Diagnosis of Abdominal Tuberculosis: The Importance of Laparoscopy

Differential Diagnosis of Abdominal Tuberculosis in the Adult-Literature Review

Tuberculosis (TB) is a public health issue that affects mostly, but not exclusively, developing countries. Abdominal TB is difficult to detect at first, with the incidence ranging from 10% to 30% of individuals with lung TB. Symptoms are non-specific, examinations can be misleading, and biomarkers commonly linked with other diseases can also make appropriate diagnosis difficult. As a background for this literature review, the method used was to look into the main characteristics and features of abdominal tuberculosis that could help with differentiation on the PubMed, Science Direct, and Academic Oxford Journals databases. The results were grouped into three categories: A. general features (the five forms of abdominal tuberculosis: wet and dry peritonitis, lymphadenopathy, lesions at the level of the cavitary organs, lesions at the level of the solid organs), B. different intra-abdominal organs and patterns of involvement (oesophageal, gastro-duodenal, jejunal, ileal, colorectal, hepatosplenic, and pancreatic TB with calcified lymphadenopathy, also with description of extraperitoneal forms), and C. special challenges of the differential diagnosis in abdominal TB (such as diagnostic overlap, the disease in transplant candidates and transplant recipients, and zoonotic TB). The study concluded that, particularly in endemic countries, any disease manifesting with peritonitis, lymphadenopathy, or lesions at the level of the intestines or solid organs should have workups and protocols applied that can confirm/dismiss the suspicion of abdominal tuberculosis.

Tuberculosis in the Elderly

The tuberculosis (TB) epidemic is most prevalent in the elderly, and there is a progressive increase in the notification rate with age. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. The mortality rate from tuberculosis remains higher in elderly patients. Symptoms of active TB are nonspecific and less pronounced in the elderly. Diagnostic difficulties in the elderly are common in many diseases but it is important to use all possible techniques to make a microbiological diagnosis. Recognising frailty to prevent loss of independence is a major challenge in dealing with the therapeutic aspects of elderly patients. Several studies report contrasting data about poorer tolerance of TB drugs in this population. Adherence to antituberculosis treatment is a fundamental issue for the outcome of treatment. Decreased completeness of treatment was shown in older people as well as a higher risk of treatment failure.

Place of Laparoscopy in Peritoneal Tuberculosis

Introduction: Peritoneal tuberculosis (PT) is a rare form of extrapulmonary tuberculosis in children. The diagnosis is difficult because of its clinical polymorphism. Laparoscopy is the gold standard to make the diagnosis by exploring and performing peritoneal biopsies. Our aim was to show the place of laparoscopy in the diagnosis of PT, to compare the anatomopathological results of peritoneal biopsies with a macroscopic appearance to quick start antituberculosis treatment. Case Reports: We reported 4 patients with PT, 3 girls and 1 boy. The middle age was 9 years old. The revealing symptomatology was ascites in all cases. Radiological exploration was not contributing. Laparoscopy was performed for all patients. The exploration revealed an agglutination of the intestinal loops with the presence of whitish micronodules scattered over the entire abdominal cavity. Peritoneal biopsies were done in all cases. Histological examination confirmed the diagnosis of PT in all patients and antituberculosis treatment was introduced. There was a good clinical evolution with a follow-up of 30 months. Conclusion: PT is a public health problem due to its clinical and biological polymorphism. Laparoscopy with peritoneal biopsies remains the essential means for the diagnosis of this pathology in children.

Reappraisal of the Role of Ascitic Fluid Adenosine Deaminase for the Diagnosis of Peritoneal Tuberculosis in Cirrhosis

Backgrounds/Aims

Although peritoneal tuberculosis (TB) is one of the important differential diagnoses among cirrhotic patients with ascites, a peritoneal biopsy is not always available. High ascitic fluid adenosine deaminase (ADA) has been indicative of peritoneal TB. On the other hand, studies to assess its diagnostic utility based on the confirmation of peritoneal biopsy in cirrhotic patients are scarce.

Methods

Patients with new-onset ascites were enrolled prospectively from a tertiary hospital. Peritoneal biopsy was applied according to clinical judgment when required. Based on pathology diagnosis of the peritoneum, the diagnostic efficacy of ascitic fluid ADA for peritoneal TB was evaluated in total and cirrhotic patients, respectively.

Results

Among 286 patients enrolled, 78 were diagnosed with peritoneal TB. One hundred and thirty-two patients had cirrhosis, and 30 of those were diagnosed with peritoneal TB. The mean ADA was 72.2 U/L and 22.7 U/L in the peritoneal and non-peritoneal TB group, respectively, among the total study population, and 64.0 U/L and 19.1 U/L in the peritoneal and non-peritoneal TB group, respectively, among the subgroup with cirrhosis. The area under the curve for ADA to diagnose peritoneal TB was 0.96 in the total study population with a cutoff value of 41.1 U/L, and 0.93 in cirrhotic patients with a cutoff value of 39.9 U/L.

Conclusions

The ascitic fluid ADA measurements showed high diagnostic performance for peritoneal tuberculosis in patients with ascites regardless of cirrhosis at a similar cutoff value.

Management of abdominal tuberculosis in a community-based hospital in a high-income developing country

Background

The delayed diagnosis and management of abdominal tuberculosis increases its mortality. We aimed to study the clinical presentation, management, and outcome of patients who had abdominal tuberculosis and were treated at Al-Ain Hospital, Al-Ain City, United Arab Emirates.

Methods

All patients who had abdominal tuberculosis and were treated at Al-Ain Hospital between January 2011 and December 2018 were studied. Data were collected retrospectively using a structured protocol including demography, clinical presentation, diagnostic methods, management, and outcome.

Results

Twenty-four patients having a median age of 30 years were studied with an incidence of 0.6/100,000 population. The most common symptoms were abdominal pain (95.8%) and malaise (79.2%). Fever was present only in nine patients (37.5%). Laboratory investigations, except for polymerase chain reaction immunoassay, were not helpful. Chest X-ray was abnormal in three patients (12.5%). Ultrasound and abdominal CT scan were non-specific. Thirteen patients needed surgical intervention for diagnosis or therapy. Diagnosis was confirmed by histopathology in 15 patients (62.5%), immunological assays in 7 patients (29.2%), microbiological culture in 1 patient (4%), and therapeutic trial in 1 patient (4%). The most common type of abdominal tuberculosis was gastrointestinal in 13 patients (54.2%) followed by free wet peritonitis in 5 patients (20.8%). All patients had quadruple anti-tuberculous therapy for a minimum of 6 months. The median hospital stay was 6.5 days. None of our patients died.

Conclusions

Diagnosis of abdominal tuberculosis remains challenging despite advances in medical technology and diagnostic tools. The limited need for diagnostic therapy in our study supports the benefit of PCR assay. Surgery was mainly indicated as the last option to reach the diagnosis or to treat complications.

TB or not TB: A comprehensive review of imaging manifestations of abdominal tuberculosis and its mimics

The ever-growing prevalence of tuberculosis is a cause for concern among both developing and developed countries. Abdominal tuberculosis is the most common site of extrapulmonary tuberculosis and involves almost all of the visceral organs. Clinical presentation of abdominal tuberculosis is often non-specific. Thus, having a high index of clinical suspicion is necessary to aide early diagnosis and guide prompt initiation of appropriate treatment. In this review, we focus on the entire spectrum of abdominal tuberculosis and other diseases mimicking it with an emphasis on their imaging findings.

Abdominal tuberculosis in Ecuador, a problem that is still not solved

Background

Tuberculosis (TB) in the gastrointestinal tract or peritoneum is an uncommon condition in clinical practice. Its rarity, combined with its nonspecific presentations, makes this kind of extrapulmonary tuberculosis difficult to diagnose as it can mimic other inflammatory or malignant conditions. Delays in treatment and frequent misdiagnosis can lead to hazardous complications. In countries like Ecuador where the disease is endemic, TB should always be considered in the differential diagnosis of a patients who present with nonspecific abdominal symptoms. In these scenarios, laparoscopy can be an invaluable tool when used with sufficiently high clinical awareness and adequate training.

Case presentation

We present the case of a 37-year-old female patient from Ecuador with a 1-year history of abdominal pain, nausea, intermittent vomits, night sweats, and weight loss. After clinical evaluation and a laparoscopic intervention, abdominal TB was detected and promptly treated. Antituberculosis chemotherapy was initiated, and the patient successfully recovered.

Conclusions

High clinical awareness is imperative when approaching abdominal TB due to its wide spectrum of clinical symptoms and its rarity. Early detection and prompt treatment are critical to minimize the possibility of hazardous complications.

Gastrointestinal Bleeding in a Patient With Gastric Lymphoma, Tuberculosis Enteritis, and Cytomegalovirus Enteritis

Bleeding from the small bowel can be challenging to identify by endoscopic or radiographic evaluation. We present the case of a patient with incompletely treated latent tuberculosis and medical history of T-cell lymphoma who developed gastrointestinal bleeding because of concurrent Burkitt lymphoma, tuberculosis enteritis, and cytomegalovirus enteritis. The interplay of these 3 diagnoses is discussed.

Uncloaking an ancient adversary: Can pathogen biomarker elicitors play a role in confirming extrapulmonary TB and latent TB infection?

Latent tuberculosis infection (LTBI) is diagnosed immunologically using the Mantoux tuberculin skin test (TST) or interferon-gamma release assays (IGRAs). While widely used, immunodiagnostics can produce false negative or false positive results. Pathogen biomarkers provide an alternative, but direct detection in LTBI and extrapulmonary TB cases is challenging. Mycobacterium tuberculosis grows slowly, has limited hematogenous movement, is protected by a lipid rich cell wall, and produces low levels of secreted factors. Here we discuss the potential of elicitors by first considering pathogen markers that may be released following the administration of isoniazid. Isoniazid targets the cell wall of mycobacteria found in extracellular compartments and within monocytes, macrophages, dendritic cells, and lymphatic endothelial cells. Isoniazid's dual-purpose potential as an antibiotic and elicitor is supported by knowledge of latent infection dynamics, time-kill kinetics, and new detection techniques. Within hours, the bactericidal action of isoniazid likely enriches plasma with M. tuberculosis DNA, RNA, proteins/peptides, and lipids. Undoubtedly a portion of these biomarkers are eliminated as some bacilli undergo phagocytosis and lysosomal destruction. However, advances in immunoprecipitation and nucleic acid amplification, combined with the use of larger blood volumes during assay development, may overcome these losses. Other anticipated challenges include determining optimal sample collection times and designing diagnostic workflows that minimize processing-associated marker loss and degradation. Conventional, commercial, and emerging technologies that address these variables are discussed. If realized, isoniazid associated markers could provide proof of concept for novel elicitor-based diagnostic approaches capable of confirming LTBI and empirically treated extrapulmonary TB.

Abdominal tuberculosis in children

BACKGROUND

Abdominal tuberculosis (TB) includes infection of the gastrointestinal tract, peritoneum, mesentery, abdominal lymph nodes, liver, spleen, and pancreas. The most common forms of abdominal TB in children are adhesive peritonitis and nodal disease.

PATIENTS AND METHODS

We report our experience with abdominal TB treated in our hospital from 1995 to 2008.

RESULTS

Thirteen patients (3 boys and 10 girls) of mean age 9.8 years were diagnosed as having abdominal TB. Eight patients presented with abdominal distension and abdominal pain. Fever was seen in 4 patients. One patient had surgical abdominal pain and 2 had abdominal mass. Two patients had coexisting pleural effusion and 1 of them had multifocal TB. Abdominal TB involved peritoneum in 9, abdominal lymph nodes in 7, gastrointestinal tract in 3, spleen in 2 patients, and liver in 1. Ascitic fluid analysis of 9 patients showed exudative fluid with predominately lymphocytes. Laparotomy was performed in 3 patients. The diagnosis of abdominal TB was confirmed histopathologically in 5 patients and microbiologically in 3. The remaining patients had been diagnosed by ascitic fluid diagnostic features, abdominal imaging, tuberculin skin test, history of exposure, and a positive response to antituberculous treatment. Twelve patients completed the antituberculous therapy without any complications. One patient with multifocal TB had neurological sequelae.

CONCLUSIONS

In the areas with a high prevalence of tuberculosis and confirmatory investigations are inadequately available, treatment may be initiated, based on strong clinical diagnosis and supportive investigations. In such situations, it is the response to therapy that indirectly proves the diagnosis.

Pitfalls of diagnostic laparoscopy in abdominal tuberculosis

BACKGROUND

Diagnostic laparoscopy currently is emerging as an important tool in the diagnostic armamentarium for abdominal tuberculosis (TB). However, the laparoscopic view may be deceiving even to the most experienced eyes, and it is not uncommon for TB to be diagnosed erroneously before the final histologic confirmation is received.

METHODS

A retrospective review of 20 diagnostic laparoscopies was conducted. The cases erroneously diagnosed at laparoscopy were collected and analyzed.

RESULTS

Five cases (20%) were identified. For two patients, the laparoscopic findings were thought to be those of carcinomatosis, but histology showed TB. For the other three patients, TB was suspected laparoscopically, but the final diagnoses were carcinomatosis, spontaneous bacterial peritonitis, and panniculitis. Two patients died: one due to delayed diagnosis and treatment of abdominal TB and the other due to carcinomatosis.

CONCLUSION

For a percentage of patients, the laparoscopic features of abdominal TB at diagnostic laparoscopy may be mistaken for other pathologies. Caution should be exercised before disclosure of the provisional diagnosis to the patient based on laparoscopy alone without histologic confirmation.

Review article: the diagnosis and management of Crohn's disease in populations with high-risk rates for tuberculosis

BACKGROUND

Distinguishing Crohn's disease from intestinal tuberculosis in endemic areas is challenging as both conditions have overlapping clinical, radiological, endoscopic and histological characteristics. Furthermore, high rates of latent tuberculosis confer a considerable risk of reactivation once therapy for established Crohn's disease is started.

AIM

To review current strategies in differentiating these two conditions, and in managing Crohn's disease, in populations with high rates of tuberculosis.

METHODS

Literature review and clinical experience.

RESULTS

While various clinical, radiological, endoscopic and histological parameters may aid in differentiating Crohn's disease from intestinal tuberculosis, these remain imperfect and as treatment options differ misdiagnosis has grave consequences. We propose a diagnostic algorithm, based on currently available evidence and experience, to aid in this dilemma. We also discuss approaches to the management of Crohn's disease, including agents targeting tumour necrosis factor-alpha, in patients at risk of developing tuberculosis.

CONCLUSIONS

A diagnosis of Crohn's disease in individuals at risk for tuberculosis should only be made after careful interpretation of clinical signs, abdominal imaging and systematic endoscopic and histological assessment. Newer techniques for the diagnosis of latent tuberculosis still need to be validated in this environment, and guidelines on the treatment of latent tuberculosis in this setting require clarification.