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Garg P, Goyal A, Yagnik VD, Dawka S, Menon GR. Diagnosis of anorectal tuberculosis by polymerase chain reaction, GeneXpert and histopathology in 1336 samples in 776 anal fistula patients. World J Gastrointest Surg 2021; 13:355-365. [PMID: 33968302 PMCID: PMC8069068 DOI: 10.4240/wjgs.v13.i4.355] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/11/2021] [Accepted: 04/14/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The association of tuberculosis (TB) with anal fistulas can make its treatment quite difficult. The main challenge is timely detection of TB in anal fistulas and its proper management. There is little data available on diagnosis and management of TB in anal fistulas.
AIM To detect TB in fistula-in-ano patients were analyzed in different methods utilized.
METHODS A retrospective analysis of different methods, polymerase chain-reaction (PCR), GeneXpert and histopathology (HPE), utilized to detect tuberculosis in fistula-in-ano patients, treated between 2014-2020, was performed. The sampling was done for tissue (fistula tract lining) and pus (when available). The detection rate of various tests to detect TB and prevalence rate of TB in simple vs complex fistulae were studied.
RESULTS In 1336 samples (776 patients) tested, TB was detected in 133 samples (122 patients). TB was detected in 52/703 (7.4%) samples tested by PCR-tissue, in 77/331 (23.2%) samples tested by PCR-pus, 3/197 (1.5%) samples tested with HPE-tissue and 1/105 (0.9%) samples tested by GeneXpert. To detect TB, PCR-tissue was significantly better than HPE-tissue (52/703 vs 3/197 respectively) (P = 0.0012, significant, Fisher’s exact test) and PCR-pus was significantly better than PCR-tissue (77/331 vs 52/703 respectively) (P < 0.00001, significant, Fisher’s exact test). TB fistulas were more complex than non-tuberculous fistulas [78/113 (69%) vs 278/727 (44.3%) respectively] (P < 0.00001, significant, Fisher’s exact test) but the overall healing rate was similar in tuberculous and non-tuberculous fistula groups [90/102 (88.2%) vs 518/556 (93.2%) respectively] (P = 0.10, not significant, Fisher’s exact test).
CONCLUSION This is the largest study of anorectal TB to be published. The detection of TB by polymerase chain-reaction was significantly higher than by histopathology and GeneXpert. Amongst polymerase chain-reaction, pus had a higher detection rate than tissue. TB fistulas were more complex than non-tuberculous fistulas but aggressive diagnosis and meticulous treatment led to comparable overall success rates in both groups.
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Affiliation(s)
- Pankaj Garg
- Department of Colorectal Surgery, Indus International Hospital, Mohali 140507, Punjab, India
- Department of Colorectal Surgery, Garg Fistula Research Institute, Panchkula 134113, Haryana, India
| | - Ankita Goyal
- Department of Pathology, Gian Sagar Medical College and Hospital, Patiala 140506, Punjab, India
| | - Vipul D Yagnik
- Department of Surgery, Nishtha Surgical Hospital and Research Centre, Patan 384265, Gujarat, India
| | - Sushil Dawka
- Department of Surgery, SSR Medical College, Belle Rive, Mauritius
| | - Geetha R Menon
- Department of Statistics, Indian Council of Medical Research, New Delhi 110029, India
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Perianal Tuberculosis: Lessons Learned in 57 Patients From 743 Samples of Histopathology and Polymerase Chain Reaction and a Systematic Review of Literature. Dis Colon Rectum 2019; 62:1390-1400. [PMID: 31596764 DOI: 10.1097/dcr.0000000000001493] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Few data are published on perianal tuberculosis. OBJECTIVE This study aimed to determine the best method to diagnose tuberculosis in patients with fistula-in-ano and to conduct a systematic review to determine the incidence and characteristics of tuberculosis fistula-in-ano. DATA SOURCES The prospective study data and existing literature were derived from PubMed, Google scholar, and Scopus STUDY SELECTION:: Prospective analysis of patients with tuberculous fistula-in-ano treated between 2014 and 2018 was conducted, and a systematic review of studies describing ≥3 patients with tuberculosis fistula-in-ano was completed. INTERVENTION Testing of tuberculosis was performed by histopathology or polymerase chain reaction of tissue or pus from the fistula tract. MAIN OUTCOME MEASURES The primary outcomes measured were the detection rate of various tests to detect tuberculosis in fistula-in-ano and the prevalence rate of tuberculosis in simple versus complex fistulas. RESULTS In 637 samples (410 patients) tested, tuberculosis was detected in 49 samples (43 patients). Additional samples (n = 106) sent in patients with a high index of suspicion tested positive in 14 more patients. Thus, overall, 63 samples tested positive in 57 patients (total: 743 samples in 410 patients were tested). Tuberculosis was detected in 2 of 181 patients (1.1%) in tissue (histopathology), in 28 of 341 patients (8.2%) in tissue (polymerase chain reaction), and in 19 of 115 patients (16.5%) in pus (polymerase chain reaction) samples. To detect tuberculosis, tissue (polymerase chain reaction) was significantly better than tissue (histopathology) (28/341 vs 2/181, p < 0.00001) and pus (polymerase chain reaction) was significantly better than tissue (polymerase chain reaction) (19/115 vs 28/341, p < 0.0009). Tuberculosis was significantly more common in complex fistulas than in simple fistulas (20.3% vs 7.2%, p = 0.0002). The systematic review (n = 199) highlighted that tubercular fistulas are more common in recurrent and complex fistulas and in tuberculosis endemic regions. LIMITATIONS The true sensitivity and specificity of each testing modality could not be determined because not all patients with tuberculosis fistula-in-ano were tested by every diagnostic modality studied. CONCLUSIONS The tuberculosis detection rate of polymerase chain reaction was significantly higher than histopathology. Among polymerase chain reaction, pus had higher detection rate than tissue. Tuberculosis was associated with more complex and recurrent fistulas.
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Choi YS, Kim DS, Lee JB, Kim JK, Jung HJ, Lee SD, Song KH, Lee DH, Kim MJ. Clinical Features of Tuberculous Versus Crohn's Anal Fistulas, in Korea. J Crohns Colitis 2015; 9:1132-7. [PMID: 26374663 DOI: 10.1093/ecco-jcc/jjv164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 09/07/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIMS In Western countries, tuberculous anal fistula may not be an issue because tuberculosis [TB] is not common, and this is a very rare form of extrapulmonary manifestation of TB. However in TB-endemic countries, careful diagnostic differentiation is required because the clinical features of TB anal fistula and Crohn's disease [CD] anal fistula are similar, with distinguishing features remaining unclear. We aimed to analyse the clinical features of TB versus CD anal fistulas. METHOD Among 13872 patients who underwent anal fistula surgery from 2003 to 2014, 87 patients with TB fistulas and 116 patients with CD fistulas were included. Data on the annual incidence of TB and CD, as well as the clinical, pathological, ultrasonographic, colonoscopic and surgical data were analysed. RESULTS Compared with CD, the TB group was older [median: 37 vs 22 years] and underlying chronic illness was more common [20.3% vs 2.6%]. In the TB group, 46 patients [59.7%] showed active or inactive pulmonary TB, and acid-fast bacilli and caseating granuloma were found in 56.3% and 62.1%, respectively. During colonoscopy, mucosal lesions were observed more frequently in CD [96.9% vs 16.9%]. CONCLUSIONS TB anal fistula is clinically very similar to CD anal fistula. In Korea, the incidence of CD anal fistula has recently increased in prevalence, whereas the prevalence of TB anal fistula is decreasing but is still persistent. We recommend that clinicians should prepare for a possibility of TB as well as CD anal fistula in TB-endemic countries including Korea.
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Affiliation(s)
- Yong-Sung Choi
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | - Do-Sun Kim
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Jae-Bum Lee
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Jong-Kyu Kim
- Department of Gastroenterology, Daehang Hospital, Seoul, Korea
| | | | - Seong-Dae Lee
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Kee-Ho Song
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Doo-Han Lee
- Department of Surgery, Daehang Hospital, Seoul, Korea
| | - Mi-Jung Kim
- Department of Pathology, Daehang Hospital, Seoul, Korea
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Tago S, Hirai Y, Ainoda Y, Fujita T, Takamori M, Kikuchi K. Perianal tuberculosis: A case report and review of the literature. World J Clin Cases 2015; 3:848-852. [PMID: 26380834 PMCID: PMC4568536 DOI: 10.12998/wjcc.v3.i9.848] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2014] [Accepted: 07/06/2015] [Indexed: 02/05/2023] Open
Abstract
Tuberculosis (TB) is still a major health problem worldwide. We present a rare case of an immuno-competent patient with perianal TB. A 38-year-old man visited a clinic with pain, swelling, and redness in the perineum. He had been persistently coughing for the past 6 mo. The abscess had formed a fistula to the perianal region, indicating perianal abscess. Mycobacterium tuberculosis was found in sputum and perianal abscess. Surgical drainage was performed, and oral anti-tuberculous drugs were administered for 6 mo. The patient’s clinical course was favorable. On review of the literature on 58 cases of perianal TB, we found that the duration of persistent perianal lesion was much longer in patients without active pulmonary TB (APTB) than in those with APTB (66.4 mo vs 8.3 mo; confidence interval, 0.0760-0.9620, P = 0.0380). Thus, in cases of non-healing or recurrent perianal lesions, TB should be considered.
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Gary MA, Wu J, Bradway M. The space between: a supralevator abscess caused by perforated diverticulitis. J Surg Case Rep 2013; 2013:rjt041. [PMID: 24964449 PMCID: PMC3813776 DOI: 10.1093/jscr/rjt041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Supralevator abscesses are the rarest manifestation of anorectal suppurative disease. We report a supralevator abscess in a 60-year-old male whose earliest presentation included poorly localized abdominal and pelvic pain, tenesmus, urinary retention and weight loss, initially treated as diverticular disease based upon imaging and presentation. Progressive symptoms led to the discovery of a pelvic abscess with subsequent percutaneous drainage, later followed by emergent laparotomy, where a single perforated diverticulum was revealed to be the source fistulization. He underwent a Hartmann procedure with concomitant drainage of supralevator and ischiorectal collections. Perirectal pain with neurological involvement is part of a constellation of signs and symptoms that should invoke a high index of clinical suspicion for supralevator abscess formation. Percutaneous attempts at drainage are often inadequate; definitive surgical therapy is the best approach to prevent recurrence and associated morbidity.
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Affiliation(s)
- Monique A Gary
- Department of Surgery, Berkshire Medical Center/University of Massachusetts Medical School, Pittsfield, MA, USA
| | - Jacqueline Wu
- Department of Surgery, Berkshire Medical Center/University of Massachusetts Medical School, Pittsfield, MA, USA
| | - Marcella Bradway
- Department of Surgery, Berkshire Medical Center/University of Massachusetts Medical School, Pittsfield, MA, USA
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Exceptional dissemination of perineal tuberculosis up to the right flank: a tribute to J.P. Nesselrod's study on the anatomy of pelvic lymphatics published in 1936 in the Annals of Surgery. Int J Colorectal Dis 2013; 28:723-6. [PMID: 23334691 PMCID: PMC3646164 DOI: 10.1007/s00384-012-1624-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2012] [Indexed: 02/04/2023]
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Affiliation(s)
- L C M Low
- National Skin Centre, Singapore, Singapore.
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Abstract
AIM Perianal Mycobacterium tuberculosis is rare, but tuberculosis (TB) is now endemic in many areas of the world. It is essential to recognize TB to institute appropriate management. We report three cases of TB presenting with supralevator abscess. METHOD We analysed the outcomes of three patients who presented to our unit, from 2004 to 2009, with supralevator abscess caused by TB. RESULTS The patients presented as emergencies with symptoms of per-anal sepsis. All required multiple drainage procedures. Supralevator extension was confirmed clinically and radiologically (by magnetic resonance imaging in two patients and by computed tomography scanning in one patient). One patient was diagnosed by perianal biopsy, the second by culture of pus and the third by sputum culture. Following drainage, all three patients were given anti-TB medication for 6 months. In all patients, the fistulae had high communication with the anal canal. In one patient, local drainage and medical therapy led to sepsis resolution, the second patient has residual complex fistulae and the third patient has recently commenced antimicrobial therapy. CONCLUSION As TB is endemic in many parts of Europe, TB should be suspected in patients with complex and/or recurrent perianal sepsis. Samples for histological and bacteriological analyses should be obtained from these patients. Recurrent perianal drainage procedures are likely to be required, and sepsis may persist after anti-TB therapy.
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Affiliation(s)
- J A Barker
- Department of Surgery, Central Manchester University Hospitals, Manchester Royal Infirmary, Manchester, UK
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Abstract
BACKGROUND Tuberculosis is one of the causes of granulomatous disease within the anorectal region. The clinical features, which include symptoms and signs of anal pain or discharge, multiple or recurrent fistula in ano and inguinal lymphadinopathy, are not characteristically distinct from other anal lesions. It is also difficult to distinguish it from other granulomatous diseases involving the same area. MATERIALS AND METHODS A Medline database was used to perform a literature search for articles relating to the term 'anal', 'tuberculosis' and 'Koch's'. CONCLUSION Analysis of the available literature shows that Koch's lesion in and around the anus is not uncommon. The presentation is varied in nature and tuberculosis should be suspected in lesions not responding to the conventional approaches. The treatment is two-fold: surgical for the suppuration and medical for the tuberculosis.
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Affiliation(s)
- P J Gupta
- Consulting Proctologist, Gupta Nursing Home, D/9 Laxminagar, Nagpur, India.
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Gierthmühlen M, Laiffer G, Viehl CT, Savic S, Bremerich J, Mueller C, Christ M. [No ordinary anal fistula...]. Internist (Berl) 2008; 49:490, 492-4. [PMID: 18320154 DOI: 10.1007/s00108-008-2063-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We present the case of a 63 year-old male Swiss patient with chronic diarrhea, mucous anal discharge, anal fistula, chronic anal ulceration and history of tuberculosis 56 years ago. Imaging and endoscopy was highly suspicious for Crohn's Disease, but histology and culture for M. tuberculosis proved tuberculous proctitis with perianal involvement and fistulation. The consideration of extrapulmonal tuberculosis with its various manifestations is crucial for the investigation of chronic abdominal complaints in order to avoid serious consequences of tuberculosis treated with immunosuppressive therapy.
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Affiliation(s)
- M Gierthmühlen
- Medizinische Klinik, Universitätsspital, Petersgraben 4, 4031, Basel, Switzerland
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Abstract
Gastrointestinal tuberculosis represents 1% of extrapulmonary tuberculoses and only sporadic cases of anal tuberculosis have been reported in the literature. We report two cases of tuberculous anal abscess and a review of the literature for diagnosis and treatment.
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