Diagnostic dilemma of abdominal tuberculosis in non-HIV patients： An ongoing challenge for physicians

INTRODUCTION In developing countries, tuberculosis is associated with poverty, deprivation, overcrowding, illiteracy, and limited access to health care facilities. While in developed worlds, tuberculosis is commonly accompanied with HIV infection, ageing …     

The ectopic kidney in the emergency department

Renal ectopia can present as abdominal pain and be a predisposing factor to several pathologies seen in the genitourinary system. We present the case of a 21-year-old man with intermittent right lower quadrant abdominal pain who was found to have a nonfunctioning pelvic kidney and underwent nephrectomy. Although specific findings on renal ectopia are often absent, associated congenital defects above the pelvic organs raise the suspicion for renal ectopia. Early detection and recognition of the ectopic kidney can prevent long-term complications.     

Surgical presentation of abdominal tuberculosis: a protean disease

BACKGROUND/AIMS: The incidence of tuberculosis is rising again in the Western world, due to the emergence of new groups of patients at risk. This paper intends to describe the various patterns of surgical presentation of abdominal tuberculosis in an industrialized country. METHODOLOGY: A retrospective study was made of all patients admitted to our surgical institution, and in whom a diagnosis of abdominal tuberculosis was established. Eleven patients were identified. Ten of them were migrants from countries endemic for tuberculosis. RESULTS: Six patients presented with acute abdominal pain (3 in right lower quadrant) and had surgery in emergency. Two patients had elective surgery for diagnostic purposes. Two patients underwent other invasive diagnostic and/or therapeutic procedures. One patient was treated conservatively. Unusual presentations included 2 patients with periportal lymphadenitis and compressive features on the main bile duct and/or the portal vein, and 1 patient with acute duodenal tuberculous perforation. The main localization of disease was lymph nodes for 5 patients, intestinal for 4 and peritoneal for 2. CONCLUSIONS: Surgeons must be aware of the wide clinical spectrum of abdominal tuberculosis and have a high index of suspicion when confronted with patients from an endemic area and presenting with unclear abdominal symptoms.     

Adenosine deaminase is useful for the diagnosis of peritoneal tuberculosis in patients with end-stage renal failure

INTRODUCTION: End-stage renal failure patients are particularly at risk for tuberculosis, especially for peritoneal tuberculosis. Microbiological diagnosis remains hazardous in many cases. CASE REPORT: We report on a case of peritoneal tuberculosis in an end-stage renal failure patient. The diagnosis was suspected on the basis of adenosine deaminase dosage in peritoneal fluid, allowing an early presumptive treatment and a favourable outcome with a 3 years follow-up. DISCUSSION: The measurement of adenosine deaminase activity in ascites represents a diagnostic advance in tuberculous peritonitis among end-stage renal failure patients.     

Bronchial stricture due to endobronchial tuberculosis

From 1974 to 1986, there were 14 cases of bronchial stricture or obliteration caused by endobronchial tuberculous lesions. Nine cases had histories of tuberculosis but five were suspected of having malignant respiratory passage obstruction at the initial diagnosis. Five cases were kept under observation because of mildness of the subjective symptoms or refusal of operation. Nine cases underwent operation. As the bronchial lesions in three cases were confined to the lobar or segmental bronchus, lobectomies were done. One case with a history of infantile tuberculosis developed complete obliteration of the left main bronchus and cystic bronchiectasis in the entire lung parenchyma, so pneumonectomy was inevitable. Five cases which had strictures in the main bronchus underwent bronchoplastic surgery. The operative procedures were right sleeve upper lobectomy in four cases and left sleeve upper lobectomy in one case. All of the cases undergoing operation showed no post-operative complication or recurrence of the tuberculosis. The results of our present series of tuberculous bronchial stricture indicate the need for early detection and operation. For the cases with main bronchus involvement, bronchoplastic surgery should be selected as an alternative to pneumonectomy to preserve the pulmonary function.     

Colonic tuberculosis

Tubercle bacillus was discovered in 1882 by Robert Koch. With the introduction of chemotherapy for tuberculosis in the 1940s the incidence of this entity decreased. The incidence of the tuberculosis of the colon began to increase at the 1980s with the rise in numbers of patients considered as high risk for this entity, such as HIV-infected individuals, patients with chronic renal disease, and immunosuppressed patients with prolonged steroid therapy. We report on two patients with history of chronic abdominal pain and weight loss with a palpable mass in the right lower quadrant. In one patient chest radiography revealed a miliary reticulonodular pattern. In both, abdominal CT scan showed retroperitoneal lymphadenopathy and colonic wall thickness. Colonoscopic examination showed ulcerative lesions and ileocecal valve disruption. Microscopic examination of intestinal content showed evidenced M. tuberculosis. Tuberculosis of the colon should be suspected in patients suffering from chronic abdominal pain and weight loss.     

Unsuspected ileal stenosis causing obscure GI bleeding in patients with previous abdominal surgery—diagnosis by capsule endoscopy: a report of two cases

Peri-anastomotic ulcerations may occur in patients with previous abdominal surgery. They may present only with obscure GI bleeding. We report two cases in whom capsule endoscopy identified postsurgical stenoses with ulcers as the cause of obscure GI bleeding. Case 1. A 57-year-old male operated on in 1970 for a post-traumatic diaphragm hernia followed by displacement of the caecum in the upper left abdominal quadrant. Case 2. A 32-year-old female with a salpingectomy for tuberculosis (1978) followed by segmental ileal resection for intestinal obstruction. Both patients had undergone extensive work-up including bidirectional endoscopies and enteroclysis with negative results. Capsule endoscopy with the GIVEN diagnostic system was done. Ileal stenoses with mucosal ulcers in dilated prestenotic loops were observed in both cases. The capsule was retained at the stenosis site, requiring ileal resection and anastomosis. Pathology reports showed mucosal ulcers. In case 2, tuberculosis was ruled out by tissue and faecal polymerase chain reaction and culture. Ileal stenoses with prestenotic ulcerations causing GI bleeding may occur in patients with previous abdominal surgery. Capsule endoscopy may clarify the diagnosis and shorten the diagnostic work-up. However, these patients should be warned that capsule retention requiring surgery might occur.     

43例腹腔结核并发肠穿孔患者的外科治疗效果分析

目的 分析外科治疗腹腔结核致肠穿孔患者的临床情况。方法 收集河北省胸科医院2008—2016年收治的43例经手术病理确诊的腹腔结核伴肠穿孔患者,所有患者经胸部X线摄影或CT扫描检查均为可疑肺结核。描述性总结分析其术前临床表现、实验室检测及各项检查、术中探查及手术方式、术后治疗及并发症、治疗结果、随访结果等临床资料。结果 43例患者术后病理证实均存在腹腔结核,其中32例非急诊患者临床诊断明确者18例,11例急诊患者术前均未明确诊断;术中探查均存在肠穿孔,其中术前考虑单纯肠梗阻3例、肠梗阻伴肠穿孔30例(8例急诊和22例非急诊患者术前经诊断性穿刺诊断肠穿孔)、单纯肠穿孔10例。40例(93.0%)因病变范围广泛、感染严重行Ⅰ期肠切除+造瘘术,其中12例切口感染患者经切口换药、引流后治愈;8例发生肠瘘患者除2例(保守治疗、二次手术各1例,年龄均>65岁)因多脏器功能衰竭死亡外,余6例经治疗后预后良好;2例发生肠梗阻患者1例行二次手术、1例保守治疗后治愈;余18例患者造瘘术后恢复良好。2例(回盲部肿物伴穿孔1例,腹腔感染较轻1例)行回盲部切除+回结肠吻合术;1例因近回盲部出现回肠局部单一穿孔,且同时并发腹腔淋巴结结核、局部淋巴结节和穿孔部位回肠粘连,但腹腔感染较轻的患者行回肠部分切除+肠吻合术,术后无严重并发症。抗结核治疗12个月后均治愈停药。37例患者停药后随访18~24个月,4例患者失访,随访期内16例患者有间断轻微腹痛症状,其他患者一般情况均良好。结论 腹腔结核伴肠穿孔是严重的消化道结核并发症,规范的抗结核药物治疗是基础,而外科手术是有效治疗的首选方式,治疗效果良好。     

Transperitoneal laparoscopic radical nephrectomy after multiple previous abdominal surgeries and intraperitoneal hyperthermic chemotherapy: a case report

Laparoscopic indications are still growing due to the acquisition and development of new skills and expertise in the laparoscopic field. We report the first case of a successful transperitoneal right radical nephrectomy after intraperitoneal hyperthermic chemotherapy in a 56-year-old female who previously underwent multiple abdominal surgeries for appendicular adenocarcinoma with pseudomyxoma peritonei. In patients with multiples previous abdominal surgeries and intraperitoneal chemotherapy, transperitoneal laparoscopic surgeries are feasible in experienced hands. However, patient safety is paramount and conversion to open surgery should always be considered in case of complications.     

High blood pressure due to aortic coarctation and renal artery stenosis in a teenager with type 1 neurofibromatosis

Hypertension affect about 1% of patients with neurofibromatosis type 1 (NF1). Major causes are concomitant pheocromocytoma in adults and renovascular hypertension in children. In most cases, NF1 is associated with renal artery stenosis, smooth cell proliferation and advential fibrosis. We describe a 16 year old girl with hypertension complicating NF1 secondary to severe coarctation of abdominal aorta and tight stenosis of right renal artery, a very uncommon case. She was first diagnosed when she was 3-years-old and managed with antihypertensive drugs (atenolol, hidralazine and nifedipine); she experienced progressive uncontrollable hypertension but no symptoms, thus she was admitted to repeat studies. Laboratory evaluation (including creatinine, serum electrolytes, urinalysis, urine catecholamines and creatinine clearance) was normal Percutaneous transfemoral magnetic resonance angiography disclosed severe coarctation of abdominal aorta, functional occlusion of superior mesenteric artery and tight stenosis of right renal artery with poststenotic dilatation. Patient underwent surgery with aorto-aortic by-pass and right kidney artery reimplantation. Periodical controls confirmed no hypertension, even four years after surgery and normal flow patterns in Doppler ultrasonography. Patients with NF1 must be screened for pheochromoctyoma and renovascular hypertension. If hypertension appears, careful management is mandatory, as periodical follow-up even after surgery, since the long-term recurrence rate of renovascular lesions is not well established.     

Intestinal and peritoneal tuberculosis: Report of two cases

One hundred and seven cases of abdominal tuberculosis were analyzed. There were no specific laboratory or x-ray findings pathognomonic of abdominal tuberculosis. Leukopenia was often found, but was nonspecific. An abdominal tumor was often palpable. A great rarity in our series was profuse hemorrhage from a jejunal tuberculous ulcer; the patient had to be subjected to an emergency operation. In another case tuberculosis appeared in a side-to-side small intestinal anastomosis and in its blind ends, which had developed as a late complication. The diagnosis of abdominal tuberculosis must be confirmed by histologic examination of biopsy specimens; if the results are inconclusive, acid-fast bacilli must be seen or culture should be positive. Guinea-pig inoculation is rarely positive, probably owing to the low virulence of the tuberculous bacteria in abdominal tuberculosis. Good results are obtained with chemotherapy in both intestinal and peritoneal tuberculosis. The complications, obstruction being most usual, must be surgically treated. Resection of the affected segment is the best surgical procedure. For ileocecal tuberculosis, right hemicolectomy was performed. According to the authors, roentgenographic evidence of tuberculosis in the abdomen must always be confirmed by operation, because differentiation from carcinoma and other inflammatory lesions is impossible. For good results after operation, anti-tuberculosis chemotherapy is mandatory.     

16例脾结核临床分析

目的 探讨脾结核的诊断和治疗措施.方法 对16例脾结核患者的临床资料进行回顾性分析.结果 16例病人中表现为发热、盗汗、腹胀、腹痛和脾肿大分别为11例次(68.8%)、6例次(37.5%)、8例次(50%)、10例次(62.5%)和13例次(81.2%).腹部B超及CT检查10例有脾内占位性病变,3例脾内有钙化灶,另3例为脾弥漫性肿大.手术及病理诊断脾结核9例,3例因脾内有钙化灶诊断脾结核,另4例诊断性抗结核治疗有效而诊断脾结核.16例病人中有8例合并脾外结核.所有病人都经过半年以上的抗结核治疗,经随访预后良好.结论 脾结核诊断主要依据睥病理学检查及诊断性治疗,系统性抗结核治疗及选择性手术治疗是脾结核的主要有效治疗手段.     

Isolated gastric tuberculosis of the cardia

BACKGROUND: Isolated gastric tuberculosis is extremely rare, especially in the subcardiac region, where the low pH, high motility and absence of lymphoid tissue result in an unfavourable environment for the development of tuberculous lesions. METHODS AND RESULTS: Here we present a case of isolated gastric tuberculosis in the gastric cardia with no evidence of pulmonary involvement. Our patient was a young man with vague gastrointestinal symptoms and no previous history of tuberculosis. His condition was first detected on upper endoscopy as a raised subcardiac ulcer similar in appearance to a submucosal tumour. An endoscopic forceps biopsy showed the presence of caseating granulomata and acid-fast bacilli. The lesion resolved completely with 12 months of oral anti-tuberculosis therapy. CONCLUSIONS: This case illustrates the need for a high index of suspicion in order to diagnose this rare condition, as it can present in patients with no particular risk factors or symptoms. Once diagnosed, a complete cure can often be achieved with a course of oral anti-tuberculosis medication, with surgery being reserved for severely symptomatic or refractory lesions.     

Incidence of port-site metastasis after undergoing robotic surgery for biliary malignancies

AIM: To investigate the incidence of clinically detected port-site metastasis (PSM) in patients who underwent robotic surgery for biliary malignancies.METHODS: Using a prospective database, the patients undergoing fully robotic surgery for biliary malignancies between January 2009 and January 2011 were included. Records of patients with confirmed malignancy were reviewed for clinicopathological data and information about PSM.RESULTS: Sixty-four patients with biliary tract cancers underwent robotic surgery, and sixty patients met the inclusion criteria. The median age was 67 year (range: 40-85 year). During a median 15-mo follow-up period, two female patients were detected solitary PSM after robotic surgery. The incidence of PSM was 3.3%. Patient 1 underwent robotic anatomatic left hemihepatectomy and extraction of biliary tumor thrombi for an Klatskin tumor. She had a subcutaneous mass located at the right lateral abdominal wall near a trocar scar. Patient 2 underwent robotic pancreaticoduodenectomy for distal biliary cancer. She had two metachronous subcutaneous mass situated at the right lateral abdominal wall under a same trocar scar at 7 and 26 mo. The pathology of the excised PSM masses confirmed metastatic biliary adenocarcinoma.CONCLUSION: The incidence of PSMs after robotic surgery for biliary malignancies is relatively low, and biliary cancer can be an indication of robotic surgery.     

上腹部术后行腹腔镜胆总管探查术的难点与对策

目的探讨上腹部术后腹腔镜胆总管探查术(LCBDE)的难点与对策。方法回顾性分析遵义医学院附属医院2008年1月-2013年10月期间72例上腹部手术后行LCBDE的临床病例资料。对术中的困难情况及处理进行总结分析。数据分析采用SPSS19.0统计软件,计量资料组间比较采用成组t检验。结果术中出现相对困难情况共16例。其中9例严重腹腔及术区粘连,4例胆总管确认困难,3例取石困难。总体手术时间为(164.36±19.06)min,术中困难组为(179.31±13.25)min,非术中困难组为(160.09±18.37)min。术中困难组手术时间明显长于非术中困难组和总体手术时间,差异有统计学意义(t=-3.898,P=0.000;t=-2.976,P=0.004)。非术中困难组与总体手术时间比较,差异无统计学意义(t=-1.278,P=0.204)。结论上腹部术后LCBDE是一项高难度、高风险、高技术含量的手术。术中困难情况会导致手术时间延长,须根据术中具体情况,采用相应的个体化对策,以确保手术成功。     

Active Tuberculous Infection among Adult Sudanese Patients on Long Term Peritoneal Dialysis

Introduction: The prevalence of tuberculosis in Sudan is 209 cases per 100,000 populations. There are no reports available regarding the prevalence of tuberculosis among the end-stage kidney disease and dialysis populations. Methods: We reviewed the medical records of all adults who were on peritoneal dialysis (PD) in the Sudan Peritoneal Dialysis Program, during the period from June 2005 to December 2011. Those diagnosed as having active tuberculous infections were retrospectively studied regarding their demography, clinical presentation and outcomes. Results: Out of 350 patients in our program, 19 were diagnosed as having active tuberculosis (5.4%). All patients were diagnosed during their first year on peritoneal dialysis, 74% were males; the mean age was 37 ± 11 years, extrapulmonary tuberculosis was seen in 16/19 (84%) patients and it was abdominal in nine of the 16 (47%) patients. In addition to high clinical suspicion, the diagnosis of active tuberculosis was supported by tissue biopsy findings in 16%, positive polymerase chain reaction in 26%, exudative ascites with suggestive radiological features in 21%, strongly positive tuberculin test in 21% and a favourable response to empirical antituberculous therapy in 26% of patients. HIV test was negative in all 19 patients and only one patient tested positive for hepatitis B viral infection. Antituberculous drugs side effects were seen in 68% of patients. Forty seven percent of patients showed complete recovery and continued on peritoneal dialysis. Our case fatality was 32%. Conclusion: Abdominal tuberculosis is common among PD patients and its diagnosis should always be considered in suspected patients. Keywords: Active Tuberculosis; Peritoneal Dialysis; Outcome; Sudan.     

74例结核性淋巴结炎针吸活检标本结核菌培养临床分析

目的本研究对临床怀疑为结核性淋巴结炎的病人采用细针活检标本做细菌学培养,评价其诊断价值及耐药发生率。方法对110例临床怀疑为结核性淋巴结炎病人采用细针针吸活检术,对所获病理组织进行细胞组织学和细菌培养检查。结果74例患者经组织细胞学及细菌学被诊断为结核性淋巴结炎,其中14例（18．9％）吸引标本分离培养到结核分枝杆菌。14例病人中12例为人型结核分枝杆菌,2例牛型结核分枝杆菌。大多对四种常规抗结核药物敏感,4例（28．5％）一种或多种药物耐药。结论对临床怀疑为结核性淋巴结炎者,凡窦道、脓肿型或见有脓性吸引标本都应作结核菌培养,而结节型培养结果均为阴性,临床意义不大。     

Is the Learning Curve of Robotic Low Anterior Resection Shorter Than Laparoscopic Low Anterior Resection for Rectal Cancer?: A Comparative Analysis of Clinicopathologic Outcomes Between Robotic and Laparoscopic Surgeries

As robotic surgery was developed with ergonomic designs, there are expectations that the technical advantages of robotic surgery can shorten the learning curve. However, there is no comparative study, so far, to evaluate the learning curve between robotic and laparoscopic rectal cancer surgeries. Therefore, the aim of this study is to compare the learning curve of robotic low anterior resection (LAR) with laparoscopic LAR for rectal cancer.Patients who underwent robotic or laparoscopic LAR by a single surgeon were compared retrospectively (robot n = 89 vs laparoscopy n = 89). Cumulative sum (CUSUM) was used to evaluate the learning curve. The patients were divided into phase 1 (initial learning curve period) and phase 2 (post-learning curve period). The perioperative clinicopathologic characteristics were compared by phases and surgical procedures.According to CUSUM, the learning curve of robotic LAR was the 44th case and laparoscopic LAR was the 41st case. The learning phases were divided as follows: phase 1 (cases 1–41) versus phase 2 (cases 42–89) in the laparoscopic group, and phase 1 (cases 1–44) versus phase 2 (cases 45–89) in the robotic group. Comparison between phase 1 and phase 2 in each type of surgery showed no significant difference for the perioperative outcomes. Comparison between robotic and laparoscopic surgeries in each phase showed similar perioperative results. Pathologic outcomes were not significantly different in both procedures and phases.The learning curve of robotic LAR for rectal cancer was similar to laparoscopic LAR, and the clinicopathologic outcomes were similar in both the procedures.     

Tuberculous Appendicitis

Gastrointestinal tuberculosis is quite rare, representing only 3% of all extrapulmonary cases. Involvement of the appendix is rare, only occurring in about 1% of cases. It is usually secondary to tuberculosis elsewhere in the abdomen. A prompt diagnosis depends on a high index of suspicion as clinical signs may be nonspecific and microbiological confirmation is difficult. Histopathologic examination is often the only way to reach a diagnosis and to establish specific antibiotic therapy. In these cases, due to the absence of specific symptoms and signs, the diagnosis is delayed until after surgery.     

Comprehensive findings on clinical, bacteriological, histopathological and therapeutic aspects of cutaneous tuberculosis

OBJECTIVE: To define the bacteriological and histological correlates of the three predominant clinical forms of cutaneous tuberculosis and to evaluate the efficacy of a 9-month daily regimen containing rifampicin and isoniazid. METHODS: In the dermatological clinics of two major teaching hospitals in Chennai, 213 patients with suspected clinical manifestations of cutaneous tuberculosis underwent examination and a skin biopsy for bacteriological and histological tests. They were treated with a daily regimen of rifampicin and isoniazid for 9 months and follow-up for 3 years. RESULTS: Bacteriological and/or histological confirmation of tuberculosis was obtained in 88% of the cases. Lupus vulgaris lesions were seen mainly in the extremities and verrucosa cutis occurred predominantly on the sole and foot, while the cervical and axillary regions were the commonest sites for scrofuloderma. Ninety-two per cent of the patients showed resolution of the lesions within the first 6 months of chemotherapy; 1% failed to respond to this regimen. There was no relapse in any of the cases during the follow-up period of 3 years. CONCLUSIONS: Clinical findings were adequate to identify major forms of cutaneous tuberculosis as evidenced by bacteriological and histopathological examination. A daily regimen of rifampicin and isoniazid for 9 months was effective in treating cutaneous tuberculosis.