Role of CT and MRI in Abdominal Tuberculosis

Surgical Management of Complicated Abdominal Tuberculosis: The First Systematic Review-New Treatments for an Ancient Disease and the State of the Art

Background: Abdominal tuberculosis comprises all forms of tuberculosis that involve the gastrointestinal tract. Controversies exist regarding the surgical approach and timing and type of intervention for complicated forms of abdominal tuberculosis. The aim of this systematic review is to define the rate of surgical treatment, the type of surgical procedures performed and the role of minimally invasive surgery in the management of abdominal tuberculosis. Methods: The literature in MEDLINE, Scopus and Google Scholar and forward and backward citations for studies published between database inception and July 2022 were searched without language restrictions. All prospective and retrospective studies were included. The electronic database search yielded 2440 records. Additionally, eight records were identified through snowball searching. Following duplicate removal (45 duplicates found), 2403 records were screened for titles and abstracts. After screening for titles and abstracts and exclusion criteria, 38 reports were included for systematic review, 27 retrospective studies and 11 prospective studies. Data extracted included the general and demographic characteristics of the studies, diagnostic methods used, clinical presentation, site of involvement and details on surgical treatment. Results: In total, 2870 patients with a diagnosis of abdominal tuberculosis were included, and 1803 (63%) underwent a surgical procedure. The majority of patients underwent an open surgical procedure (95%). The most commonly performed procedures were adhesiolysis (21%) and small bowel resection with primary anastomosis (21%). Conclusions: The results of this review suggest that whenever surgery is required, there is a tendency to perform open surgical procedures in patients with complicated abdominal tuberculosis, both in emergency and elective settings, despite advances in minimally invasive surgery. The study protocol was registered on PROSPERO (CRD42022354322).

Acute abdomen revealing abdominal tuberculosis complicated by a proximal jejunal perforation: Case report

Abdominal tuberculosis (TB) remains a significant health concern globally, particularly in regions with high endemicity such as North Africa and Morocco. Despite advances in diagnostic modalities, the nonspecific presentation of abdominal TB poses challenges for timely diagnosis and management. Here, we report a case of abdominal TB in a critically state of a young man from Morocco, presenting with acute abdominal pain and signs of sepsis. Radiological investigations revealed features suggestive of intestinal perforation complicating peritoneal TB. Urgent laparotomy confirmed the diagnosis, yet the patient succumbed to advanced sepsis postoperatively. This case underscores the complexity of abdominal TB diagnosis and management, necessitating a high index of suspicion and multidisciplinary collaboration. With evolving surgical techniques and ongoing research efforts, optimizing strategies for early detection and treatment of abdominal TB remains imperative, particularly in endemic regions.

Imaging of infra-thoracic tuberculosis

Tuberculosis (TB) is a potentially curable disease that is a leading cause of death globally. While it typically affects the lungs, this disease may involve many extra-pulmonary sites, particularly in patients with risk factors. Extra-pulmonary TB often mimics a variety of different diseases, posing a diagnostic dilemma. Imaging aids in early diagnosis of TB, especially in patients with non-specific or atypical symptoms found at extra-pulmonary infra-thoracic locations. Imaging also helps guide appropriate laboratory investigation, monitor disease progress, and response to treatment. This review aims to highlight the imaging spectrum of TB affecting the infra-thoracic region, that is, gastrointestinal tract, abdominal lymph nodes, peritoneal cavity, intra-abdominal solid organs, and urogenital system.

Imaging recommendations and algorithms for pediatric tuberculosis: part 2-extrathoracic tuberculosis

Despite advances in diagnosis and treatment in recent years, tuberculosis (TB) remains a global health concern. Children are amongst the most vulnerable groups affected by this disease. Although TB primarily involves the lungs and mediastinal lymph nodes, it can affect virtually any organ system of the body. Along with clinical history combined with physical examination and laboratory tests, various medical imaging tools help establish the diagnosis. Medical imaging tests are also helpful for follow-up during therapy, to assess complications and exclude other underlying pathologies. This article aims to discuss the utility, strengths and limitations of medical imaging tools in the evaluation of suspected extrathoracic TB in the pediatric population. Imaging recommendations for the diagnosis will be presented along with practical and evidence-based imaging algorithms to serve as a guide for both radiologists and clinicians.

Imaging recommendations and algorithms for pediatric tuberculosis: part 1-thoracic tuberculosis

Tuberculosis (TB) remains a global health problem and is the second leading cause of death from a single infectious agent, behind the novel coronavirus disease of 2019. Children are amongst the most vulnerable groups affected by TB, and imaging manifestations are different in children when compared to adults. TB primarily involves the lungs and mediastinal lymph nodes. Clinical history, physical examination, laboratory examinations and various medical imaging tools are combined to establish the diagnosis. Even though chest radiography is the accepted initial radiological imaging modality for the evaluation of children with TB, this paper, the first of two parts, aims to discuss the advantages and limitations of the various medical imaging modalities and to provide recommendations on which is most appropriate for the initial diagnosis and assessment of possible complications of pulmonary TB in children. Practical, evidence-based imaging algorithms are also presented.

Isolated pancreatic tuberculosis with splenic tuberculosis mimicking lymphoma malignum: A case report

Tuberculosis is an endemic disease in certain parts of the world. This disease typically presents in the lungs, but it may also appear within the abdomen, such as in the pancreas. There can be challenges in diagnosing isolated pancreatic tuberculosis as it may mimic other diseases radiologically. We present a 33-year-old female with intermittent abdominal pain and weight loss. Chest x-rays showed normal findings while noncontrast abdominal computed tomography (CT) showed a solid cystic mass in the pancreas and in the spleen. Contrast-enhanced CT showed an inhomogeneous cystic mass in the body and tail of the pancreas with peripheral rim enhancement. A laparotomy procedure was performed, and tuberculosis was confirmed histopathologically. In this case report, we highlight the challenging nature of diagnosing isolated pancreatic and splenic tuberculosis due to its presentation, which is similar to other neoplastic processes.

S, Chawla H, Kaushik S, Khan Z, . R, Chitravanshi S, Kabir U, Ansari D. Comparative Evaluation of Multidetector Computed Tomography and Dual-Energy Computed Tomography Findings in Gastrointestinal Tuberculosis

AIM

To compare multidetector computed tomography (MDCT) and dual-energy computed tomography (DECT) imaging findings in gastrointestinal (GI) tuberculosis.

OBJECTIVE

To study imaging findings of MDCT and DECT in GI tuberculosis.

METHODOLOGY

All the patients falling in the sampling frame and fulfilling the eligibility criteria were clinically examined and demographic details, presenting complaints, medical history, history of anti-tubercular treatment (ATT) intake, personal habits, and family history of tuberculosis were noted. All the patients underwent sputum acid-fast bacilli (AFB) assessment. Outcomes of investigations like bronchoscopy and fine-needle aspiration cytology (FNAC)/biopsy were also noted wherever available. Ascitic fluid AFB and culture assessments were also performed wherever feasible. All CT scans were performed on a 384-slice dual-energy CT scanner (Somaton Force, Siemens Healthcare) and all the images were post-processed on a workstation using syngo.via software that allows the analysis of images using three material decompositions. Features like peritonitis, lymph node involvement, GI wall thickening, and solid organ involvement were focused on. Subjective assessment of images of both MDCT and DECT were assessed by two experienced radiologists to prepare the CT diagnosis. The mutual agreement of the two observers was considered final.

CONCLUSIONS

The findings of the study showed that both MDCT, as well as DECT, were useful in the diagnosis of GI tuberculosis. On the basis of these findings, DECT could be considered to have an edge over MDCT in the diagnosis of GI tuberculosis. Keeping in view the small sample size and high prevalence, further studies on a larger sample size with relaxed sampling criteria are recommended to validate the findings of the present study.

Diffusion-weighted magnetic resonance imaging of abdominal tuberculosis: a new take on an old disease

Abdominal tuberculosis is a major cause of mortality and morbidity in developing countries also re-emerging in western world due to the AIDS epidemic and population migration. Large proportion of the patients are young and hence radiation exposure is of concern. In addition, in some patients, contrast may be contraindicated or repeat studies may be required, where MR especially DWI may be useful. The aim of the study is to describe MRI features in abdominal tuberculosis including DWI in the involved bowel, lymphadenopathy, omental, and peritoneal thickening. Nodes being especially easy to appreciate on DWI, thus DWI in conjunction with routine noncontrast MR sequence can be useful technique to identify abdominal tubercular lesions in patients with contraindication to contrast.

The Diagnostic Deceiver: Radiological Pictorial Review of Tuberculosis

Tuberculosis (TB) is a bacterial infection with Mycobacterium tuberculosis; it is a public health problem worldwide and one of the leading causes of mortality. Since December 2019, the COVID-19 pandemic has created unprecedented health challenges and disrupted the TB health services, especially in high-burden countries with ever-increasing prevalence. Extrapulmonary and even pulmonary TB are an important cause of nonspecific clinical and radiological manifestations and can masquerade as any benign or malignant medical case, thus causing disastrous conditions and diagnostic dilemmas. Clinical manifestations and routine laboratory tests have limitations in directing physicians to diagnose TB. Medical-imaging examinations play an essential role in detecting tissue abnormalities and early suspecting diagnosis of TB in different organs. Radiologists and physicians should be familiar with and aware of the radiological manifestations of TB to contribute to the early suspicion and diagnosis of TB. The purpose of this article is to illustrate the common radiologic patterns of pulmonary and extrapulmonary TB. This article will be beneficial for radiologists, medical students, chest physicians, and infectious-disease doctors who are interested in the diagnosis of TB.

Recent updates in diagnosis of abdominal tuberculosis with emphasis on nucleic acid amplification tests

INTRODUCTION

Abdominal tuberculosis (TB) is a common epitome of extrapulmonary TB (EPTB), wherein peritoneal and intestinal TB are the most prevalent forms. Diagnosis of abdominal TB is a daunting challenge owing to variable anatomical locations, paucibacillary nature of specimens and atypical clinical presentations that mimic other abdominal diseases, such as Crohn's disease and malignancies. In this review, we made a comprehensive study on the diagnosis of abdominal TB.

AREA COVERED

Various modalities employed for abdominal TB diagnosis include clinical features, imaging, bacteriological tests (smear/culture), histopathological/cytological observations, interferon-gamma release assays and nucleic acid amplification tests (NAATs). Among NAATs, loop-mediated isothermal amplification assay, PCR, multiplex-PCR, nested PCR, real-time PCR and GeneXpert® MTB/RIF were discussed. Identification of circulating Mycobacterium tuberculosis cell-free DNA by real-time PCR within ascitic fluids is another useful approach.

EXPERT OPINION

Several novel molecular/immunological methods, such as GeneXpert Ultra, aptamer-linked immobilized sorbent assay, immuno-PCR (I-PCR) and nanoparticle-based I-PCR have recently been developed for detecting pulmonary TB and several EPTB types, which may also be explored for abdominal TB diagnosis. Precise and prompt diagnosis of abdominal TB may initiate an early therapy so as to reduce the complications, i.e. abdominal pain, ascites, abdominal distension, intestinal obstruction/perforation, etc., and avoid surgical involvement.Plain Language SummaryAbdominal tuberculosis (TB) is a manifestation of extrapulmonary TB (EPTB), where peritoneal and intestinal TB are two major forms. Diagnosis of abdominal TB is difficult owing to low bacterial load present in clinical samples and non-specific clinical presentations as it mimics other diseases such as inflammatory bowel diseases, abdominal malignancies, etc. Bacteriological tests (smear/culture) almost fail owing to poor sensitivities and it is not always possible to get representative tissue samples for histopathological and cytological observations. In recent years, molecular tests i.e. nucleic acid amplification tests (NAATs), such as PCR/multiplex-PCR (M-PCR), nested PCR and GeneXpert are widely employed. Markedly, PCR/M-PCR and nested PCR exhibited reasonable good sensitivities/specificities, while GeneXpert revealed low sensitivity in most of the studies but high specificity, thus it could assist in differential diagnosis of intestinal TB and Crohn's disease. Further, novel molecular/immunological tests employed for pulmonary TB and other EPTB types were described and those tests can also be utilized to diagnose abdominal TB. Reliable and rapid diagnosis of abdominal TB would initiate an early start of anti-tubercular therapy and reduce the severe complications.

Tuberculosis of Cystic Duct Lymph Node Associated with Cholecystitis

Tuberculosis of the cystic duct lymph node is very rare. Only four cases have been reported in the literature. This paper presents the case of a young male patient with a tuberculous cystic duct lymph node and chronic cholecystitis, who was diagnosed with cystic duct stones and a gall bladder polyp preoperatively.

Diagnostic performance of CT for differentiating peritoneal tuberculosis from peritoneal carcinomatosis: a systematic review and meta-analysis

AIM

To undertake a systematic review and meta-analysis of the diagnostic performance of CT for differentiating peritoneal tuberculosis (PTB) from peritoneal carcinomatosis (PC).

MATERIAL AND METHODS

PubMed, Embase, the Web of Science, and the Cochrane Library were searched for papers published before 23 July 2019. The methodological quality of the studies was analysed. Overlapping descriptors used in different studies to denote the same image finding were subsumed under a single CT feature. Sensitivity, specificity, and positive and negative likelihood ratios were pooled. A summary receiver operating characteristic curve (sROC) was constructed and the area under the curve (AUC) of the included studies was calculated when possible.

RESULTS

Six studies were included and 17 CT features were analysed. The pooled sensitivity and specificity of smooth peritoneal thickening were 59% (95% CI: 52-66%) and 84% (95% CI: 79-88%), respectively. The AUC of smooth peritoneal thickening was 0.83. Omentum line/rim, lymph node necrosis or calcification, and mesenteric macro nodules had a pooled specificity ranging from 95% to 100% and a pooled sensitivity ranging from 12% to 67%. The other 12 signs had a pooled sensitivity ranging from 21% to 79% and a pooled specificity ranging from 19% to 81%. Omentum involvement (cake-like pattern) showed a threshold-effect, so only the AUC (=0.70) was calculated.

CONCLUSIONS

Smooth peritoneal thickening shows fairly good diagnostic accuracy, while omentum rim/line, lymph nodes necrosis or calcification, mesenteric macro nodules have good specificity but limited sensitivity. The informative features summarised in this study may aid clinical practice and future studies.

GeneXpert in stool: Diagnostic yield in Intestinal Tuberculosis

Background

Diagnosing intestinal (Luminal) tuberculosis is challenging due to limited yield of diagnostic modalities like CT scan, colonoscopy with blind ileal biopsies. GeneXpert MTB/RIF (Xpert) assays for diagnosing tuberculosis have been performed in the body secretions with excellent results. Its yield in stool is tested in this study.

Objective

The study aims to evaluate the yield of GeneXpert assay in stool of suspected cases of intestinal tuberculosis.

Methods

Hundred patients with suspected intestinal tuberculosis underwent routine biochemical tests, radiological investigations, colonoscopy with caecal and blind ileal biopsies for histopathology. Fresh stool samples were collected, processed for DNA extraction, tested using 2:1 ratio of GeneXpert reagent to sample to give positive or negative results for Mycobacterium tuberculosis and Rifampicin resistance.

Results

Out of hundred participants, 52% were female. Mean age was 28.21 ± 12.13. CT scan and colonoscopy findings suggestive of TB were present in 47% and 43% participants respectively. GeneXpert in stool was positive in 20% cases. Considering mucosal biopsy with histopathology of intestinal specimens as diagnostic of abdominal Tuberculosis, sensitivity and specificity of GeneXpert was 39.1% and 85.7% respectively.

Conclusion

Stool GeneXpert assay offers an alternative approach to detect intestinal tuberculosis rapidly with good diagnostic accuracy. Although it cannot replace the AFB culture and histopathology but contribute for early diagnosis and management.

Abdominal ultrasound for diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals

BACKGROUND

Accurate diagnosis of tuberculosis in people living with HIV is difficult. HIV-positive individuals have higher rates of extrapulmonary tuberculosis and the diagnosis of tuberculosis is often limited to imaging results. Ultrasound is such an imaging test that is widely used as a diagnostic tool (including point-of-care) in people suspected of having abdominal tuberculosis or disseminated tuberculosis with abdominal involvement.

OBJECTIVES

To determine the diagnostic accuracy of abdominal ultrasound for detecting abdominal tuberculosis or disseminated tuberculosis with abdominal involvement in HIV-positive individuals.To investigate potential sources of heterogeneity in test accuracy, including clinical setting, ultrasound training level, and type of reference standard.

SEARCH METHODS

We searched for publications in any language up to 4 April 2019 in the following databases: MEDLINE, Embase, BIOSIS, Science Citation Index Expanded (SCI-EXPANDED), Social Sciences Citation Index (SSCI), Conference Proceedings Citation Index- Science (CPCI-S), and also ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform to identify ongoing trials.

SELECTION CRITERIA

We included cross-sectional, cohort, and diagnostic case-control studies (prospective and retrospective) that compared the result of the index test (abdominal ultrasound) with one of the reference standards. We only included studies that allowed for extraction of numbers of true positives (TPs), true negatives (TNs), false positives (FPs), and false negatives (FNs). Participants were HIV-positive individuals aged 15 years and older. A higher-quality reference standard was the bacteriological confirmation of Mycobacterium tuberculosis from any clinical specimen, and a lower-quality reference standard was a clinical diagnosis of tuberculosis without microbiological confirmation. We excluded genitourinary tuberculosis.

DATA COLLECTION AND ANALYSIS

For each study, two review authors independently extracted data using a standardized form. We assessed the quality of studies using a tailored Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We used the bivariate model to estimate pooled sensitivity and specificity. When studies were few we simplified the bivariate model to separate univariate random-effects logistic regression models for sensitivity and specificity. We explored the influence of the type of reference standard on the accuracy estimates by conducting separate analyses for each type of reference standard. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included 11 studies. The risks of bias and concern about applicability were often high or unclear in all domains. We included six studies in the main analyses of any abnormal finding on abdominal ultrasound; five studies reported only individual lesions.The six studies of any abnormal finding were cross-sectional or cohort studies. Five of these (83%) were conducted in low- or middle-income countries, and one in a high-income country. The proportion of participants on antiretroviral therapy was none (1 study), fewer then 50% (4 studies), more than 50% (1 study), and not reported (5 studies). The first main analysis, studies using a higher-quality reference standard (bacteriological confirmation), had a pooled sensitivity of 63% (95% confidence interval (CI) 43% to 79%; 5 studies, 368 participants; very low-certainty evidence) and a pooled specificity of 68% (95% CI 42% to 87%; 5 studies, 511 participants; very low-certainty evidence). If the results were to be applied to a hypothetical cohort of 1000 people with HIV where 200 (20%) have tuberculosis then:- About 382 individuals would have an ultrasound result indicating tuberculosis; of these, 256 (67%) would be incorrectly classified as having tuberculosis (false positives).- Of the 618 individuals with a result indicating that tuberculosis is not present, 74 (12%) would be incorrectly classified as not having tuberculosis (false negatives).In the second main analysis involving studies using a lower-quality reference standard (clinical diagnosis), the pooled sensitivity was 68% (95% CI 45% to 85%; 4 studies, 195 participants; very low-certainty evidence) and the pooled specificity was 73% (95% CI 41% to 91%; 4 studies, 202 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

In HIV-positive individuals thought to have abdominal tuberculosis or disseminated tuberculosis with abdominal involvement, abdominal ultrasound appears to have 63% sensitivity and 68% specificity when tuberculosis was bacteriologically confirmed. These estimates are based on data that is limited, varied, and low-certainty.The low sensitivity of abdominal ultrasound means clinicians should not use a negative test result to rule out the disease, but rather consider the result in combination with other diagnostic strategies (including clinical signs, chest x-ray, lateral flow urine lipoarabinomannan assay (LF-LAM), and Xpert MTB/RIF). Research incorporating the test into tuberculosis diagnostic algorithms will help in delineating more precisely its value in diagnosing abdominal tuberculosis or disseminated tuberculosis with abdominal involvement.

Multimodal imaging of fibrosing mesenteric tuberculosis

This article presents fibrosing mesenteric tuberculosis in a 19-year-old Arab boy who presented with weight loss, fever, abdominal pain, and distension. Abdominal contrast enhanced computed tomography (CECT) was performed which showed large infiltrative ill-defined mesenteric-based enhancing soft tissue phlegmonous mass with surrounding desmoplastic reaction causing retraction-kinking of small bowel loops associated with central necrotic mesenteric lymph nodes, multifocal small bowel wall thickening, and ascites. Abdominal tuberculosis is a diagnostic challenge particularly if pulmonary tuberculosis is absent as in this case. CT appears to be the modality of choice if clinical and epidemiological suspicion is high in order to ensure early treatment for a favorable outcome.

Computed tomographic features of abdominal tuberculosis: unmask the impersonator!

PURPOSE

Abdominal tuberculosis (ATB) mimics various infectious, inflammatory, and neoplastic conditions and hence requires a high index of suspicion for accurate diagnosis, especially in low prevalence areas. It is difficult to consistently establish a histopathological diagnosis of ATB which underlines the importance of supportive evidences for institution of prompt empirical therapy to prevent associated morbidity and mortality.

METHODS

We retrospectively evaluated clinical and imaging features of 105 ATB cases and classified their CT findings based on peritoneal, lymph node, bowel, and solid organ involvement. Concomitant pulmonary and extra-pulmonary involvement was assessed.

RESULTS

Abdominal pain (78.1%) followed by fever (42.9%) were the commonest presenting symptoms. Peritoneal TB (77.14%) most commonly presented with a mix of ascites (49.38%), peritoneal (28.40%), and omental involvement (27.16%). Lymphadenopathy (57.1%) most commonly presented as necrotic nodes (81.67%) at mesenteric, peripancreatic, periportal, and upper paraaortic regions. Commonest site of bowel involvement (cumulative of 62.85%) was ileocecal region, with the commonest pattern of involvement being circumferential bowel wall thickening without bowel stratification with mild luminal narrowing. Hepatic (13.33%) and splenic (16.2%) involvement predominantly presented as multiple microabscesses. Adrenal and pancreatic involvement was noted in 4.7% and 1.9% of patients, respectively. 38.1% patients showed concomitant pulmonary and extra-pulmonary TB.

CONCLUSION

ATB has varied radiological features; however, peritoneal involvement in the form of mild ascites, smooth peritoneal thickening, smudgy omentum, multi-focal bowel involvement, necrotic nodes, and multiple visceral microabscesses point towards a diagnosis of ATB in appropriate clinical setting.