiology • Distinguishing tuberculous strictures from those caused by Crohn’s disease, ischaemia or malignancy Ultrasonography • Distinguishing tuberculous lymph nodes from lymphoma Endoscopy • Distinguishing colonoscopic findings of tuberculosis (ulcer, nodules, strictures, polyps) from those of malignancy Operative • Distinguishing hypertrophic ileocaecal mass from carcinoma of the caecum • Distinguishing miliary peritoneal tuberculosis from carcinomatosis peritonei
Figure 3 Limited resection of a small intestinal stricture. Open intestinal specimen shows ulceration. Bisected mesenteric lymph node shows caseation.
Table 3
MEDICINE 35:5
259
© 2007 Published by Elsevier Ltd.
Infection
(Describes in detail the pathology of abdominal TB and its differentiation from Crohn’s disease.) Tandon RK, Sarin SK, Bose SL, et al. A clinico-radiological reappraisal of intestinal tuberculosis – changing profile? Gastroenterol Jap 1986; 21: 17–22. (A medical series of 186 patients.)
Prognosis The prognosis in patients with abdominal TB has improved markedly as a result of advances in diagnostic methods, better antitubercular drugs and safer surgical procedures. However, TB is associated with significant mortality (5–10%) and morbidity (anastomotic leak and fistula), and recurrence is a problem. ◆
Practice points
Further reading Anand BS, Nanda R, Sachdev K. Response of tuberculous strictures to antituberculous treatment. Gut 1988; 29: 62–9. (Reports successful management of obstructing intestinal lesions with antituberculous therapy.) Bhansali SK. Abdominal tuberculosis. Experiences with 300 cases. Am J Gastroenterol 1977; 67: 324–37. (A study of 300 patients managed surgically.) Kapoor VK. Abdominal tuberculosis. Postgrad Med J 1998; 74: 459–67. (Abdominal TB revisited – a review with 115 references.) Tandon HD, Prakash A. Pathology of intestinal tuberculosis and its distinction from Crohn’s disease. Gut 1972; 13: 260–9.
MEDICINE 35:5
• Abdominal tuberculosis should be considered as a possible differential diagnosis in many conditions • Definitive diagnosis requires histological examination • Tuberculosis should be looked for in patients with HIV • Diagnostic laparotomy is frequently required • All patients should receive antitubercular therapy; surgery is commonly required for complications • Inadequate and incomplete anti-tubercular therapy may lead to emergence of multi-drug resistant tuberculosis
260
© 2007 Published by Elsevier Ltd.