QJM Advance Access originally published online on January 30, 2008
QJM 2008 101(3):189-195; doi:10.1093/qjmed/hcm125
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Abdominal tuberculosis in a district general hospital: a retrospective review of 86 cases
From the 1Department of Gastroenterology and 2Department of Chest Medicine, Royal Blackburn Hospital, Blackburn, Lancs BB2 3LR, and 3Lancashire Postgraduate School of Medicine and Health, University of Central Lancashire, Preston, Lancs PR1 2HE, UK
Address correspondence to Prof. L.P. Ormerod, Chest Clinic, Royal Blackburn Hospital, Blackburn, Lancashire BB2 3HH, UK. email: lawrence.ormerod{at}elht.hs.uk
Received 6 June 2007 and in revised form 12 September 2007
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Summary |
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Background: Abdominal tuberculosis (ATB) is a great mimic and an important cause of morbidity. Its incidence is more common in certain groups.
Aim: To review the cases of ATB in Blackburn from 1985 to 2004, with emphasis on presentation, investigation, diagnosis, treatment and follow-up.
Methods: A retrospective cases note analysis from a prospectively compiled database.
Results: Eighty-six cases of ATB were on a prospective database of all tuberculosis (TB) cases in Blackburn for 1985–2004 inclusive. Full case papers were available for 82 and partial data for the remaining four cases. Median age was 34.8 years, with an equal sex distribution. South Asians accounted for 91% of cases. The highest proportion of patients had peritoneal TB, and a considerable number (27%) had TB at multiple sites.
Conclusions: The diagnosis can be difficult to make because of the varied presentation, the low percentage with positive microscopy for acid-fast bacilli and the time delay of up to several weeks for a positive TB culture. The thresholds for laparoscopy and/or laparotomy for the diagnosis were therefore very low. The diagnosis could be made rapidly by these methods, and early treatment instituted. Six months short-course chemotherapy is very effective in ATB. This should be changed, if appropriate, on the basis of drug susceptibility data.
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Introduction |
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The incidence of tuberculosis (TB) has been increasing in England and Wales since 19871 reaching over 6000 cases in 1998,2 and is now approaching over 8000 cases per year.3 Over the same time, there has also been an increasing proportion of cases in non-white ethnic groups, now over 70% of all cases.3 This is important as these ethnic groups have higher rates of non-respiratory TB.3,4 Blackburn has been in the highest 20 TB incidence areas in England and Wales for many years. It is also recognized that abdominal TB (ATB) is common and increasing in both the developing and developed world.5–7 However, its presentation can be vague, non-specific and can masquerade as other conditions.8
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Aim |
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We report our experience with unselected cases of ATB since our last report in 1985,9 and the use of 6 months short-course chemotherapy as advised in the national treatment guidelines.10,11 We also took the opportunity to compare and contrast our experience with other reports and will discuss the modern investigation and management of ATB.
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Methods |
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A detailed prospective clinical and epidemiological database has been kept on all notified cases of TB in the Blackburn, Hyndburn and Ribble Valley districts in the Northwest Region of England since 1981. This was searched for cases of ATB and these case notes were examined in detail documenting patient's symptoms, investigations, management and outcome.
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Results |
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Demographics
Between 1985 and 2004, 1194 cases of TB were reported, 251 of white ethnic origin and 943 of non-white ethnic origin. Eighty-six had ATB, 7 out of 251 (2.75%) of white ethnic origin and 79 out of 943 (8.4%) of non-white ethnic origin.
Of the 86 patients with ATB, seven (8%) were of white ethnic origin, one Chinese (1%) and the remaining 78 (91%) were of South Asian ethnic origin. Of the South Asian patients, 39 were born in Pakistan, 26 were born in India and 13 were born in the UK. The overall median age was 34.8 years (range 6–93) of which six patients, all of South Asian origin were in the paediatric age group (ages 6,12,12,13,14,15) of whom five out of six were UK born. There was however a distinct difference between the white and non-white groups. In the non-white group the male/female ratio was virtually one, with a median age of 32.8 years (range 6–93). In the white group, there were five females and two males, with a much higher median age of 63 years (range 45–79). There was a mean of 4.3 cases per year (range of 0–8) notified over the 20 years.
History
Seven (8%) had a prior history of TB, whilst 10 (12%) had a family history of TB; no case however was detected as a household contact of anyone with recently notified TB. Five out of 86 (6%) had prior BCG vaccination.
Symptoms and signs
The majority of patients presented with weight loss (57%), abdominal pain (50%) or fever (46%). One-fifth of patients presented with abdominal distension and 15% had vomiting (Table 1). The median weight at diagnosis (n = 54) was 51 kg, the average weight gain after completion of treatment was 9.6 kg with a range of 0–35 kg. The clinical signs were dominated by pyrexia (46.5%), ascites (27%), abdominal tenderness (27%) (Table 1). Ten (11.5%) patients had a detectable abdominal mass, three (3%) patients presented with frank peritonitis and two (2%) as small bowel obstruction needing emergency surgery. Atypical presentations were noted in a number of cases. One patient with abnormal liver enzymes had hepatic TB confirmed on liver biopsy. Another presented as an emergency with cholecystitis and underwent cholecystectomy. The pathology specimen showed TB. Rectal carcinoma was mimicked in an elderly lady with rectal bleeding and a large perianal mass. Carcinoma was suspected but biopsies showed TB and the ‘tumour’ vanished with anti-TB chemotherapy. Two patients with pelvic masses were suspected of having ovarian carcinoma until biopsy and were successfully treated with anti-TB chemotherapy.
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Investigations and diagnosis
Blood investigations
Blood tests revealed a microcytosis in 64%, anaemia in 64% and thrombocytosis in 46%. The ESR was elevated in 98%, the globulins in 51% and the albumin reduced in 73% in keeping with the inflammatory response. The degree of abnormality was greater in females, but all parameters returned to normal with treatment.
Chest radiography
The chest X-ray was normal in 64 out of 86 (74%), with definite abnormality in 22 (26%). These abnormalities included infiltrates (n = 7), pleural effusion (n = 7) and mediastinal lymphadenopathy (n = 5) and classical miliary disease (n = 1). In two patients, there were changes of previous TB disease.
Endoscopy
Endoscopy was mainly used as a targeted investigation depending on the symptoms and was useful in both establishing a diagnosis and obtaining tissue for histology and microbiology. Upper gastrointestinal endoscopy was performed in five patients. Two with dysphagia where the diagnosis was confirmed on histology, and three were normal. Colonoscopy was performed in 10 cases (11.5%) and in 8 out of 10 was abnormal with ulceration, nodules and inflammation, TB being confirmed histologically.
Barium studies
These were performed mainly to look at the small bowel after an initial assessment to look for an obvious target to arrive at a diagnosis had failed to give a cause, or when symptoms such as diarrhoea or abdominal pain suggested mid-gut pathology. Barium follow-through was performed in 24 (28%) and was abnormal in 21 out of 24 (87.5%) of examinations.
Imaging studies
Computerized tomography (CT) (n = 6) and/or abdominal ultrasound scanning (n = 26) were performed in 29 cases (34%) in all. Three patients had both CT and ultrasound scanning. Imaging using these modalities was abnormal and pointed to the diagnosis.
Tuberculin test
Heaf test was done in 14 cases and Tine test in one. All were positive (grade 2 or greater).
Laparoscopy and laparotomy
Fifty-nine (67%) patients in all underwent laparoscopy (n = 37) and or laparotomy (n = 22). Three patients had a laparoscopy converted to a laparotomy. These procedures had a very high percentage of confirming and/or making the diagnosis of TB; 35 out of 37 (94.5%) in the case of laparoscopy, and 100% for laparotomy.
Laparotomy was mainly performed in cases with abdominal masses (n = 12) (ileocaecal, peritoneal, gall bladder), symptoms of small bowel obstruction (n = 6), or peritonitis (n = 3) and in one patient with cholecystitis.
Histology
Tissue was obtained for histology in 79 (92%) and in 75 out of 79 (95%) of these there were granulomas and/or Langhan's giant cells consistent with the diagnosis of TB. In the 11 cases not supported by positive histology, three were culture confirmed, with only eight being diagnosed by response to treatment and other evidence (Table 2).
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Microbiology
Positive culture confirmation was obtained in 35 cases by the isolation of Mycobacterium tuberculosis. In cases with a positive culture from both abdominal and respiratory sites, this is recorded under the abdominal site (Table 2). Five patients had culture confirmation from sputum. One was microscopy positive and four negative. Only one case was microscopy positive from ascitic fluid (culture confirmed). Three of the 35 positive cultures showed resistance to isoniazid, two with additional resistance to streptomycin (8.5%).
Ascitic diagnostic through paracentesis
This was performed in 23 (27%) of cases. The ascitic fluid was exudative (protein >30 g/dl) in 20 cases, and lymphocyte predominant on cytology in 18.
Associated risk factors
The major risk factors that could be seen from this series apart from ethnicity were chronic renal failure (six cases), diabetes mellitus (two cases) and carcinoma of the stomach (one case). No case in this series was known to have, or was subsequently found to have, HIV co-infection.
Sites of involvement
Forty-one patients had evidence of peritoneal TB; 14 ileocaecal disease; 12 ileal; four colonic and two in the anal margin simulating carcinoma in one. Evidence of TB in multiple sites could be seen in 28 cases. Other sites of TB are shown in Table 3. Of the cases of liver and gall bladder TB, one was diagnosed after liver biopsy for abnormal liver enzymes, one presented with liver abscess and the rest were findings of tubercles on the liver at laparotomy or laparoscopy. Gall bladder TB was diagnosed in three cases, one presenting as a mass in the gallbladder. We did not encounter TB in the stomach while there were two each in the oesophagus and duodenum. Respiratory TB was encountered in 21 out of 86 (24%) cases.
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Death
Four deaths occurred in this group. Two could be directly attributed to TB and these were in elderly white patients (age 74 and 78) with extensive pulmonary TB as well. One patient with severe congestive cardiac failure died before treatment was commenced. The one patient with co-existing gastric carcinoma died from this after 2 months’ treatment.
Treatment regimens
Treatment was given with regimens based on rifampicin (R), isoniazid (H) and pyrazinamide (Z), often with additional initial ethambutol (E). The initial phase of 2 months is described as 2RHZ(E), the continuation phase as a number of months followed by the drugs given. Treatment was completed by 82 patients, with two out of seventy-nine non-white patients and two out of seven white patients dying before treatment was commenced (n = 3) or completed (n = 1). Of the South Asian patients, 6 months short course chemotherapy was given to 58 (2RHZE/4RH 37: 2RHZ/4HR 21). Four patients treated in 1985–86 were given 2RHZ/10RH and five patients treated 1987–89 received 2RHZ/7RH. Five patients received modified regimens because of drug intolerances to pyrazinamide or rifampicin. One patient with advanced renal failure received 2RHZ+Ciprofloxacin/4RH. Two of the patients with isoniazid resistance were treated with 2RZE/9RE (n = 1), and 2RZS/8R+Prothionamide+Ciprofloxacin (patient visually impaired: isolated isoniazid resistance). The Chinese patient had miliary and ATB and was treated with 2RHZE/4RH. Of the five white cases treated, one patient received 2RHZ/10RH, two 2RHZ/7RH and two 2RHZ/4RH. Overall, 61 patients received a 6-month regimen. There has only been one relapse. This was in a patient with isoniazid resistance who started on RHZE but then returned to the Indian subcontinent after a few weeks where he later admitted to not taking the recommended treatment (2RZE/7RE). He relapsed 12 months after return to the UK. Of the 61 having treatment with 6-month regimens in the UK, with regular treatment compliance monitoring, no relapses have occurred since treatment completion.
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Discussion |
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In contrast to the findings of our previous (1985) review,9 the incidence of TB in the West is rising, due to a number of factors including: increases in the sizes of ethnic groups and the incidence of HIV/AIDS; an ageing population; and deprivation.12 Extra-pulmonary TB is commoner in the non-white population4 with ATB estimated to occur in up to 25% of patients. The incidence of ATB is relatively high in certain parts of the country due to geographical variation in one or more of the factors described above,13–16 as is the case in Blackburn.9
Possible methods of disease dissemination include the ingestion of infected sputum, haematogenous spread from active pulmonary or miliary TB; the ingestion of contaminated milk or food and contiguous spread from adjacent organs. The affinity of M. tuberculosis for the ileocaecal region may be due to relative stasis and abundant lymphoid tissue in that region of the gastrointestinal tract. There must be spread other than through the ingestion of infected sputum as not all patients have evidence of pulmonary TB. This highlights the likely contribution from the primary translocation of the organism across the intestinal mucosa from haematogenous or other spread.
The age distribution of white cases matches that of white TB cases in general, with the majority over 50 years probably representing reactivation of earlier infection.3 That of the non-white ethnic group showed ATB to be a disease of the young and immunocompetent.9,17 Even in a study of ATB in Southern Indians in Leicester (UK), which showed a bimodal age distribution, the mean age was also lower.8 The proportion of cases in our series of non-UK born cases was 76.7%, a fall from 84.4% in 1985.9 This suggests that the UK born are still at risk either from the higher rates of TB in their population subgroups2,3 or from return visits to South Asia.18
The rise in incidence in the US has been associated with HIV infection and AIDS.19 No case in this series was known to be, or subsequently found to be HIV positive, and TB/HIV co-infection is not the main reason for the UK rise in TB.2,3 Of the 86 cases in this series, only two had diabetes and one carcinoma stomach as additional risk factors.
The presence of ascites, usually of a high protein concentration, suggests a disorder other than inflammatory bowel disease. The serum to ascites albumin gradient is <11 g/dl, distinguishing it from ascites found in portal hypertension and congestive cardiac failure. The fluid is usually a lymphocyte predominant exudate, but acid-fast bacilli are rarely seen on microscopy.
Polymerase chain reaction (PCR) assays, which amplify mycobacterial RNA, have been suggested for TB diagnosis, from either ascitic fluid or on biopsy samples20 but have not been validated in ATB. Because of significant levels of false-negative results, use of these tests in smear-negative forms of TB, is discouraged in the 2006 National Institute of Clinical Excellence (NICE) guidelines.21 The detection of adenosine deaminase (ADA) in ascitic fluid has been proposed as a useful non-culture method for detecting tuberculous peritonitis, with a high sensitivity and specificity (depending on the cutoff values used).22 Neither of these modalities was used in our patients as we regard them of limited value, as they do not remove the need for biopsy for histology and TB culture.
Targeted endoscopy is indicated in patients with upper gastrointestinal symptoms or an abnormal bowel habit. Colonoscopy with biopsy is the most useful non-operative diagnostic test for ileocaecal TB. A recent study23 classified mucosal lesions into four types: type 1, circumferential ulceration with nodules; type 2, round or irregularly shaped small ulcers, arranged circumferentially, without nodules; type 3, multiple erosions restricted to the large intestine; and type 4, small ulcers or erosions restricted to the ileum. Some histological features can be used to differentiate TB and Crohn's disease in mucosal biopsy specimens obtained at colonoscopy.24–26 These include large, confluent, caseating granulomata. Ideally, deep biopsies should be taken from the ulcer margins and beds, as granulomata may be submucosal. We suggest that multiple biopsies are taken from all colonic regions if ATB is a possible diagnosis irrespective of whether or not the mucosa is macroscopically normal.
Laparoscopy with biopsy has been used for ATB diagnosis since 1976,27 with considerable specificity.28 Findings include ascites; adhesions between the liver/diaphragm, the liver/intestines and intestines/abdominal wall; miliary tubercles on the peritoneum and intestinal serosa; abdominal lymphadenopathy and intra-abdominal mass lesions. Extra caution is advised in patients with plastic peritonitis and severe adhesions, because of the risk of bowel perforation, but no major complications were described in this subset in one study,29 and the need for laparotomy was reduced. No complications were encountered in our cohort, <10% of laparoscopies (3/37) needed to be converted to laparotomy, and the proportion requiring laparotomy (27%) was substantially less than the 66% in our previous cohort.9 The greater experience in, and availability of, laparoscopy over the last two decades highlights its safety, and our experience along with previous reports30–33 support a low threshold for its use as a diagnostic tool for ATB, with caution exercised in the fibroadhesive group.
Radiological findings are non-specific and may raise the possibility of Crohn's disease, lymphoma, carcinoma or TB. They may result in endoscopic evaluation or laparoscopy/laparotomy. CT scanning may suggest the diagnosis if there is ascites with septae, mural or peritoneal thickening, omental caking or areas of liquefaction in areas of mesentery neighbouring other abnormalities.34
A 6-month course of chemotherapy for gastrointestinal TB was recommended in the 1990 treatment guidelines, by extrapolation from data for respiratory disease.10 Such treatment was again recommended in the 1998 treatment guidelines, now based on extrapolation from lymph node, bone and joint and pericardial sites.11 There have been no formal clinical trials of 6-month short course treatment in gastrointestinal disease. Our clinical experience with this treatment shows that it is highly effective, when combined with minimum monthly drug treatment monitoring of patient's self-administered treatment as recommended,10,11 with no relapses in 61 patients treated and monitored in the UK. A 6-month, four-drug initial regimen is being advised for ATB by NICE.21
Since the advent of effective chemotherapy for TB, laparotomy is performed mainly for complications of ATB i.e. peritonitis, bowel obstruction and in one case, in our series, with cholecystitis. As ATB is a great mimic the diagnosis is most often made at laparotomy or by histology.
ATB can be difficult to diagnose, and hard to distinguish from other diseases such as Crohn's disease. In our high prevalence district1–4 with a predominantly South Asian immigrant population, if the diagnosis is not confirmed as either TB or Crohn's disease, empirical anti-TB treatment is given initially because of the higher probability of the former in this ethnic group. This also substantially reduces the risk of TB reactivation in the future if the diagnosis is ultimately Crohn's disease and, steroids, immunosuppression or anti-TNF-
treatments are later used.
A high incidence of suspicion for ATB, and a low threshold for laparoscopy are needed to make the diagnosis. Well-monitored, 6-month anti-TB treatment gives excellent outcomes with minimal relapse and late morbidity.
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Acknowledgement |
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Dr MAM Al-Jibury for the initial collection of results.
Conflict of interest: None declared.
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References |
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