Clinicopathological profile and surgical treatment of abdominal tuberculosis: a single centre experience in northwestern Tanzania

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).

Recognizing and addressing the challenges of gastrointestinal tuberculosis

In this editorial, we comment on the article by Ali et al published in the recent issue of the World Journal of Clinical Cases. This case report shed light on a particularly rare manifestation of this disease-primary gastrointestinal tuberculosis (GTB) presenting as gastric outlet obstruction. GTB presents diagnostic challenges due to its nonspecific symptoms and lack of highly accurate diagnostic algorithms. This editorial synthesizes epidemiological data, risk factors, pathogenesis, clinical presentations, diagnostic methods, and therapies to raise awareness about GTB. GTB constitutes 1%-3% of all tuberculosis cases globally, with 6%-38% of patients also having pulmonary tuberculosis. Pathogenesis involves various modes of Mycobacterium tuberculosis complex entry into the gastrointestinal system, with the terminal ileum and ileocecal valve commonly affected. Clinical presentation varies, often resembling other intra-abdominal pathologies, necessitating a high index of suspicion. Diagnostic tools include a combination of biochemical, microbiological, radiological, and endoscopic assessments. Anti-tubercular medication remains the cornerstone of treatment, supplemented by surgical intervention in severe cases. Multidisciplinary management involving gastroenterologists, surgeons, pulmonologists, and infectious disease specialists is crucial for optimal outcomes. Despite advancements, timely diagnosis and management challenges persist, underscoring the need for continued research and collaboration in addressing primary GTB.

Immunohistochemistry and real-time Polymerase Chain Reaction: importance in the diagnosis of intestinal tuberculosis in a Peruvian population

INTRODUCTION

The diagnosis of intestinal tuberculosis is challenging even nowadays. This study aims to report the positivity rates of new diagnostic methods such as immunohistochemistry and Real-Time Polymerase Chain Reaction in patients with intestinal tuberculosis, as well as describe the pathological and endoscopic features of intestinal tuberculosis in our population.

METHODS

This was a retrospective observational study conducted in patients diagnosed with intestinal tuberculosis, between 2010 to 2023 from the Hospital Nacional Daniel Alcides Carrion and a Private Pathology Center, both located in Peru. Clinical data was obtained, histologic features were independently re-evaluated by three pathologists; and immunohistochemistry and real-time Polymerase Chain Reaction evaluation were performed. The 33 patients with intestinal tuberculosis who fulfilled the inclusion criteria were recruited.

RESULTS

Immunohistochemistry was positive in 90.9% of cases, while real-time Polymerase Chain Reaction was positive in 38.7%. The ileocecal region was the most affected area (33.3%), and the most frequent endoscopic appearance was an ulcer (63.6%). Most of the granulomas were composed solely of epithelioid histiocytes (75.8%). Crypt architectural disarray was the second most frequent histologic finding (78.8%) after granulomas, but most of them were mild.

CONCLUSION

Since immunohistochemistry does not require an intact cell wall, it demonstrates higher sensitivity compared to Ziehl-Neelsen staining. Therefore, it could be helpful for the diagnosis of paucibacillary tuberculosis.

Totally laparoscopic treatment of intestinal tuberculosis complicated with bowel perforation: The first case report in worldwide literature with a brief review

Introduction

Bowel perforation is a relatively rare presentation of abdominal tuberculosis, whose diagnosis is challenging but fundamental to minimize morbidity and mortality. Laparoscopy is considered an effective modality for diagnosis, but its role in surgical treatment is still not established. We reported the first worldwide case of totally laparoscopic treatment of intestinal tuberculosis complicated with bowel perforation.

Case presentation

A 30-year-old man with a history of weight loss, preceded by 2 years of nonproductive cough, was admitted to the Infectious Disease Department with a presumed diagnosis of tuberculosis. A microbiological culture test confirmed the diagnosis, and the patient undertook quadruple antituberculous therapy. During hospitalization, he presented sudden abdominal pain, fever, and vomit. An abdominal CT scan showed small bowel perforation with granulomatous reaction. Laparoscopy was performed and revealed a 2 cm perforation on the medium ileum. Small bowel resection and totally intracorporeal side-to-side anastomosis were performed. No complication occurred until a clinical follow-up of 2 months.

Conclusion

In consideration of the increasing incidence of intestinal TB in both underdeveloped and Western countries, the diagnosis of this pathology should be taken into account in high-risk patients. Probably, the diagnostic challenges and emergency settings of intestinal TB with perforation and peritonitis, together with the lack of standardized guidelines regarding surgical management, make the use of laparoscopy apparently arduous, but the known advantages of laparoscopy and its technical feasibility should make it a conceivable option for the treatment of complicated cases.

Small Bowel Obstruction As a Consequence of Peritoneal Tuberculosis

Peritoneal tuberculosis (PTB) is a rare subset of extrapulmonary tuberculosis which account for only 0.5-1% of all cases. PTB diagnosis can be challenging due to nonspecific clinical manifestations. We present a known case of pulmonary tuberculosis that admitted to the surgery ward due to the major complaint of abdominal pain since ten days before admission. In imaging studies, positive findings favoring mechanical obstruction were detected. There were also several hypodense lesions in the liver suggestive of visceral tuberculosis. An adhesion was noted during exploratory laparotomy prior to the ileocecal valve responsible for intestinal obstruction, which was released. Pathology reports of excised tissues were consonant with the PTB diagnosis. PTB diagnosis can be challenging because of its presentation. This can delay the treatment of patients and thus increase morbidity and mortality. As a result, physicians should always be aware of the PTB diagnosis in patients with nonspecific abdominal involvement.

Gastrointestinal tuberculosis: A systematic review of epidemiology, presentation, diagnosis and treatment

Tuberculosis (TB) once considered a disease of the developing world is infrequent in the developing world too. Its worldwide prevalence with a huge impact on the healthcare system both in economic and health terms has prompted the World Health Organization to make it a top priority infectious disease. Tuberculous infection of the pulmonary system is the most common form of this disease, however, extrapulmonary TB is being increasingly recognized and more often seen in immunocompromised situations. Gastrointestinal TB is a leading extrapulmonary TB manifestation that can defy diagnosis. Overlap of symptoms with other gastrointestinal diseases and limited accuracy of diagnostic tests demands more awareness of this disease. Untreated gastrointestinal TB can cause significant morbidity leading to prolonged hospitalization and surgery. Prompt diagnosis with early initiation of therapy can avoid this. This timely review discusses the epidemiology, risk factors, pathogenesis, clinical presentation, current diagnostic tools and therapy.

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.

CLINICAL PROFILE, DRUG RESISTANCE PATTERN AND TREATMENT OUTCOMES OF ABDOMINAL TUBERCULOSIS PATIENTS IN WESTERN INDIA

ABSTRACT BACKGROUND: Abdominal tuberculosis is an increasing problem in developing world. OBJECTIVE: The objective of the study was to describe the clinical presentations, drug resistance pattern and treatment outcomes of abdominal tuberculosis in Western India. METHODS: All the cases of abdominal tuberculosis from May 2014 to April 2017, diagnosed on the basis of clinical profile and gross morphological findings at endoscopy, imaging, followed by histology and/or GeneXpert and MGIT culture were included. All patients received antitubercular drug (AKT) therapy according to national protocol. Patients were followed from diagnoses till completion of treatment and various parameters were studied. RESULTS: Out of the 176 patients, 48% were males. Abdominal pain was most common complaint in 83.5%. On colonoscopy terminal ileum and ileocaecal valve were most commonly involved segments. Upper gastrointestinal tract was involved in four patients. Overall ulceronodular lesions were most common followed by ulcerative/nodular lesion. Strictures in bowel were seen in 28 (15.9%) patients with ileocaecal valve being most commonly involved, of which 23 had symptomatic relief with AKT and only three required dilatation. Histopathology showed granuloma in 80.8% cases. MGIT was positive in 43 (35.80%) cases and GeneXpert was positive in 35 (26.1%) cases. Eight patients had multi drug resistant tuberculosis. Only two patients required surgical management. CONCLUSION: Abdominal tuberculosis with wide spectrum of presentation, can still be managed with early diagnosis and treatment even in patients with sub acute intestinal obstruction. Weight gain or resolving symptoms were considered early markers of treatment response. Patients with stricture can become asymptomatic with medical treatment alone.

Isolated gastric varices secondary to abdominal tuberculosis mimicking lymphoma: a case report

Background

Abdominal tuberculosis (TB) rarely presents with abdominal masses and rarely causes isolated gastric varices.

Case presentation

We report a case of isolated gastric varices secondary to abdominal TB mimicking lymphoma. A 42-year-old woman without any history of liver disease presented with melena and mild abdominal pain. Upon admission to the hospital, laboratory investigations revealed a hemoglobin level of 76 g/L. Gastroduodenoscopic examination showed isolated gastric fundal varices with red color signs. Abdominal contrast-enhanced computed tomography (CECT) revealed non-enhanced masses of soft-tissue density in the lesser omental and the retropancreatic areas, multiple para-aortic lymph nodes, and multiple small hypodense splenic lesions. Positron emission tomography-CT showed hypermetabolic [F-18]2-fluoro-2-deoxyglucose activity involving multiple regional lymph nodes and the bone marrow, suggestive of lymphoma. Bone marrow biopsy revealed no abnormality. Histopathological examination of a CT-guided biopsy specimen showed granulomatous inflammation with necrosis and microorganisms that stained positive with acid-fast stains. Abdominal CECT showed a decrease in the size of the lesser omental and peripancreatic masses, as well as the para-aortic lymph nodes after 4-month anti-TB therapy.

Conclusions

TB should be considered among the differential diagnoses in patients with abdominal masses, isolated gastric varices, and regional lymphadenopathy. Prompt and definitive diagnosis of abdominal TB requires a coordinated approach involving laboratory tests, radiological examination, and invasive procedures for optimal decision making and management.

Clinical features and outcomes of abdominal tuberculosis in southeastern Korea: 12 years of experience

Background

Abdominal tuberculosis (TB) is an uncommon form of infection with Mycobacterium tuberculosis in Korea. In this study, we aimed to highlight the clinical features, diagnostic methods, and outcomes of abdominal TB over 12 years in Southeastern Korea.

Methods

A total of 139 patients diagnosed as having abdominal TB who received anti-TB medication from January 2005 to June 2016 were reviewed. Among them, 69 patients (49.6%) had luminal TB, 28 (20.1%) had peritoneal TB, 7 (5.0%) had nodal TB, 23 (16.5%) had visceral TB, and 12 (8.6%) had mixed TB.

Results

The most frequent symptoms were abdominal pain (34.5%) and abdominal distension (21.0%). Diagnosis of abdominal TB was confirmed using microbiologic and/or histologic methods in 76 patients (confirmed diagnosis), while the remaining 63 patients were diagnosed based on clinical presentation and radiologic imaging (clinical diagnosis). According to diagnostic method, frequency of clinical diagnosis was highest in patients with luminal (50.7%) or peritoneal (64.3%) TB, while frequency of microscopic diagnosis was highest in patients with visceral TB (68.2%), and frequency of histologic diagnosis was highest in patients with nodal TB (85.2%). Interestingly, most patients, except those with nodal TB, showed a good response to anti-TB agents, with 84.2% showing a complete response. The mortality rate was only 1.4% in the present study.

Conclusions

Most patients responded very well to anti-TB therapy, and surgery was required in only a minority of cases of suspected abdominal TB.

Hepatic and Intra-abdominal Tuberculosis: 2016 Update

Mycobacterium tuberculosis (TB) infection affects nearly 10 million people a year and causes 1.5 million deaths. TB is common in the immunosuppressed population with 12 % of all new diagnoses occurring in human immune deficiency virus (HIV)-positive patients. Extra-pulmonary TB occurs in 12 % of patients with active TB infection of which 3.5 % is hepatobiliary and 6-38 % is intra-abdominal. Hepatobiliary and intra-abdominal TB can present with a myriad of non-specific symptoms, and therefore, diagnosis requires a high level of suspicion. Accurate and rapid diagnosis requires a multidisciplinary team (MDT) approach using radiology, interventional radiology, surgery and pathology services. Treatment of TB is predominantly medical, yet surgery plays an important role in managing the complications of hepatobiliary and intra-abdominal TB.

Abdominal tuberculosis in a low prevalence country

OBJECTIVE

Abdominal tuberculosis is a rare disease. The clinical and radiological manifestations are non-specific and the diagnosis is difficult. Our objective was to describe the characteristics and treatment of patients presenting with abdominal tuberculosis in a low-incidence country.

PATIENTS AND METHODS

We reviewed the clinical, diagnostic, treatment, and outcome features of patients presenting with abdominal tuberculosis diagnosed by bacteriological and/or histological results and managed in five French university hospitals from January 2000 to December 2009.

RESULTS

We included 21 patients. The mean diagnostic delay was 13 months. Twelve patients (57%) came from a low-incidence area and only two had a known immunosuppressed condition. Eighteen patients (86%) presented with abdominal symptoms. The main organs involved were the peritoneum (n=14, 66%), the mesenteric lymph nodes (n=13, 62%), and the bowel (n=7, 33%). Sixteen patients (76%) underwent surgery, including two in an emergency setting. Seventeen patients (81%) received six months or more of anti-tuberculosis treatment. Finally, 16 patients (76%) had a positive outcome.

CONCLUSION

New diagnostic procedures, and especially molecular biology, may help diagnose unusual clinical presentations of tuberculosis. Invasive procedures are frequently necessary to obtain samples but also for the treatment of digestive involvement.