Perforated tubercular enteritis of childhood: a ten year study

Abdominal tuberculosis in children: A real-world experience of 218 cases from an endemic region

Background and Aim

Abdominal tuberculosis (ATB) in children poses a diagnostic challenge because of its nonspecific clinical features, which often delay the diagnosis. Our aim was to present our real-world experience and provide an insight into the presentation, pattern of distribution, and diagnosis of the disease.

Methods

A retrospective review was conducted of case records of all children ≤12 years of age diagnosed with ATB from January 2007 to January 2018. Clinical details and investigations were recorded and analyzed.

Results

A total of 218 children (110 boys), with a median age of 10 (0.25-12) years, were included. There was a median delay of 4 (0.5-36) months in establishing the diagnosis. Abdominal pain, fever, and loss of weight were the most common presenting features, with the triad of symptoms present in 54%. Multiple intra-abdominal sites were involved in 118 (54%) patients, with a combination of the gastrointestinal tract (I) and abdominal lymph nodes (L) being the most common (53/118). Among children with single-site involvement (n = 100), the most commonly involved was L in 39 (39%), followed by I in 35(35%). Loss of weight was more common in children with involvement of multiple sites (85/118 vs 60/100, P = 0.03). Overall, a confirmed diagnosis was possible in 94 participants (43.1%). Suggestive imaging had the highest diagnostic yield of 85%. Nine (4.1%) patients needed surgical management.

Conclusion

A triad of abdominal pain, fever, and weight loss is suggestive of ATB. Multiple intra-abdominal sites are frequently involved. Microbiological confirmation is possible in only one-third of the cases.

Abdominal tuberculosis: a histopathological study with special reference to intestinal perforation and mesenteric vasculopathy

BACKGROUND

Along with the increased incidence of pulmonary tuberculosis in parallel with the increase in population in various parts of the world, in recent years, the incidence of abdominal tuberculosis has also increased. The pathogenetic events in intestinal tuberculosis, which culminate in ulcer formation, perforation, and stricture, still have to be identified.

AIM

To correlate the gross and microscopic features in intestinal tuberculosis, in particular tuberculous perforation with changes in mesenteric vasculature.

PATIENTS AND METHODS

A one-year prospective study of excised/resected tissues from patients with abdominal tuberculosis requiring surgical intervention was conducted. Tissues from fifty-six patients were included in the study-of which 36 were resected intestinal segments and 20 were intestinal and lymph node biopsies. Hematoxylin and Eosin and Ziehl-Neelsen stains were used for histopathological examination.

RESULTS

Tuberculous enteritis was found to be present in 49 of the 56 patients (87.5%) (ileum being the site most commonly affected), while nodal involvement was seen in 39 (69.6%) patients. Perforations were present in 39 out of 49 (79.6%) intestinal tissues; most being solitary and ileum was the commonest site. Typical epithelioid cell granulomas were seen in the intestine and lymph nodes, with caseation being more prevalent in the latter. The mesenteric vasculature was frequently involved by granulomatous inflammation, with intravascular organizing thrombus being present in 30% of the resected specimens with perforation. Acid fast bacilli were demonstrated in the tissue sections of 37.5% of the patients. AFB positivity was higher in caseating granulomas.

CONCLUSION

Involvement of mesenteric vasculature by granulomatous inflammation was commonly associated with the ulcerative type with perforation, suggesting that ischemia caused by vascular thrombosis is responsible for tissue breakdown. This implies that vasculitis plays an important role in the natural history of abdominal tuberculosis.

Jejunal tuberculosis in a 10-year-old girl

Abdominal tuberculosis in children usually presents with involvement of the peritoneum, lymph nodes or gastro-intestinal tract. Disease of the gastro-intestinal tract is commonest in the ileocaecal region. A 10-year-old girl presented with abdominal pain and fever of 15 days duration. Abdominal CT detected dilated small bowel loops with enlarged mesenteric nodes and barium meal follow-through demonstrated a small annular stricture in the jejunum, suggestive of jejunal tuberculosis. She was treated with anti-tuberculous chemotherapy and corticosteroids, to which she made a good response. Tuberculosis of the jejunum is rare in children.

Usefulness of histopathological examination in nontraumatic perforation of small intestine

INTRODUCTION

Nontraumatic perforation of small intestine (NTPSI) is a fairly common cause of peritonitis in developing world requiring early surgical intervention. Various etiological factors have been proposed for the cause of small bowel perforation. This retrospective study was conceded with an aim to determine the prevalence patterns of the different etiologies of NTPSI.

MATERIALS AND METHODS

A total of 164 patients were included in the study who had segments of small intestine removed for perforation during emergency procedures. Preoperative definitive diagnoses were not known in these cases. On gross examination, most of the small intestine perforations, n =  110 (67%), were found in the terminal ileum. On microscopy, the most frequent category was that of ulcers of nonspecific etiology, n = 61 (37.2%), which showed general features like inflammatory granulation tissue, serositis, and foreign body giant cell reaction.

RESULTS

In cases where a definite opinion could be established, infection was the commonest cause, n = 71 (43.3%), wherein tuberculosis (49, 29.9%) and typhoid (22, 13.4%) constituted the greatest number of cases. There were two cases of lymphoma and one case of metastatic adenocarcinoma involving the small intestine. Thus, histopathological examination of operated specimen is a useful guide for the surgeon to decide further management of the patient especially in the case of infections.

High jejunal perforation complicating tuberculous abdominal cocoon: a rare presentation in immune-competent male patient

BACKGROUND

Tuberculosis (TB) peritonitis is a rare presentation of TB that is typically insidious, presenting with systemic symptoms and nonspecific abdominal pain. In the majority of the cases, this leads to bowel obstruction and rarely causes abdominal cocoon. The disease process predominantly affects the small bowel with a tendency to involve the terminal ileum, leading to perforation on rare occasions.

METHODS

We are presenting a case report of multiple small-bowel perforations in immune-competent male patient complicating a TB cocoon and discuss clinical course and therapeutic options.

DISCUSSION

TB cocoon is a rare form of TB peritonitis presenting usually in the form of bowel obstruction. However, TB can cause multiple bowel perforations, particularly in children and immune-compromised patients. Such presentation carries a high rate of mortality. With the global increase in TB infections and the emergence of aggressive, multidrug-resistant strains, more severe manifestations are expected to increase. We presented a case of such severe acute manifestation on a background of insidious TB cocoon in a fit immune-competent male. Although primary repair of TB perforation is considered hazardous, it could not be avoided on this occasion. Nevertheless, proximal defunctioning jejunostomy and the early use of anti-TB drugs seemed to facilitate healing in such scenario.

CONCLUSIONS

TB should be considered in all cases of atypical bowel perforations. Proximal jejunostomy and early use of anti-TB drugs can facilitate primary repair in aggressive TB infection with multiple bowel perforations.

Multiple jejunoileal perforations because of intestinal involvement of miliary tuberculosis in an infant

Infants are more susceptible to tuberculous bacilli and may develop severe extrapulmonary and miliary forms of the disease. However, miliary tuberculosis (MT) presenting with multiple intestinal perforations as an initial manifestation of the disease is extremely rare in children. The authors describe an infant who underwent emergency laparotomy because of jejunoileal perforations secondary to intestinal involvement of MT to emphasize the characteristics of the abdominal disease and the importance of controlling systemic disease to achieve a favorable outcome.

Early enteral feeding by nasoenteric tubes in patients with perforation peritonitis

Malnutrition is well recognized as a potential cause of increased morbidity and mortality in surgical patients. Early postoperative enteral nutrition through a feeding jejunostomy has been shown to improve results in patients undergoing major resections for gastrointestinal malignancies, trauma, and perforation peritonitis. We conducted a prospective study to assess the feasibility and short-term efficacy of early enteral feeding through a nasoenteric tube placed intraoperatively in patients with nontraumatic perforation peritonitis with malnutrition. One hundred patients with nontraumatic perforation peritonitis with malnutrition undergoing exploratory laparotomy were randomly divided into a test group (TG) and a control group (CG) of 50 patients each. TG patients had a nasoenteric tube placed at the time of surgery and were started on an enteral feeding regime 24 hours postoperatively. Patients in CG were allowed to eat orally once they passed flatus. The differences between the two groups with respect to nutritional intake in terms of energy and protein, changes in nutritional status as assessed by anthropometric, biochemical, and hematological values, amount of nasogastric aspirate, return of bowel motility, and complication rates were analyzed. The nasoenteric feeding was well tolerated. Total calorie and protein intake in TG was significantly higher than in CG: 981 vs. 505 kcal (p < 0.01), protein 24 vs. 0 g on day 3 and 1498 vs. 846 kcal (p < 0.01), protein 44 vs. 23 g (p < 0.01) on day 7, respectively. There was reduction in the amount of nasogastric aspirate in TG compared with that in CG: 431 vs. 545 ml/24 h on day 2 and 301 vs. 440 ml/24 h on day 3, respectively. There was much faster recovery of bowel motility in TG than in CG at 3.34 vs. 4.4 days (p < 0.01). Complications developed in 39 of 50 patients in TG and in 47 of 50 in CG. The major complications occurred in 6 patients in TG and 12 patients in CG (p < 0.05). Patients with perforation peritonitis with malnutrition are likely to develop large energy deficits postoperatively, resulting in higher incidence of infective complications. Early enteral feeding through a nasoenteric tube is well tolerated by these patients and helps to improve energy and protein intake, reduces the amount of nasogastric aspirate, reduces the duration of postoperative ileus, and reduces the risk of serious complications.

Abdominal tuberculosis

Tuberculosis has staged a global comeback and forms a dangerous combination with AIDS. The abdomen is one of the common sites of extrapulmonary involvement. Patients with abdominal tuberculosis have a wide range and spectrum of symptoms and signs; the disease is therefore a great mimic. Diagnosis, mainly radiological and supported by endoscopy, is difficult to make and laparotomy is required in a large number of patient. Management involves judicious combination of antitubercular therapy and surgery which may be required to treat complications such as intestinal obstruction and perforation. The disease, though potentially curable, carries a significant morbidity and mortality.

Abdominal tuberculosis in Indian children

During the period 1980-1991, 166 cases (121 surgically explored and 45 treated conservatively) of abdominal tuberculosis in children were encountered at the Children's Hospital, Institute of Medical Sciences, Banaras Hindu University. Various types of presentations and their management are discussed in the light of pertinent literature.