Abdominal tuberculosis: continuation of surgical scourge.

Abstract

Epidemiology of surgical diseases has undergone a remarkable change over the last few decades and older diseases have been replaced by others. However, tuberculosis of GIT remains an important infection requiring surgical intervention. The gravity of this disease can be judged by the fact that annually, it results in the death of 3 million people globally. Under the existing conditions and at present working pace of the TB control program, an estimated one billion people will be infected by 2020, and 35 million will die from TB.1 Its control remains elusive due to the myriad clinical manifestation involving every part of body and capability to thrive in poverty, complacence, ignorance and coexistence with emergent diseases like AIDS. Gastrointestinal TB is a major health problem in many underdeveloped countries. Recently, a marked rise is seen in developed countries also, especially in association with HIV infection. Autopsies of patients with pulmonary TB before the era of effective treatment demonstrated intestinal involvement in 55-90% of fatal cases. The previously noted association between pulmonary and intestinal TB no longer prevails, however, recent reports reveal 20-25% of patients with GI TB have concomitant pulmonary TB.2 GIT is the sixth most frequent extrapulmonary site of tuberculosis infection. Both the incidence and severity of abdominal tuberculosis are expected to increase with the spread of HIV infection and inappropriate therapy leading to multidrug-resistant strains. Mycobacterium reaches the gastrointestinal tract via haematogenous route, swallowing infected sputum, or direct spread from infected contiguous lymph nodes and viscera. The gross pathology of abdominal tuberculosis is characterized by transverse ulcers, fibrosis, mural thickening, stricturing, perforation of the bowel wall, fistulization, enlarged and matted mesenteric lymph nodes, omental thickening, and peritoneal tubercles. This wide ranging morphology thus resembles any disease including ulcer, carcinoma, intestinal obstruction, peritonitis, abdominal pain, and abdominal mass or even obstructive jaundice in case of involvement of hepatobiliary system. The most common site of involvement in the gastro intestinal tract is the ileocaecal region, possibly because of the increased physiological stasis, increased rate of fluid and electrolyte absorption, minimal digestive activity and an abundance of lymphoid tissue at this site. It has been shown that the M cells associated with Pyers patches can phagocytose the bacillus.3 Two-thirds of all patients suffering from abdominal tuberculosis belong to 2 nd and 4 th decade of age, with equal gender distribution, although some studies have suggested a slight female predominance.4 The spectrum of disease in children is different from adults, in whom adhesive peritoneal and lymph nodal involvement is more common than abdominal organ involvement. Abdominal tuberculosis may present in acute, chronic or acute and chronic forms. Most patients have generalized symptoms of fever (40-70%), abdominal pain (80-95%), diarrhea (11-20%), constipation, alternating constipation and diarrhea, weight loss (40-90%), loss of appetite and malaise. Pain can be either colicky due to intestinal obstruction or dull when the mesenteric lymph nodes or omentum is involved.