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Abdominal tuberculosis: an easily forgotten diagnosis

Abdominal tuberculosis (TB) is an uncommon condition in Australia. Diagnosis can be delayed because of its atypical presentation. We report two patients with atypical abdominal pain who turned out to have abdominal TB presenting to our institution within a month. The rst, a 34-year-old Indian male living in Australia for 3 years and no recent travel history, presented to emergency department with a 2-month history of central abdominal pain, which had increased in the last week and localized to the right side. He had previously been t and well. Clinically he was afebrile and haemodynamically stable with normal blood parameters other than a raised C-reactive protein (CRP) of 44 (normal < 10). He was markedly tender in his right iliac fossa with no other abnormal ndings. A computed tomography (CT) scan of his abdomen and pelvis demonstrated a 5 5 5 cm rim-enhancing collection around the caecal pole communicating with a 10 7 5 cm pelvic collection (Fig. 1). The provisional diagnosis of an appendiceal abscess was made and laparoscopy was arranged. However, at the time of laparoscopy, the intra-abdominal uid was found to be a serous exudate, with diffuse multiple peritoneal nodules present in all quadrants of the abdominal wall (Fig. 2). Biopsies were taken with histopathology showing necrotizing granulomatous inammation consistent with disseminated intra-abdominal TB (Fig. 3). He was subsequently treated with anti-TB treatment.

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The second patient, a 41-year-old female originally from Indonesia, who has been living in Australia for 8 years with no recent travel history, was admitted to the medical high dependency unit of the hospital with dyspnoea, malaise and diarrhoea. She was being treated empirically for atypical pneumonia, based on CT ndings prior to ascitic tap, which was done for diagnostic reasons because of ongoing abdominal symptoms. It showed acid-fast bacilli a week later. During the second week of her admission, she developed acute abdominal pain with peritonism, associated with an increase in

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

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

Fig. 3. Histopathology image of the peritoneal nodule from the 34-yearold male with abdominal pain, showing necrotizing granulomatous inammation.

2011 The Authors ANZ Journal of Surgery 2011 Royal Australasian College of Surgeons

ANZ J Surg 81 (2011) 559560

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white blood cell count and CRP. A repeat CT demonstrated some free uid and skip lesions of her proximal small and large bowel and associated fat stranding. She proceeded on to a laparotomy which demonstrated a perforation to her ileum 35 cm proximal to the ileocaecal junction. A small bowel resection of the affected segment was performed, with the ends brought out as a double barrel ileostomy. Pathology on the specimen showed granulomatous enteritis, with mycobacterial organisms seen in the specimen. She was subsequently treated with standard TB regimen. TB is an uncommon disease in Australia. TB notications in 2005 showed an incidence of 5.3/100 000, which have remained stable since 1985.1 The incidence is much higher in overseas born and indigenous populations compared with non-indigenous Australian born population (20.6 versus 5.9 versus 0.8 per 100 000).1 This is similar to other western nations with a high immigration, for example, UK.2 Incidence of abdominal TB is increasing worldwide as a result of multi-drug resistant TB and concurrent HIV infection, and because of this incidence, diagnostic dilemmas and management of complications are becoming more common. Clinical presentation of these patients depends on the predominant system affected, which may include peritoneum, gastrointestinal tract, lymphatics, spleen, liver and pancreas. The most common organs affected include the peritoneum and ileocaecal junction. Presenting symptoms may range from localized or general ascites and abdominal distension to abdominal pain, diarrhoea, fever, weight loss, 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 abdominal involvement on post-mortem studies.3 Abdominal TB tends to affect a population between 20 and 45 years of age, with infection via a haematogenous route from a primary lung focus or military TB, via lymphatics from infected nodes, direct ingestion of bacilli from sputum or infected sources, or by direct spread from adjacent organs.4 Common presentations in the gastrointestinal tract include an ulcerative process that may bleed, perforate or form stulas; or a hyperplastic reaction that may cause obstruction or present as a mass.5 The classic histological ndings include a caseating granulomas and acid-fast bacilli on ZiehlNeelsen-stained specimens. Mycobacterium bovis infections have been all but eliminated by public health measures, and are only a rare cause of presentation of intestinal TB secondary to direct ingestion of infected material. Almost all cases of abdominal TB in western countries are caused by Mycobacterium tuberculosis, but an increasing incidence of infection with Mycobacterium intracellulare is noted in association with HIV infection.5 Clinical diagnosis is difcult and relies on a combination of imaging and pathological techniques including ultrasound, CT scan, endoscopy, colonoscopy and laparoscopy with biopsies of suspi-

cious granulomas. Analysis of ascitic uid, skin-prick testing and microbiological conrmation with or without polymerase chain reaction for testing of biopsy tissue and culture may also be useful in establishing diagnosis.6 Interestingly, only 15 to 20% of patients with abdominal TB have radiographic evidence of active pulmonary TB on a chest X-ray, and therefore a high index of suspicion in a low prevalence population is required.7 Treatment includes a similar approach as for pulmonary TB with 69 months of directly observed treatment, short course combination drug treatment.8 However, sometimes patients will present with acute complications of their abdominal TB and will require emergent laparotomy to manage ulcers, perforations, adhesions, obstructions, bleeding, stulae formation and stenosis. Corticosteroids have a role in the management of systemic symptoms and local pressure effects, but their use is controversial and uncertain, but may be of benet in established intestinal strictures.9 In conclusion, abdominal TB is a non-specic disease that may present with a wide variety of symptoms and complications. High index of suspicion is required in particular in low volume populations such as Australia. Medical treatment is the mainstay of therapy; however, surgical involvement may be needed for diagnosis and management of acute complications.

References
1. Roche P, Bastian I, Krause V et al. Tuberculosis notications in Australia. Commun. Dis. Intell. 2007; 31: 7180. 2. Bennet D, Watson JM, Jenkins PA, McGuirk S. The UK mycobacterium network 1994. Tuber. Lung Dis. 1995; 76: 99109. 3. Sculley RE, Galdabini JJ, McNeely BU. Case records of Massachusetts General Hospital. N. Engl. J. Med. 1980; 303: 44557. 4. Lazarus AA, Thilagar B. Abdominal tuberculosis. Dis. Mon. 2007; 53: 328. 5. Aston NO, Chir MA. Abdominal tuberculosis. World J. Surg. 1997; 21: 4929. 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: 5059. 7. Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum. Am. J. Gastroenterol. 1993; 88: 98999. 8. Blumberg HM, Leonard MK, Jasmer RM. Update on the treatment of tuberculosis and latent tuberculosis infection. JAMA 2005; 293: 277684. 9. Allen MB, Cooke NJ. Corticosteroids and tuberculosis. BMJ 1991; 303: 8712.

Michael Yunaev, MBBS Andrew Ling, MBBS Saleh Abbas, FRACS Michael Suen, FRACS Henry Pleass, FRACS Surgery, Westmead Hospital, Sydney, New South Wales, Australia doi: 10.1111/j.1445-2197.2011.05801.x

2011 The Authors ANZ Journal of Surgery 2011 Royal Australasian College of Surgeons