|Year : 2021 | Volume
| Issue : 4 | Page : 414-420
Abdominal tuberculosis: Clinical profile and outcome
Arkadeep Dhali1, Kausik Das2, Gopal Krishna Dhali3, Ranajoy Ghosh4, Avik Sarkar5, Debashis Misra3
1 Department of GI Surgery, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
2 Department of Hepatology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
3 Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
4 Department of GI Pathology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
5 Department of GI Radiology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
|Date of Submission||22-Sep-2021|
|Date of Decision||13-Oct-2021|
|Date of Acceptance||05-Nov-2021|
|Date of Web Publication||13-Dec-2021|
Department of Gastroenterology, School of Digestive and Liver Diseases, Institute of Postgraduate Medical Education and Research, Kolkata - 700 020, West Bengal
Source of Support: None, Conflict of Interest: None
Background : Tuberculosis (TB) is common form of communicable disease in India. Abdominal TB is one of the most common yet misdiagnosed forms of extrapulmonary TB. It is missed due to its similarity to other conditions such as Crohn's disease and nonspecific clinical presentation. Methods: Medical records of 317 patients who were diagnosed with abdominal TB from August 2015 to December 2020 were reviewed retrospectively from our prospectively maintained database. Results: Among 317 patients, 167 (52.7%) were male. Median age of presentation was 45 (8–85) years. Luminal involvement was seen in most of the patients (n = 157, 49.5%), followed by peritoneal (n = 63, 19.8%), mixed (n = 42, 13.2%), solid visceral (n = 30, 9.4%), and nodal (n = 25, 7.8%) involvement. Two hundred and sixty-one (82.3%) showed complete response. Seven (2.2%) patients died and 5 (1.6%) patients lost to follow-up. Median duration of treatment was 28 (25–52) weeks. Drug-induced liver injury was identified in 30 (9.5%) patients. Median follow-up duration was 32 (1–70) months. Conclusion: Abdominal TB is quite a diagnostic challenge due its vague clinical symptoms, nonspecific radiological features, and poor sensitivity and specificity of diagnostic tests. Hence, clinicians should have a high index of suspicion to diagnose and treat this treatable yet lethal condition promptly. Most cases respond very well to medical management and a small fraction requires surgical intervention if diagnosed early.
Keywords: Abdominal tuberculosis, anti-tubercular treatment, paucibacillary
|How to cite this article:|
Dhali A, Das K, Dhali GK, Ghosh R, Sarkar A, Misra D. Abdominal tuberculosis: Clinical profile and outcome. Int J Mycobacteriol 2021;10:414-20
|How to cite this URL:|
Dhali A, Das K, Dhali GK, Ghosh R, Sarkar A, Misra D. Abdominal tuberculosis: Clinical profile and outcome. Int J Mycobacteriol [serial online] 2021 [cited 2022 Jan 25];10:414-20. Available from: https://www.ijmyco.org/text.asp?2021/10/4/414/332357
| Introduction|| |
Tuberculosis (TB) is one of the life-threatening communicable diseases across the world. The World Health Organization had declared it as a global emergency. Major portion of the global TB burden (56%) is represented by South East Asia and Western Pacific regions. Among these, India itself accounts for one-fourth of the cases. Abdominal TB constitutes 12% of all extrapulmonary TB cases and is one of the most common forms of extrapulmonary TB. Authors have reported increase in number of cases in both in developing and developed countries. In India, 550,000 deaths happen due to TB each year. Regarding abdominal TB, the diagnosis is often missed or delayed due to lack of specific clinical manifestations and poor sensitivity of the diagnostic tests. Moreover, there is a considerable diagnostic dilemma as it can mimic other diseases such as Crohn's disease, abdominal malignancies, or colitis.,, Hence, clinical suspicion is required for early diagnosis and better outcome. The purpose of this study was to evaluate and analyze the clinical spectrum of abdominal TB in terms of manifestation, diagnosis, treatment, and outcome.
| Methods|| |
This is a retrospective observational study. Data of all patients who were diagnosed (clinical/microbiological/histopathological) with abdominal TB between August 2015 and December 2020 were retrieved from our prospectively maintained Gastroenterology database. All patients who began treatment with antitubercular drugs were included in the present study. Patients who had mimickers such as Crohn's disease, abdominal malignancy, other abdominal infections were excluded.
Demographic and clinical details such as age, sex, underlying diseases, history of alcohol consumption, laboratory parameters, clinical presentation, diagnostic methods, and treatment response were reviewed.
This study was approved by institutional ethics committee (memo number: IPGME and R/RAC/255, dated-September 22, 2021). Informed patient consent was waived by the ethics committee as the data were anonymized and retrospective nature of the study.
Any intrabdominal foci of infection with mycobacterium TB (intra-abdominal solid or hollow organs, lymph nodes, peritoneum) were defined as abdominal TB. Diagnosis was made on the following criteria: (1) positive acid-fast staining or culture or CBNAAT from specimen (microbiological diagnosis); (2) identification of caseating granuloma on histopathological evaluation of biopsy specimen (histopathological diagnosis); (3) typical presentation or high index of suspicion with good response to trial of antitubercular treatment (ATT) (clinical diagnosis). In cases of negative biopsy for suspected peritoneal TB, adenosine deaminase value >33 IU/L was used as a criterion for clinical diagnosis. Microbiological and histopathological diagnosis was considered as confirmatory tests.
All the patients were classified into two subsets according to site of involvement: (1) luminal and (2) extraluminal. The extraluminal subset was further subclassified into (1) solid visceral; (2) peritoneal; and (3) nodal. The demographic and clinical data were analyzed according to these groups.
First-line treatment comprised of four or five drug regimen (isoniazid, rifampicin, ethambutol, pyrazinamide with without streptomycin). Any additional antitubercular drugs were considered as the second line.
Clinical outcomes were classified as follows: (1) complete response: complete disappearance of symptoms, acid-fast bacilli (AFB) on culture or smear, caseating granulomas, tubercular ulcer on relook colonoscopy; (2) partial response: disappearance of symptoms with partial resolution of lesions at the end of treatment; (3) no response: persistence of symptoms, AFB on culture or smear, caseating granulomas, tubercular ulcer on relook colonoscopy at the end of treatment; (4) lost to follow-up: primary defaulters for >2 consecutive months where treatment was interrupted; (5) recurrence: radiological or colonoscopic reappearance of characteristic lesions after complete response; (6) death: mortality during the course of treatment irrespective of the cause.
Quantitative variables were expressed as mean ± standard deviation or median with range. Dichotomous variables were expressed as a percentage. Intergroup differences in quantitative data were measured using the Mann–Whitney U test. Fisher exact test was used for qualitative data. For each test, a two-sided P value of 0.05 was considered significant. All statistical computations were performed using IBM SPSS, version 20 (IBM Corp, Chicago, Illinois, USA).
| Results|| |
In our present study, 317 patients met the inclusion criteria and were reviewed. Among them, 167 (52.7%) were male. Median age of presentation was 45 (8–85) years. Luminal involvement was seen in most of the patients (n = 157, 49.5%), followed by peritoneal (n = 63, 19.8%), mixed (n = 42, 13.2%), solid visceral (n = 30, 9.4%), and nodal (n = 25, 7.8%) involvement. Predilection for involvement of ileocecal area (n = 114, 72.6%) was identified in patients with luminal TB [Table 1]. Among the patients with solid visceral TB, genitourinary involvement (n = 28, 48.2%) was most common [Table 2]. Demographic characteristics of the patients are summarized in [Table 3]. Diabetes (n = 14, 33.3%) and HIV infection (n = 19, 45.2%) were significantly common in the mixed TB group compared to the other groups (P < 0.05). The rate of family history of TB was significantly lower in the mixed TB group (n = 0, 0%). Chronic kidney disease (n = 13, 11%) was more commonly identified in the extraluminal TB group compared to the luminal TB group.
|Table 3: Demographic features of the patients with abdominal tuberculosis|
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Details of presenting symptoms are summarized in [Table 4]. Abdominal pain (n = 126, 36.3%) was the most common presenting complaint of the patients. Eighty-seven (27.4%) patients were asymptomatic and it was significantly more common in the luminal subgroup compared to its extraluminal and mixed counterparts. Fever was more commonly identified in the extraluminal TB group (n = 23, 19.5%). Incidence of abdominal distention was significantly high in the peritoneal TB group (n = 47, 74.6%, P = 0.000). Twelve (7.6%) and 26 (16.6%) patients in the luminal TB group presented with diarrhea and bloody stood, respectively, which was significantly higher than the extraluminal TB subgroup. Jaundice was identified in 6 (24%) patients with nodal TB.
|Table 4: Clinical presentation of the patients with abdominal tuberculosis|
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Among the 317 patients, only histopathological diagnosis was achieved in 89 (28.1%) patients, only microbiological diagnosis was achieved in 53 (16.3%) and both histopathological and microbiological diagnosis was achieved in 66 (20.8%) patients. Remaining 109 (34.4%) patients were diagnosed clinically. The details of diagnostic work-up are given in [Table 5]. Microbiological diagnosis was most sensitive for solid visceral TB (n = 11, 36.7%) compared to other extraluminal TB (P = 0.000). Histopathological diagnosis was found to most sensitive in nodal TB (n = 15, 60%) compared to nodal counterparts (P = 0.02). Frequency of clinical/presumptive diagnosis was highest in case of luminal TB (n = 63, 40.1%) compared to extraluminal TB (n = 33, 28%).
Diagnosis by surgerical intervention was possible in 54 out of 59 (91.5%) patients. It was significantly high for extraluminal TB (n = 45, 38.1%) compared to luminal (n = 54, 17%) and mixed (n = 5, 11.9%) TB. Surgery was warranted for management of complications such as perforation, intussusception, obstruction in 28 patients. Percutaneous biopsy could diagnose TB in 32 out of 50 (64%) patients, significantly higher in nodal TB (n = 11, 44%), compared to other subgroups. Endoscopy could diagnose TB in 83 out of 167 (49.7%) patients having luminal involvement. Diagnostic paracentesis was successful in 35 out of 95 (36.8%) patients, mostly having extraluminal TB (n = 30, 25.4%).
Among 317 patients, 261 (82.3%) showed complete response. Partial response was achieved in 29 (9.1%) patients, no response in 7 (2.2%), recurrence in 8 (2.5%) patients. Seven (2.2%) patients died and 5 (1.6%) patients lost to follow-up [Table 6]. Frequency of complete response was found to be significantly low in nodal TB (n = 12, 48%) compared to other subgroups (P < 0.05). Recurrence of disease was found to be significantly higher in nodal TB (n = 8, 32%, P < 0.05). Median duration of treatment was 28 (25–52) weeks. Two hundred and ninety-five patients (93.1%) received first-line drugs and 22 (6.9%) patients received second-line agents. Drug-induced liver injury (DILI) was identified in 30 (9.5%) patients. DILI was diagnosed on the basis of transaminitis after starting ATT. Median follow-up duration was 32 (1–70) months.
|Table 6: Treatment outcomes across various groups of abdominal tuberculosis|
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| Discussion|| |
In this study, the entire clinical spectrum of abdominal TB at a tertiary care center in Eastern India is described. Abdominal TB is a great mimicker of multiple diseases such as Crohn's disease, abdominal malignancies, and other gastrointestinal infections. Moreover, there is a lack of specific signs and symptoms. Unlike pulmonary Tb, abdominal TB is mostly paucibacillary; hence, it creates even bigger challenge during confirmation of diagnosis. We found that the most common site of abdominal TB was luminal gastrointestinal tract (49.5%), followed by peritoneal TB (19.8%), mixed TB (13.2%), solid visceral TB (9.4%), and nodal TB (7.8%). Among the clinical manifestations, abdominal pain (n = 126, 36.3%) was most common. 87 (27.4%) patients were asymptomatic. Although we found that diabetes (n = 14, 33.3%) was significantly common in the mixed TB group compared to the other groups (P < 0.05), Shah et al. had shown that mere presence of diabetes does not seem to impact the clinical presentation or outcomes in patients with abdominal TB. We also reported some extremely rare manifestations of abdominal TB. One patient presented fluctuating jaundice for primary granulomatous hepatic TB. Pancreatic and peripancreatic nodal TB was also diagnosed postoperatively in 16 patients who presented with clinical and radiological features of malignancy at head of pancreas or pancreatic pseudocyst. In terms of diagnostic methods, microbiological diagnosis was most sensitive for solid visceral TB (n = 11, 36.7%) compared to other extraluminal TB. Histopathological diagnosis was found to most sensitive in nodal TB (n = 15, 60%) compared to other extraluminal counterparts. Among 317 patients, 261 (82.3%) showed complete response and mortality rate was 4.4% (n = 14). Colonoscopy was useful in cases of luminal TB with mucosal lesions. Diagnostic yield was was not very high (n = 83, 52.1%). Hence, a large portion of luminal TB was diagnosed by radiological screening and by seeing the clinical response to ATT. Peritoneal fluid analysis was useful, minimally invasive test conducted to diagnose abdominal TB, mostly in the extraluminal group (n = 30, 25.4%). Ascitic fluid adenosine deaminase level >33 IU/L and serum ascitic albumin gradient <1.1 have very high sensitivity and specificity for diagnosis., In cases of nodal TB, diagnosis was achieved in 18 (72%) patients by means of some surgical interventions and in 11 (44%) patients by percutaneous biopsy. Five (20%) patients were solely diagnosed clinically either by means of response to ATT or radiological imaging. Solid visceral TB was diagnosed by surgical intervention in 17 (56.7%) patients and paracentesis in 2 (23%) patients. Two (6.7%) patients in this group were diagnosed by clinically.
Sharma et al. and Small et al. have recommended a 6-month course of ATT for the treatment of luminal TB., Previously, Park et al. and Makharia et al. in their previous prospective studies have shown cure rate of >90% after 6 and 9 months of ATT regimen., Moreover, some retrospective studies have shown that ATT in case of abdominal TB is highly effective and is associated with 0%–6% mortality.,,,, In spite of these, abdominal TB itself has high mortality rate (6%–20%). This is mostly accounted to acute complications and warranted an emergency laparotomy as shown in several other studies.,,,
In our present study, 261 (82.3%) patients had complete response to ATT and had a good prognosis. Only 8 (2.5%) patients relapsed and 7 (2.2%) died. This suggests that prompt diagnosis is the key feature for better prognosis and it can be treated successfully with ATT in majority of the population. Although we found that nodal TB was associated with low rates of complete response and to ATT (n = 12, 48%) and high rate of recurrence (n = 8, 32%). Rathi and Gambhire had identified DILI as the most common cause of discontinuation of ATT. Moreover, preexisting chronic liver disease (CLD) accentuates the incidence of DILI in patients receiving ATT.,, In our study, all seven patients who had preexisting CLD developed DILI. In these patients, all drugs were stopped and after complete resolution of hepatotoxicity (evidenced by resolving transaminitis), step-wise rechallenging of drugs was done.
The study has some strength and limitations. The strength is that it is one of the largest case series where a large number of patients were successfully treated with mortality and morbidity. The drawbacks are: first, it is a retrospective study and the second, it is a single-center study. Thus further prospective studies on abdominal TB are required.
| Conclusion|| |
Abdominal TB is quite a diagnostic challenge due to its vague clinical symptoms, nonspecific radiological features, and poor sensitivity and specificity of diagnostic tests. Hence, clinicians should have a high index of suspicion to diagnose and treat this treatable yet lethal condition promptly. Most cases respond very well to medical management and a small fraction requires surgical intervention if diagnosed early.
Ethical committee approval
This study was approved by institutional ethics committee (Memo number: IPGME and R/RAC/255, dated- September 22, 2021). Informed patient consent was waived by the ethics committee as the data were anonymized and retrospective nature of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]