Presentation and Outcome of Abdominal Tuberculosis in a Tertiary Care Unit Shabana Jamal et al Original Article Presentation and Outcome of Shabana Jamal* Zainab Mahsal Khan** Abdominal Tuberculosis in a Israar Ahmed** Sidra Shabbir** Tertiary Care Unit Tanwir Khaliq*** Objective: To determine the presentation of abdominal tuberculosis and its outcome in terms of morbidity and mortality. Study design: Retrospective chart review Place and duration of study: This study was conducted at the Department of *Assistant Professor General Surgery, Pakistan Institute of Medical Sciences , Islamabad and included **Postgraduate Resident, patients with abdominal tuberculosis managed between Jan 2007 to Dec 2009. ***Professor of Surgery Materials and Methods: All adult patients of either gender who presented with abdominal tuberculosis and were managed during the study period were included in Surgical Unit IV, Pakistan Institute the study. Records of the patients were retrieved and reviewed to measure of Medical Sciences, Islamabad parameters of age, gender , mode of presentation, evidence of co-existing tuberculosis , family history, socioeconomic status and drug history of anti tuberculous treatment . The treatment modalities were also reviewed and included the duration of hospital stay. The diagnosis of abdominal tuberculosis was confirmed by histopathology. Results: A total of 92 patients were included in the study. Out of these, 57 patients (62%) were female and 35 patients (38%) were male. The mean age was 37 ± 16.23 years. 42 patients (45.6%) presented with acute while 5 patients (5.4%) presented with subacute intestinal obstruction. 38 patients (41.3%) presented with signs of peritonitis. 7 patients (7.6%) with mass right iliac fossa. 4 patients (4.4%) were treated conservatively while rest of them 88 (95.6%) had surgery. Emergency laprotomy was performed in patients with peritonitis. Two staged procedures were performed in 57 patients (64.7%) During hospital course, 12 (13.6%) patients had post operative complications in which wound infection was most common. All patients were prescribed anti tuberculous therapy for 12 months duration. Mean hospital stay was 16 ± 14.67 days. Conclusion: Abdominal tuberculosis frequently presents as acute abdomen in our Address for correspondence: Dr. Shabana Jamal set up. It predominantly affects the young females of poor socioeconomic background. It poses significant morbidity as majority of the patients need surgical Assistant Professor, Department of General Surgery, Pakistan intervention and prolonged hospitalization in addition to chemotherapy with anti tuberculous drugs. Institute of Medical Sciences, Islamabad Key words: Laprotomy, Abdominal tuberculosis, Anti tuberculous therapy, Email: shabanajamal.surgeon@gmail.com Abdominal obstruction Abdominal tuberculosis has been considered as a fatal Introduction and untreatable disease for years. Before the advent of medical therapy, there was no hope for recovery of Abdominal tuberculosis is a common disease in patients with abdominal tuberculosis. 4 The underlying Pakistan and other tropical countries. 1 Tuberculosis is a mechanism for this disease is still unclear but the universal public health concern resulting in an probable route of infection is the involvement of other estimated 8 – 10 million new cases and 2 -3 million organs, especially lungs and the transmission of deaths yearly. 2 Abdominal tuberculosis is the fourth mycobacterium through blood or swallowed sputum. involvement. 3 common site of extrapulmonary Ann. Pak. Inst. Med. Sci. 2011; 7(1): 33-36 33
Presentation and Outcome of Abdominal Tuberculosis in a Tertiary Care Unit Shabana Jamal et al Direct invasion from adjacent structures might be Results another route of infection . 5 Abdominal tuberculosis is reported from a A total of 92 patients were included in the study. number of countries. 6 It is also an important health Out of these, 57 patients (62%) were female and 35 problem in Pakistan. It has various modes of patients (38%) were male. The age range of patients presentation and high index of suspicion is required for its diagnosis. 3,7 Tuberculosis is a disease affecting the presenting with abdominal tuberculosis was between 18 - 55 years and mean age of 37 ± 16.23 years. young population with an average age of 20 – 40 years with an increased incidence in females. 8 Patients with On history, 38 patients (41 %) gave positive family history of abdominal tuberculosis and 10 patients abdominal tuberculosis present with constitutional (10.8 %) had history of having pulmonary tuberculosis symptoms of fever, malaise, abdominal pain and altered and received complete course of anti-tuberculous bowel habits in the early stage of the disease. If not treatment in the past. 72 patients (78%) belonged to diagnosed early, this leads to complications like poor socio economic class and had no permanent intestinal mass, malabsorption , intestinal obstruction or intestinal perforation requiring emergency surgery. 9 source of income. As shown in table I , 82 patients (89 %) presented with pain abdomen while 7 patients (7.6 This study was undertaken to document the %) with a mass abdomen. On the basis of clinical presentation and outcome of abdominal tuberculosis in findings 42 patients (45.6 %) had intestinal obstruction, a tertiary care surgical setup. 38 patients (41.3 %) had signs and symptoms of peritonitis and 7 patients (7.6 %) had mass abdomen. Material and Methods Table II shows the various operative findings among the operated patients. This study was conducted in the Department of Table III shows the surgical procedure Surgery at Pakistan Institute of Medical Sciences, undertaken among the patients. Islamabad and included patients with abdominal Table IV shows the various postoperative tuberculosis managed from Jan 2007 to Dec 2009. The complications observed among our patients. hospital records of patients diagnosed of having There was in hospital mortality of 3 patients abdominal tuberculosis were retrieved and studied. Data (4%) who had been operated for faecal peritonitis due to were reviewed for variables like age, gender, mode of late presentation. presentation, management, type of surgery, post Eighty eight patients (95.6%) underwent operative course and follow up. Patients who had acute surgical intervention while 4 patients (4.4%) were intestinal obstruction and signs of peritonitis were treated conservatively. operated in the emergency. All these patients were Patients were also trained regarding stoma resuscitated and optimized for surgery with parenteral management. All the patients had regular follow up. fluids and antibiotics. Baseline investigations were done Second stage surgery i.e. ileostomy reversal was done in all patients and included Blood Complete Picture, 3 to 4 months in patients with wide spread disease while ESR, Serum electrolytes, X - ray chest, X- ray abdomen those with localized disease it was done after two month erect and supine and ultrasound abdomen. duration. All patients were discharged on anti Patients who had presented with an abdominal tuberculous therapy for a duration of 12 months. mass and sub- acute intestinal obstruction were initially managed conservatively and investigated accordingly. Table I: Presenting complaints among patients The investigations included Barium meal follow through (n= 92) and colonoscopy. Among those operated in emergency, Presenting No. of Percentage diagnosis of tuberculosis was made on finding tubercles, complaints patients enlarged mesenteric lymph nodes, strictures and Pain abdomen 82 89.1% ascites. Definitive diagnosis of abdominal tuberculosis Abdominal 75 81.5% was made by histopathology. In patients who presented with peritonitis due to intestinal peforation, distension ileostomy was performed as a first stage procedure. Fever 50 54.4% Where indicated, resection of the disease segment of Nausea 55 59.8% gut and ileostomy was performed. Patients with Vomiting 65 71% strictures underwent stricturoplasty. Patients with Altered bowel 78 84.8% ileostomy had reversal of stoma as a second stage habits procedure. During this period all the patients had a full Mass abdomen 7 7.6% course of anti tuberculous therapy for twelve month duration. Ann. Pak. Inst. Med. Sci. 2011; 7(1): 33-36 34
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