Surgical management of abdominal tuberculosis

Recent reports suggest an increased incidence of abdominal tuberculosis in the United States, particularly in high-risk groups. The aim of this study was to review the spectrum of abdominal tuberculosis and its surgical management at a tertiary referral center in the United States. The medical records of patients treated for abdominal tuberculosis at our institution between January 1992 and June 2001 were retrospectively reviewed. Eighteen patients were diagnosed with abdominal tuberculosis by microbiologic and/or histologic examination. The 10 men and eight women had a mean duration of symptoms of 4 months (range 1 to 24 months). Five were born in the United States, and 13 were foreign born (7 Asians and 6 Africans). The United States-born patients with abdominal tuberculosis, as compared to the foreign-born patients, were older (mean age 74 years vs.35 years), more likely to have chronic medical illnesses (80% vs.7%), and had concomitant pulmonary tuberculosis (60% vs. 0%). Computed tomography was the most frequent imaging modality (88%); findings suggestive of abdominal tuberculosis were mesenteric/omental stranding (50%), ascites (37%), and retroperitoneal lymphadenopathy (31%). Seventeen of the 18 patients required operative intervention, and one patient underwent CT-guided drainage of a psoas abscess. Laparoscopy was useful for diagnosis in eight patients; laparotomy was performed for complications of abdominal tuberculosis in six patients and to obtain a tissue diagnosis in three patients. Abdominal tuberculosis continues to represent a diagnostic challenge to clinicians. Among native-born white Americans, abdominal tuberculosis is primarily a disseminated disease of elderly, debilitated patients with chronic illnesses. Among foreign-born individuals, abdominal tuberculosis occurs in young, immunocompetent patients from endemic areas. Characteristic CT findings should be evaluated for abdominal tuberculosis in the appropriate clinical setting. Laparoscopy is an effective modality for diagnosis of peritoneal tuberculosis. Presented at the Forty-Third annual meeting of The Society for Surgery of the Alimentary Tract, San Francisco, California, May 19–22, 2002 (poster presentation) and published as an abstract in Gastroenterology.     

Abdominal tuberculosis--a surgical reality

Abdominal tuberculosis is a rare disease, with non-specific findings. Peritoneal tuberculosis is a frequent cause of low gradient ascites. The records of 22 patients (Il males, 11 females, mean age 41,17 years, and range 17-74 years) diagnosed with abdominal tuberculosis (TBC) in First Surgical Clinic, "St. Spiridon" University Hospital Ia?i between 1995 and 2006 were analyzed retrospectively and the literature was reviewed. From these 22 patients diagnosed with abdominal tuberculosis, there were: peritoneal TBC in 16 cases, intestinal TBC in 5 cases, mesenteric lymph nodes TBC in 1 case. The patients with intestinal TBC, were presented with complications, 2 perforations with peritonitis, 1 intestinal obstruction, and 2 as ileo-cecal "tumors" solved by right colectomy, 4 enterectomy (3 entero-enterostomies and 1 ileo-colic anastomosis). The patients with peritoneal TBC were diagnosed by laparoscopy and peritoneal biopsy in 13 cases, and by laparotomy in 3 cases. In peritoneal tuberculosis ascites was present in 15 cases. Other common findings were weight loss (12 cases), weakness (5 cases), abdominal pain (15 cases), anorexia (5 cases) and night sweat (2 cases). Only two patients had chest radiography suggestive of a new TBC lesion. In those patients with peritoneal tuberculosis, subjected to operation, the findings were multiple diffuse involvements of the visceral and parietal peritoneum, white "miliary nodules" or plaques, enlarged lymph nodes, ascites, "violin string" fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. Post operatory evolution and management were applied by the TBC Medical System and the patients were treated 6 months by tuberculostatics, with favorable evolution. Abdominal tuberculosis should be considered for diagnosis, in patients with non-specific symptoms of abdominal pain, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen. Laparoscopy is the best approach for peritoneal tuberculosis, and emergency surgery is necessary for acute complication like obstruction and peritonitis. Specific antituberculosis drugs are indicated in postoperative period.     

A prospective audit of the use of diagnostic laparoscopy to establish the diagnosis of abdominal tuberculosis

Background

The incidence of abdominal tuberculosis is much higher in an HIV-positive cohort. The use of laparoscopy in the diagnostic work-up of suspected abdominal tuberculosis is underutilized and its use and efficacy in the context of HIV co-infection has never been examined.

Methods

A prospective clinical audit of the use of diagnostic laparoscopy was conducted in patients with clinically suspected abdominal tuberculosis but histologically or microbiologically unconfirmed tuberculosis at any site.

Results

From January 2008 to June 2010, 81 patients underwent diagnostic laparoscopy; 34 were male and 47 were female, with a mean age of 33 years, and 77 % were HIV-positive. Fifty-five patients (68 %) had positive histology or culture for tuberculosis. In 15 patients (19 %), histology revealed non-specific inflammation, no pathology was found in one patient, and no specimen was taken from one patient. Eighty percent of peritoneal deposits and 77 % of lymph nodes were positive for tuberculosis, whereas 35 % of ascitic fluid cultures were positive. In nine patients (11 %) an alternative diagnosis was found; nine patients (11 %) had conversion to laparotomy. There was no procedure-related death. Nine patients (11 %) died during the 2-month follow-up period.

Conclusions

Diagnostic laparoscopy avoids the morbidity and mortality of laparotomy in chronically ill patients, and reduces the rate of misdiagnosis of other abdominal conditions and unnecessary long-term therapy. Diagnostic laparoscopy and tissue sampling is a viable and reliable strategy in patients with suspected abdominal tuberculosis.     

Genital tuberculosis at Tygerberg Hospital--prevalence, clinical presentation and diagnosis.

Over a period of 30 months (1 July 1986-31 December 1988) 57 cases of genital tuberculosis were diagnosed at Tygerberg Hospital. Forty of these cases were diagnosed as a result of routine screening in 650 patients who presented with infertility and the other 17 were diagnosed in patients admitted to the gynaecological wards. The prevalence in patients presenting with infertility was 6.15%. The commonest gynaecological presenting symptom was infertility (73.7%). Dysmenorrhoea in 29.8% and deep dyspareunia in 12.3% were the only other frequently occurring gynaecological symptoms. Menstruation was normal in 50 patients (87.7%). Seven per cent of patients were postmenopausal. Abdominal symptoms were only present in 15.8%. These findings re-emphasise that genital tuberculosis is often a disease of absent or few symptoms. General, abdominal and pelvic examinations were normal in 56.1% of patients and even when clinical signs were present they were nonspecific. Menstrual fluid collection and culture proved to be the most reliable diagnostic procedure, since it was positive in 11 patients in whom premenstrual endometrial sample cultures were negative and also in 17 patients in whom histological examination of premenstrual endometrial samples for tuberculosis were negative. The possible reasons for this and its clinical importance are discussed. Other than histological examination of operation and/or biopsy specimens, special investigations proved to be of little help in the diagnosis of genital tuberculosis.     

肠结核26例诊断与治疗的临床分析

目的:探讨肠结核的诊断要点及治疗特殊性,减少临床误诊误治.方法:回顾性分析普外科13年来26例肠结核病例的诊治资料. 结果:入出院诊断符合的仅5例(19.2%).术前行B超、CT、全消化道钡透或结肠镜检查的14例(53.8%)中,提示结核的仅2例(14.3%),大部分怀疑腹腔肿瘤或诊断为不能定性的腹腔肿块.手术24例,开腹后能肉眼确诊的2例(8.33%),另22例经术中快速病理切片得以确诊.所有手术患者术后均抗痨治疗,无并发症发生. 结论:肠结核临床症状不典型,临床医生对本病缺乏警惕性常导致较多的误诊误治.手术治疗有其特殊性,根据开腹所见决定手术方式,效果较好.     

肠结核的外科治疗(附26例分析)

目的 探讨肠结核病的临床特点和治疗经验,提高对肠结核病的诊断水平,减少误诊率。方法 回顾性分析自1993年1月至2003年4月手术治疗26例肠结核病例。结果 肠结核病人术前确诊率低,本组术前确诊6例,占23．1％。所有病例均治愈出院。结论 手术是针对肠结核病的并发症而进行的;抗结核治疗对肠结核病人有良好治疗效果;术前明确诊断可使部分肠结核病人免于手术。     

胰腺结核临床分析13例

目的进一步深入对胰腺结核的认识,提高对临床胰腺结核诊断率及治愈率。方法回顾性分析我院截止2004年10月收治的胰腺结核13例。结果本组有结核病史2例,临床表现:发热6例、腹痛13例、腹部包块4例、黄疸3例、盗汗4例、体重减轻7例、脾大和脾亢1例等。根据临床表现及淋巴结活检诊断2例;剖腹探查12例,经病理学检查确定诊断11例,1例术后合并肺结核经抗结核治疗证实胰腺结核诊断。全部病例经抗结核治疗治愈,1例未手术患者结核控制2年后出现区域性门脉高压、食管下段静脉曲张。结论腹痛、发热、体重减轻及影像学证实胰腺局限性、节段性病变病例,应考虑胰腺结核的可能。抗结核治疗是治愈胰腺结核的主要手段,外科手术对胰腺结核特别是胰腺结核性脓肿治疗具有重要意义。     

Diagnosis of tuberculosis of gastrointestinal tract]

The article deals with the difficulties of establishing the diagnosis of abdominal tuberculosis. Seven patients were under observation. In 5 the diagnosis was made histologically after operative intervention. In 6 patients abdominal tuberculosis was combined with a specific process in the lungs. Two cases of tuberculosis of the stomach, intestine, and mesenteric lymph nodes following a course resembling that of an abdominal "tumor" are described. For the exclusion of tuberculosis it is recommended that fluorographic examination of the lungs should be included in the complex preoperative management of patients.     

肠系膜上动脉综合征的诊治：附11 例报告

目的：探讨肠系膜上动脉综合征（SMAS）的诊疗方法,旨在提高对本病的认识,以降低误诊率。 方法：对中国医科大学附属第一医院1992年6月—2012年6月期间病历完整的11例SMAS患者行回顾性分析。 结果：11例中男7例,女4例,男女比例为1.75:1,以14~25岁高发（72.7%）;均以上腹部饱胀不适作为首发症状就诊,伴恶心、呕吐6例（54.5%,6/11）,消瘦7例（63.6%,7/11）;上消化道全程造影过程中见明显肠管逆蠕动4例,出现典型“钟摆样运动”1例,4例有肠系膜上动脉压迹;CT检查中3例显示肠系膜上动脉与腹主动脉夹角明显减小（<22°）;7例行静脉营养支持等保守治疗,4例保守治疗失败给予手术治疗,均恢复良好。8例患者术后随访6~102个月,均无复发及其他并发症。 结论：SMAS临床上相对少见,易于误诊,应加强对本病的认识,熟悉其诊断与治疗方法。     

Laparoscopy in suspected abdominal tuberculosis is useful as an early diagnostic method

Background: Establishing a histological diagnosis in abdominal tuberculosis can be difficult, frequently delaying treatment. The aim of the study was to evaluate the role of laparoscopy for ascertaining the diagnosis in suspected abdominal tuberculosis. Methods: A retrospective review was undertaken of patients who underwent diagnostic laparoscopy for suspected abdominal tuberculosis over a 6‐year period, analysing its usefulness in establishing a histological diagnosis. Results: From May 1999 to April 2005, 131 patients underwent diagnostic laparoscopies in our institution, of which 41 patients had unknown aetiologies for ascites or abdominal pain. This subset of patients had been investigated for suspected abdominal tuberculosis with biochemical tests of serum and ascitic fluid; ultrasound and computed tomography scanning, upper and lower gastrointestinal endoscopies and contrast series, before being considered for diagnostic laparoscopy. None had manifest extra‐abdominal tuberculosis. At laparoscopy, 39 of these patients (95%) had peritoneal nodules. Frozen‐section biopsy from the peritoneal nodules established the diagnosis of tuberculosis in 33 patients (80%) whereas metastatic adenocarcinoma was reported in 6 (14%). Permanent sections confirmed the diagnosis of tuberculosis in all 33 patients. Only 2 (5%) patients had no findings on laparoscopy; nevertheless, on continuing follow up, no sinister diagnoses were made for these patients. Conclusion: In patients suspected to have abdominal tuberculosis without evidence of extra‐abdominal disease, early laparoscopy may be useful to establish a histological diagnosis with acceptably low morbidity (8%). Frozen section is useful to assess adequacy of biopsy and sampling. An extensive work‐up may hence be averted by a timely laparoscopy and early treatment can be instituted.     

泌尿系结核的诊断体会（附36例报告）

目的：提高泌尿系结核的诊断水平,方法：回顾性分析36例泌尿系结核的临床资料,总结其诊断经验,结果：最常见的主诉为尿路刺激征和血尿,分别为64％和47％;尿沉渣涂片找抗酸杆菌和尿PCR－TBDN阳性率分别为22％和30％,IVU,逆行肾盂造影,CT的确诊率分别为33％,29％和68％,36例接受手术治疗,且术后病理检查均证实为泌尿系结核。结论：泌尿系结核的临床诊断应综合病史,尿液分析,影像学检查,病原学诊断等多种方法,力求寻找更多证据,X线检查应首选IVU和逆行肾盂造影,对两者未能明确诊断者,可选择CT检查,对于中,晚期肾结核,CT的诊断价值较逆行肾盂造影更大。     

Tuberculosis: Experience in a Low Endemic Area Australian Tertiary Hospital

Background

Abdominal tuberculosis (ATB) poses a significant diagnostic, management, and resource challenge. In Australia, an increasing number of tuberculosis (TB) cases are being reported, and we describe our experience of ATB in an Australian tertiary institution.

Methods

All diagnosed cases of tuberculosis (TB) at the Royal North Shore tertiary hospital campus of the University of Sydney are entered prospectively into a central registry. Cases of ATB encountered between September 1991 and November 2011 were identified and retrospectively reviewed.

Results

In all, 841 cases of TB were identified, of which 20 were abdominal (2.4 %). Median age at presentation was 34 years (range: 22–79 years), and 55 % of patients were women. None of the patients were born in Australia and 11 patients were of South Asian origin. The most common presenting symptom was abdominal pain (65 %). Diagnosis was based primarily on histology (90 % sensitivity), and the sensitivity of PCR analysis in this series was low (44 %). Eleven of the patients required laparoscopy or laparotomy. 40 % of cases involved the peritoneum, and disease was also seen in solid organs (liver, spleen, pancreas, adrenal gland) and bowel (esophagus, small bowel, colon).

Conclusions

In our local experience ATB was seen exclusively in the immigrant population. The presentation of ATB varies greatly, necessitating a high index of suspicion within the context of abdominal symptoms in high-risk groups. The role of surgical involvement is indispensable for both diagnosis and management of ATB-related complications. Surgeons should remain mindful of the diagnosis in an age of increasing worldwide incidence.     

Thoracic lymphadenopathy in Asians resident in the United Kingdom: role of mediastinoscopy in initial diagnosis.

Although the incidence of superficial glandular tuberculosis is high in Asian immigrants, a clinical diagnosis without biopsy has previously been shown to be inaccurate in 22% of cases. The role of diagnostic mediastinoscopy and biopsy in thoracic lymphadenopathy was therefore evaluated in 41 consecutive Asian patients. Tuberculosis was diagnosed by histological examination or culture (or both) of gland biopsy material in 24 (59%). A further 12 patients, however, also received antituberculous chemotherapy, with a response in 10 cases. If these are included, 34 (83%) were finally considered to have tuberculosis. The symptoms and ages of the patients with tuberculosis were similar to those typically seen in caucasians with sarcoidosis. Six had tuberculous bilateral hilar lymphadenopathy. In only four cases (10%) was a positive diagnosis other than tuberculosis established; in two (lymphoma and thymoma) mediastinoscopy confirmed preoperative suspicions, and saved only two more (with sarcoidosis and vascular anomaly) from unnecessary antituberculous treatment. Complications included severe haemorrhage (1) and chronic tuberculous sinus in the endoscopy tract (2). Mediastinoscopy is unlikely to change management in most patients, produces an appreciable amount of morbidity, and should be reserved for cases in which there is additional clinical doubt. Any future decline in the prevalence of tuberculosis in Asians may, however, require its further evaluation.     

Value of sonographic ileus diagnosis

Patients in an early state of mechanical bowel obstruction, with unspecific clinical symptoms, negative laboratory findings and no evidence of ileus in plain abdominal X-ray, are a pitfall for diagnosis and therapeutic decisions. In a partly retrospective, partly prospective study 11% (n = 13) of ileus patients admitted to our hospital met these criteria of "early state" bowel obstruction. Using conventional methods of diagnosis, in 6% (n = 7) false negative diagnosis was obtained; 4% (n = 5) were primarily admitted to the internal medical department. In all these cases, abdominal sonography yielded a correct diagnosis by demonstrating specific criteria of bowel obstruction even at onset of disease. The correct diagnosis was uniformly confirmed by early operation.     

非典型性肾结核8例

目的：提高对不典型肾结核的诊断和治疗水平。方法：回顾性分析8例误诊的非典型肾结核临床资料。结果：行肾切除术2例，右肾切除和肠膀胱扩大术1例，右肾输尿管全切术3例，肾造瘘和活检1例，抗结核治疗1例。结论：非典型肾结核的特殊性在于缺乏肾结核的典型临床表现，而主要表现为大量血尿、肾区及腹部疼痛、发热、前列腺炎或泌尿系外结核病灶等症状；缺乏实验室检查、膀胱镜检或X线检查的典型表现。     

The symptoms and surgical tactics for complicated forms of the abdominal cavity tuberculosis

The results of treatment of 12 patients, suffering complicated forms of abdominal tuberculosis and external intestinal fistulas, were presented. Late diagnosis of abdominal tuberculosis in the patients, suffering the complications phase of the disease, is caused by unclear symptoms presence in early stages of the disease. Clinical and laboratory indices in peritonitis of a phthisis origin are nonspeciphic. In 91% of patients, admitted to the hospital for complicated forms of abdominal tuberculosis and external intestinal fistulas, the operative treatment was indicated. Surgical intervention (more frequently right-sided hemicolectomy, enterostomy, the abscesses opening, the caseously-changed lymph nodes excision, formation of anastomosis) was performed in 11 patients for peritonitis and external intestinal fistulas. The method of a secure invagination anastomoses formation was elaborated, permitting to perform primary restoration operations. An early diagnosis, early effective therapy and radical surgical intervention conduction for complicated abdominal tuberculosis promote the patients to survive.     

肾结石并发肾结核的诊断(附6例报告)

目的：探讨肾结石并发肾结核的诊断方法。方法：回顾性分析６例此病患者临床资料。结果：临床诊断正确者１例,术后病理确诊者４例,１例因接受ＥＳＷＬ后尿液结核杆菌培养阳性而确立诊断,临床诊断准确率为１６．７％。结论：肾结石并发肾结核临床表现不典型,肾结核症状多被肾结石症状掩盖,故应注意临床资料中有提示意义的线索,对肾结石伴肾功能严重损害而患肾大小变化不显著尤应警惕并发肾结核。     

Tuberculosis following kidney transplantation

Morbidity of tuberculosis following kidney transplantation is about 1% (14/1719 kidney transplantations). All cases occurred within 1 year after transplantation; surprising was the relative high incidence in patients from outside Central Europe. Four patients with lack of clinical symptoms in whom the diagnosis was made by routine X-ray films of the chest survived after immediate therapy while five of ten patients with miliary tuberculosis died although proper treatment was performed. In cases of fever not caused by rejection or in pneumonia resistant to common antibiotics prophylactic antituberculous therapy should be considered even if microbiological evidence is not yet confirmed.     

Chronic rupture of abdominal aortic aneurysms. (Report of 3 cases)

Rupture of an abdominal aortic aneurysm often presents with an abdominal pain, hypotension and a pulsatile abdominal mass. In the last years same clinical reports describe patients with less apparent clinical signs who were found later in their evaluation to have a contained rupture of an abdominal aortic aneurysm. The diagnosis may be delayed by consideration of other disease causing similar symptoms (herniated disc, renal colic). In these patients with confusing abdominal symptoms CT scan provides a rapid and noninvasive diagnosis. We report three cases of contained rupture of an abdominal aortic aneurysm evaluated by computed tomography with different clinical presentation: back pain for erosion into the lumbar vertebral bodies, lower extremity neuropathy and obstructive jaundice. All patients were operated on within 24 hours on admission; there was no operative mortality and survival was 100% at one year.     

A rare cause of anemia due to intestinal tuberculosis in a renal transplant recipient

A renal transplant recipient with stable allograft function presented with massive hemorrhagic diarrhea and severe anemia. No microbial infection could be found in stool cultures. Early colonoscopy showed severe colitis with ulceration. Histological samples confirmed granulomatous inflammation with acid-resistant Ziehl-Neelson-positive microorganisms of mycobacterial type. Polymerase chain reaction (PCR) analysis of native mucosal biopsies specified the infectious organism as Mycobacterium tuberculosis complex. The patient responded well to antimycobacterial therapy and was still asymptomatic after 6 months with a stable graft function. Our case shows that tuberculosis can be a severe clinical problem in transplant recipients. Most of the patients with intestinal tuberculosis, reported to literature, were diagnosed post mortem or after explorative laparotomy and bowel resection. Thus, intestinal tuberculosis should be considered when a transplant recipient shows abdominal symptoms with no clear evidence of another infection. Proper diagnosis and treatment resulted in a beneficial outcome in our patient.