Model Answer
0 min readIntroduction
Abdominal tuberculosis (TB) constitutes a significant proportion of extra-pulmonary TB, particularly in developing countries like India. It often presents with non-specific symptoms, mimicking other abdominal pathologies, leading to diagnostic delays. The disease typically arises from ingestion of *Mycobacterium tuberculosis* or secondary spread from pulmonary TB. Understanding the diverse clinical manifestations, employing a comprehensive investigative approach, and judiciously utilizing surgical interventions are crucial for effective management. The incidence of abdominal TB is rising due to factors like HIV co-infection and increased immigration from endemic areas.
(i) Key Clinical Features of Abdominal Tuberculosis
The clinical presentation of abdominal TB is often insidious and non-specific, making diagnosis challenging. Symptoms vary depending on the site and extent of involvement.
- Intestinal TB: This is the most common form, presenting with abdominal pain (often right lower quadrant), diarrhea (may be bloody), weight loss, fever, and night sweats. Intestinal obstruction is a common complication.
- Peritoneal TB: Characterized by ascites (often serous, sometimes exudative), abdominal distension, and pain. A palpable abdominal mass may be present.
- Lymph Node TB: Presents with abdominal pain and a palpable mass, often in the mesenteric or retroperitoneal regions.
- Hepatosplenic TB: Causes hepatomegaly, splenomegaly, and potentially jaundice.
- Genitourinary TB: In women, it can manifest as pelvic pain, menstrual irregularities, and infertility. In men, it can cause epididymo-orchitis.
Other common features include loss of appetite, malaise, and a history of previous TB exposure or treatment.
(ii) Investigating a Patient Suspected of Abdominal Tuberculosis
A thorough investigation is essential to confirm the diagnosis and rule out other conditions. The approach involves a combination of imaging, laboratory tests, and tissue sampling.
- Laboratory Tests:
- Complete Blood Count (CBC): May show anemia and leukocytosis.
- Erythrocyte Sedimentation Rate (ESR) & C-Reactive Protein (CRP): Usually elevated, indicating inflammation.
- Liver Function Tests (LFTs): May be abnormal in cases of hepatic involvement.
- Ascitic Fluid Analysis: If ascites is present, analysis for adenosine deaminase (ADA) levels (high in TB), protein content, and cytology is crucial.
- Sputum Analysis: Although abdominal TB is extra-pulmonary, sputum should be examined for acid-fast bacilli (AFB) to rule out pulmonary involvement.
- Quantiferon-TB Gold/T-Spot TB: Interferon-gamma release assays can help detect latent TB infection.
- Imaging Studies:
- Chest X-ray: To rule out pulmonary TB.
- Abdominal Ultrasound: Useful for detecting ascites, lymphadenopathy, and bowel wall thickening.
- Computed Tomography (CT) Scan: Provides detailed images of the abdominal organs and lymph nodes, revealing characteristic features like caseous necrosis and calcification.
- Magnetic Resonance Imaging (MRI): Useful for evaluating soft tissue involvement and differentiating TB from other conditions.
- Tissue Sampling:
- Peritoneal Biopsy: Laparoscopy or open biopsy can be performed to obtain tissue samples for histopathology and AFB staining.
- Intestinal Biopsy: Colonoscopy with biopsy can be used to diagnose intestinal TB.
- Lymph Node Biopsy: Fine needle aspiration cytology (FNAC) or excisional biopsy of enlarged lymph nodes.
- Culture: Culture of tissue samples or ascitic fluid for *Mycobacterium tuberculosis* is the gold standard for diagnosis, but it takes several weeks.
(iii) Role of Surgery in the Management of Abdominal Tuberculosis
Surgery is generally reserved for complications of abdominal TB or when medical therapy fails. It is rarely the primary treatment modality.
- Intestinal Obstruction: Surgery is indicated for strictures causing obstruction that do not respond to medical management. Resection of the affected bowel segment with anastomosis is typically performed.
- Perforation: Perforation of the intestine or other abdominal organs requires emergency surgery for repair.
- Abscess Formation: Large, localized abscesses that do not respond to drainage and antibiotics may require surgical excision.
- Drug-Resistant TB: In cases of multi-drug resistant TB, surgery may be considered as an adjunct to prolonged chemotherapy.
- Diagnostic Laparoscopy: Laparoscopy can be used for diagnostic purposes when the diagnosis is uncertain.
- Palliative Surgery: In advanced cases with extensive disease, palliative surgery may be considered to relieve symptoms.
Post-operative anti-tubercular therapy (ATT) is crucial to prevent recurrence and complications.
Conclusion
Abdominal tuberculosis presents a diagnostic challenge due to its varied and non-specific clinical features. A comprehensive approach involving laboratory investigations, imaging studies, and tissue sampling is essential for accurate diagnosis. While medical therapy remains the cornerstone of treatment, surgery plays a vital role in managing complications and in selected cases of drug-resistant disease. Early diagnosis and appropriate management are crucial to improve patient outcomes and prevent long-term morbidity.
Answer Length
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