Submit a Manuscript: http://www.f6publishing.

com World J Gastrointest Surg 2017 August 27; 9(8): 174-181

DOI: 10.4240/wjgs.v9.i8.174 ISSN 1948-9366 (online)

MINIREVIEWS

Abdominal tuberculosis: Is there a role for surgery?

Elroy Patrick Weledji, Benjamin Thumamo Pokam

Elroy Patrick Weledji, Department of Surgery, Faculty of Health remains an important problem in endemic areas of the
Sciences, University of Buea, PO Box 63, Buea, Cameroon developing world. The aim of the review was to elucidate
the natural history and characteristics of abdominal TB
Benjamin Thumamo Pokam, Department of Biomedical Sci­ and ascertain the indications for surgery. TB can affect
ences, Faculty of Health Sciences, University of Buea, PO Box
the intestine as well as the peritoneum and the most
63, Buea, Cameroon
important aspect of abdominal TB is to bear in mind the
Author contributions: Weledji EP was the main author who diagnosis and obtain histological evidence. Abdominal TB
contributed to conception, design and drafting of the article; is generally responsive to medical treatment, and early
Pokam BT contributed to literature search. diagnosis and management can prevent unnecessary
surgical intervention. Due to the challenges of early
Conflict-of-interest statement: The authors declare no conflict diagnosis, patients should be managed in collaboration
of interests. with a physician familiar with anti-tuberculous therapy.
An international expert consensus should determine
Open-Access: This article is an open-access article which was an algorithm for the diagnosis and multidisciplinary
selected by an in-house editor and fully peer-reviewed by external management of abdominal TB.
reviewers. It is distributed in accordance with the Creative
Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this
Key words: Tuberculosis; Peritoneal; Intestinal; Surgery;
work non-commercially, and license their derivative works on Anti-tuberculous therapy
different terms, provided the original work is properly cited and
the use is non-commercial. See: http://creativecommons.org/ © The Author(s) 2017. Published by Baishideng Publishing
licenses/by-nc/4.0/ Group Inc. All rights reserved.

Manuscript source: Invited manuscript Core tip: It is important to bear in mind the non-specific
manifestations of abdominal tuberculosis. There is no
Correspondence to: Elroy Patrick Weledji, BSc (Lond), gold standard for the diagnosis and high clinical suspicion
MSc (Lond), MBBChBAO (Ireland), FRCS (Edinburgh), is required. Diagnostic laparoscopy is increasingly useful
Department of Surgery, Faculty of Health Sciences, University of
but joint decision making with physician familiar with anti-
Buea, PO Box 63, Buea, Cameroon. nfo@ubuea.cm
Telephone: +237-69-9922144 tuberculous therapy is important. Surgery is reserved for
abdominal complications.
Received: December 21, 2016
Peer-review started: December 25, 2016
First decision: January 16, 2017 Weledji EP, Pokam BT. Abdominal tuberculosis: Is there a role
Revised: May 22, 2017 for surgery? World J Gastrointest Surg 2017; 9(8): 174-181
Accepted: June 30, 2017 Available from: URL: http://www.wjgnet.com/1948-9366/full/
Article in press: July 3, 2017 v9/i8/174.htm DOI: http://dx.doi.org/10.4240/wjgs.v9.i8.174
Published online: August 27, 2017

Abstract INTRODUCTION
It is important that surgeons are familiar with the various Abdominal tuberculosis (TB) continues to represent a
[1]
manifestations of tuberculosis (TB). Although TB has diagnostic challenge to clinicians . The abdomen is
been declining in incidence in the developed world, it involved in 10%-30% of patients with pulmonary TB and

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 Weledji EP et al . Abdominal tuberculosis: Is there a role for surgery?

accounts for between 5% and 10% of TB notifications

in the United Kingdom. Greater than 75% of cases
occur in immigrants, with most coming from the Indian
[2,3]
sub-continent . There is a slight male predominance
th th
in abdominal TB with a peak incidence in the 4 and 5
decades in the immigrant population, and in the elderly
[3,4]
in the United Kingdom . In the United States, among
native-born white Americans, abdominal TB is primarily
a disseminated disease of elderly, debilitated patients
with chronic illnesses. Among foreign-born individuals,
abdominal TB occurs in the young, immunocompetent
[5]
patients from endemic areas . The diagnosis is thus
[6]
difficult and often delayed . Surgeons must be aware
of the wide clinical spectrum of abdominal TB and Figure 1 Intestinal tuberculosis (ileocaecal) (with permission from Chu­
have a high index of suspicion when confronted with mber et al[51], 2001).
patients from an endemic area presenting with unclear
[2,6]
abdominal symptoms . The aim of the review is to
offer an opinion on the role of surgery in abdominal TB
and stimulate debate in an area of ongoing interest.

PATHOGENESIS AND PATHOLOGY

The principal forms of abdominal TB are intestinal and
peritoneal but a third form - nodal - is also recognized.
[6,7]
In practice, the various forms may coexist . In the
past, many cases of abdominal TB occurred as a
direct result of the ingestion of Mycobacterium bovis
in unpasteurized milk. In most cases today intestinal
TB is due to reactivation of primary disease caused
by Mycobacterium tuberculosis. The reactivation of Figure 2 Histopathology (H/E stain): Showing multiple mucosal and
Mycobacterium tuberculosis and the atypical opportunistic submucosal epitheloid cell granulomas with Langhan’s giant cells in a
Mycobacterium avium intracellulare infection in the case of colonic tuberculosis (with permission from Tandon et al[35], 1972).
acquired immune deficiency syndrome have a poor
[8-11]
prognosis because of immunosuppression . TB s disease, with skip lesions. The gross pathology is
bacteria reach the gastrointestinal tract via haemato­ characterized by transverse ulcers, fibrosis, thickening
genous spread (from a pulmonary focus acquired during and stricturing of the bowel wall, enlarged and matted
primary infection in childhood), ingestion of infected mesenteric lymph nodes, omental thickening, and
sputum, or direct spread from infected contiguous lymph peritoneal tubercle (Figure 1). The histology shows
nodes and fallopian tubes. Swallowed bacilli pass through numerous granulomas which are not always caseating,
the Peyer’s patches of the intestinal mucosa and are and, often, acid-fast bacilli cannot be found if there is
transported by macrophages through the lymphatics to low mycobacterial load (Figure 2)
[7,13,14]
. Tuberculous
the mesenteric lymph nodes where they remain dormant. peritonitis is usually due to reactivation of a tuberculous
Reactivation of disease in these nodes especially in the focus in the peritoneum with concurrent pulmonary,
immunocompromised including diabetes, renal failure intestinal or genital TB (especially from the fallopian
and malignancy may lead to abdominal TB, with the tubes). This is usually seen in debilitated patients
[4]
spread of the bacteria to the peritoneum or intestine . [6,7]
and alcoholics . Peritoneal TB occur in three forms:
Intestinal TB can involve any part of the alimentary tract Wet type with ascites, dry type with adhesions, and
[2,11]
(from oesophagus to the anus) . Gastro-duodenal TB fibrotic type with omental thickening and loculated
is uncommon (1%) due to the bactericidal properties of [14]
ascites . Peritoneal TB is characterized by tubercles
gastric acid, scarcity of lymphoid tissue in the mucosa that appear as white “seedlings” on the parietal and
[12]
and rapid emptying of gastric contents . The ileocaecal visceral surfaces of the peritoneum. Inflammation and
region is the most common site of involvement (75%) exudation leads to the formation of straw-coloured
because of increased physiological stasis, fluid and ascites (Figure 3). When there is associated infiltration
electrolyte absorption, minimal digestive activity and and thickening of the omentum, intestinal walls, and
[12]
abundance of lymphoid tissue (Peyer’s patches) . TB formation of caseous masses it is referred to as “plastic”
[15-17]
of the ileocaecum presents usually with a palpable mass peritonitis . Mycobacterium tuberculosis can sp­
in the right iliac fossa. Perianal disease with abscesses read to the genital tract via the blood or lymphatics.
[3,7]
and fistulas can occur, but is uncommon . The naked Granulomata develop in the tubes and subsequently
eye appearance of intestinal TB may resemble Crohn’ the other genital organs. The endometrium is involved

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 Weledji EP et al . Abdominal tuberculosis: Is there a role for surgery?

subcontinent as a cause of intestinal obstruction. It

must be distinguished from Crohn’s disease which
[14]
is rare in most tropical countries . Tuberculous
enteritis may, if the patient recovers, lead to stenotic
[18]
lesions causing small bowel obstruction . Intestinal
perforation and acute bleeds do occur, but are un­
usual. Classically malabsorption from strictures and
sometimes with steatorrhoea, can result from TB of
the small intestine, and occasionally when the terminal
ileum is involved, patients present with anaemia due
[14]
to vitamin B12 deficiency . Some cases present with
disturbance of bowel habit, usually diarrhoea. The
remainder of patients with intestinal TB have vaguer
Figure 3 Peritoneal tuberculosis (with permission from Bolognesi et al[43], symptoms and signs, such as weight loss, malaise and
2013). abdominal tenderness. A few patients with only nodal
disease present with an abdominal mass consisting
[2,6]
in up to 80% of cases and the ovaries in 20%-30% .
[15] of enlarged mesenteric lymph nodes . As many as
Fillion et al
[11]
reported in a low incidence country 60% of patients with abdominal TB have evidence of
that the main organs involved were the peritoneum TB elsewhere. Chest X-ray, however, show evidence
(66%), the mesenteric lymph nodes (62%), and the of concomitant pulmonary lesions in less than 25%
[10,11,19,20]
bowel (33%). Atypical presentation of peritoneal TB of cases . Genitourinary TB may present in a
such as portal vein thrombosis from encasement, with similar manner to pelvic inflammatory disease (PID),
splenomegaly and ascites can delay diagnosis or result with chronic low-grade pelvic pain and ultimately with
[14]
in misdiagnosis . Half (50%) of HIV patients with TB amenorrhoea and infertility. Abnormal uterine bleeding
[15]
have extrapulmonary involvement, compared with only is a presenting symptom in 10%-40% of patients .
10%-15% of TB patients who are not infected with Examination is normal in many women but an adnexal
[21]
[7]
HIV . In HIV-infected patients abdominal TB is of a mass or fixing of the pelvic organs may be detected .
rapidly progressive nature, often fatal though usually It should be noted that the human immunodeficiency
treatable. virus (HIV) may alter the manifestations of, and host
[9,15,21]
susceptibility to, other infections . Other rare
clinical presentations include dysphagia, odynophagia
CLINICAL FEATURES and a mid oesophageal ulcer due to oesophageal
The clinical symptoms and signs of abdominal TB are TB; dyspepsia and gastric outlet obstruction due to
non-specific and the diagnosis may be overlooked or gastroduodenal TB; lower abdominal pain and rectal
[2]
mistaken for other disease processes . The clinical bleeding due to colonic TB; and annular rectal stricture
picture is different in children to that in adults. About and multiple perianal fistulae due to rectal and anal
[2,6]
90% of the features of abdominal TB in children are involvement .
due to involvement of the peritoneum and lymph nodes
[4-6]
and 10% related to intestinal lesions . Abdominal
INVESTIGATIONS
pain is common, accompanied by ascites (75%) or an
abdominal mass caused by an inflamed mesentery Neither clinical signs, laboratory, radiological and
[2,3]
(30%) . The most common signs are abdominal endoscopic methods nor bacteriological and histo­
tenderness and hepatosplenomegaly. Patients with the pathological findings provide a gold standard by them­
[10]
“plastic” type of peritoneal TB may have a characteristic selves in the diagnosis of abdominal TB . The clinical
[10,22]
“doughy” abdomen but this form is, however, un­ awareness is thus primary . Most laboratory tests
common today
[16,17]
. Usually the onset of tuberculous are unhelpful. The erythrocyte sedimentation rate
peritonitis is insidious with fever, anorexia and weight (ESR) is often moderately raised in 79% of patients,
loss. In a high prevalent area in sub-Saharan Africa, and although there may be a mild normochromic,
the common presenting symptoms and signs were normocytic anaemia, a leucocytosis is uncommon.
abdominal pain 76.6%; ascites 59.6%; weight loss Hypoalbuminaemia is not uncommon but liver function
[11,23]
53.2% and fever 29.8%. The average duration of tests are usually normal . Abdominal TB has a
sym­ptoms before presentation was 3 mo and 13% of multitude of possible presentations and requires
[10]
patients had earlier been treated for pulmonary TB . a diagnostic approach adjusted to the individual
Intestinal TB presents in a variety of ways. Up to presentation. This approach should be as little invasive
30% of cases may present as an acute abdomen, either as possible and be based on the best available imaging.
with acute intestinal obstruction or with symptoms Ultrasound scans of abdomen were abnormal in 68%,
and signs suggestive of an acute appendicitis from showing ascites, hepatomegaly and or enlarged nodes.
[11]
an obstructing TB lymphadenopathy . Hypertrophic Computed tomography (CT) was the most frequent
ileocaecal TB is particularly common in the Indian imaging modality (88%) in the United States. The

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 Weledji EP et al . Abdominal tuberculosis: Is there a role for surgery?

findings suggestive of abdominal TB were mesenteric/ albeit uncommon include intestinal perforation, bleeding
omental stranding (50%), ascites (37%), and retro­ and infection. Thus, for this to be safe, the patient
peritoneal lymphadenopathy (31%). Seventeen of 18 must have clinically detectable ascites. The diagnostic
patients required operative intervention, and one patient yield can be increased if the peritoneum is exposed by
[20] [11]
underwent CT-guided drainage of a psoas abscess . dissection under local anaesthesia . Some patients
Mantoux test was positive in 33% and ascitic fluid was with abdominal TB without ascites have the diagnosis
diagnostic for TB in 29%. Thus, a positive tuberculin confirmed indirectly by culture and histology of per­
[3,16]
skin test (e.g., Mantoux) may be helpful, though some cutaneously biopsied liver tissue with hepatic TB .
series have found less than 50% of the cases of proven Diagnostic laparotomy may be resorted to where
[23]
abdominal TB to be tuberculin positive . Chest X-ray endoscopic procedures are not available or when they
showed abnormal findings in 25% of the patients fail to give a definite histopathological diagnosis or for
[16]
suggesting past or present pulmonary TB and sputum an undiagnosed abdominal mass . While laparotomy
[10]
was positive for acid-fast bacilli (AFB) in 14.3% . A will reveal the diagnosis in patients with abdominal TB
high index of suspicion is, required for the diagnosis who present with an acute abdomen, the procedure
of peritoneal TB as the analysis of peritoneal fluid for may be hazardous in sick, emaciated patients with
tuberculous bacilli is often ineffective and may cause malabsorptive syndrome. It is also not always accurate
[28]
mortality due to delayed diagnosis. Examination of for the “cold” cases and laparotomy should, thus,
the ascitic fluid usually reveals an exudate (protein > essentially be performed only when complications of
[29]
25 g/L) and a raised white blood cell count (WBC) > abdominal TB develop . The suspicion of genitourinary
9
0.1 × 10 /L consisting principally of lymphocytes. A TB in a woman from an endemic area with bilateral
direct stain for acid-fast bacilli is positive in less than tubal calcification from chronic infection seen on abdo­
5% of cases, though up to 40% will be positive if the minal X-ray or radiographic evidence of pulmonary
ascitic fluid is cultured. By centrifuging large volumes of TB should be confirmed if possible, by positive culture
ascitic fluid and culturing the sediment, the diagnostic of the organisms in endometrial tissue obtained from
[23,24] [13-15]
yield may be increased to up to 80% . However, biopsy or dilatation and curettage . Endometrial
tuberculous peritonitis-associated mortality is high biopsy does not have 100% sensitivity but the detection
among patients waiting for the results of mycobacterial rate is greatest towards the end of the menstrual cycle.
[24]
culture of ascitic fluid samples . Direct stains and A Mantoux or Heaf test should be reactive in a woman
culture of stool specimens may sometimes be positive, with active TB unless she is immunosuppressed. The
[23]
but the yield is generally low . Barium studies may enzyme-linked immunoabsorbent assay (ELISA) us­
show some abnormality in about 50% of patients ing mycobacteria saline-extracted antigen for the
[25]
with intestinal TB but are not diagnostic . To confirm serodiagnosis of abdominal TB gives a diagnostic
[16,23]
the diagnosis, it is important to try to obtain material accuracy of 84% . Another test for early diagnosis of
for culture and histology. As culture may take up to tuberculous peritonitis is the determination of adenosine
[1,13]
6 wk, the histological evidence is important. There deaminase activity (ADA) in the peritoneal fluid .
are a variety of ways of obtaining tissue for histology. New diagnostic procedures, and especially molecular
Colonoscopy may be useful. Biopsy specimens obtained biology-polymerase chain reaction (PCR), may help
[11,23]
during colonoscopy of the terminal ileum and ileocaecal diagnose unusual clinical presentations of TB . As
valve may show active chronic ileocolitis with ulceration abdominal TB should be considered in all cases with
[25]
and granuloma formation . Invasive procedures are ascites. PCR of ascitic fluid obtained by ultrasound-
frequently necessary to obtain samples but also for guided fine needle aspiration is a reliable method for its
[11]
the treatment of digestive involvement . In light of diagnosis and should at least be attempted before more
[13,30]
new evidence, peritoneal biopsy through laparoscopy invasive interventions .
has emerged as the gold standard for diagnosis and
both lymphoma and carcinomatosis can be excluded
[26]
by this means . Laparoscopy is most reliable as it DIFFERENTIAL DIAGNOSIS
is minimally-invasive effective modality for diagnosis Abdominal TB, with its vague symptoms and signs and
of peritoneal TB, and can be performed under local non-specific laboratory investigations, can mimic many
anaesthesia. It is rapid, safe, greater than 75% accuracy other diseases (Table 1). The main differential diagnosis
in diagnosis and spares the patient the discomfort of to consider with intestinal TB is Crohn’s disease. Crohn’s
[11,27]
a laparotomy . It allows the biopsy of the typical disease is uncommon in the im­migrant population at risk
studded tubercles of the peritoneum and other organs for TB, and in Caucasians its peak incidence occurs in the
which are sent for culture and histology. However, 20-40 age group, while that of intestinal TB is in the older
[5]
laparoscopy is costly and is not available in many of age group (50-70 years) . Although perianal disease and
the poorer areas of the world. Blind percutaneous en­teric fistulas can be due to TB, this is uncommon in
peritoneal biopsy with an Abrams or Cope needle comparison with Crohn’s disease. Distinguishing between
biopsy usually in the left lower quadrant just lateral to these two entities is a challenge because there is marked
the rectus muscle is diagnostic in up to 75% of cases overlap in the clinical presentation and the radiographic,
[3]
of peritoneal TB . The complications of the procedure laboratory, and endoscopic findings, as well as in the

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 Weledji EP et al . Abdominal tuberculosis: Is there a role for surgery?

diagnostic laparotomy for atypical diagnostic problems

Table 1 Differential diagnosis of abdominal tuberculosis
especially as diseases such as CD, lymphoma and
[26-28]
Intestinal TB Peritoneal TB malignancy can mimic TB in every way .
Crohn’s disease Carcinomatosis
Intestinal lymphoma Bacterial peritonitis
Carcinoma Talc peritonitis
MANAGEMENT
Yersinia infections Chronic liver diseases Most patients with abdominal TB respond to medical
Amoeboma
treatment with standard anti-tuberculous chemotherapy
and carries good prognosis if promptly diagnosed and
TB: Tuberculosis. [8,26]
treated . The drug treatment is identical to pulmonary
[31-33]
TB with conventional chemotherapy for at least 6 mo.
presence of granulomas on histological examination . Rifampicin and isoniazid are given for 6 mo, with two
Misdiagnosis of Crohn’s disease in a patient with intestinal additional drugs-pyrazinamide and streptomycin (given
TB would result in treatment with steroids and biologic at a dose of 0.75-1.0 g daily depending on body weight,
agents, which then has the potential to cause disease [16]
age and renal function) for the first 2 mo . The main
progression that leads to increased morbidity and cause of failure in medical treatment in the endemic
[34]
mortality . Misdiagnosis of intestinal TB in a patient with and developing countries is patient defection or poor
Crohn’s disease would lead to prolonged anti-tuberculous [10]
compliance . Shorter and more effective regimes,
therapy and delay the necessary immunosuppression based on rifampicin that can be completed in 6 mo
[35]
required to induce disease remission . Both diseases [16]
have increased patient compliance . For patients in
have an insidious onset but diarrhoea, rectal bleeding whom the diagnosis is strongly suspected, but for whom
and extraintestinal manifestations are more common in the histological proof is unobtainable or inconclusive,
patients with Crohn’s disease. Intestinal TB can target it is justifiable to undertake a trial of anti-tuberculous
extrapulmonary sites in a manner that resembles the therapy
[10,41] [10]
. Akinkuolie et al , reported that 85.1% of
classic extraintestinal manifestations of Crohn’s disease, patients with clinically diagnosed abdominal TB in a high
such as reactive arthritis, erythema nodosum, and prevalent area recovered after receiving anti-tuberculous
[36]
uveitis . Ascites and fever are more commonly seen therapy for a period of 9-12 mo. However, all those
in patients with intestinal TB. Both diseases involve with HIV infection and not on antiretroviral treatment
the ileum and colonic segments of the bowel. Isolated died from immunosupression
[8,10]
. A few patients who
involvement of the terminal ileum is commonly seen in developed adhesions, obstruction or perforation at
patients with Crohn’s disease (terminal ileitis), whereas some time following chemotherapy required surgery .
[7]

involvement of the ileocaecal area and a patulous Intravenous anti-TB therapy in combination with surgery
ileocecal valve is seen in patients with intestinal TB (ileo- may be needed for severe forms of TB with extensive
caecal TB). In patients with Crohn’s disease, mucosal gastrointestinal involvement .
[42]

injury has a cobblestone appearance with aphthous

and longitudinal rake ulcers, whereas in patients with
intestinal TB, the ulcers are transverse in orientation
[37-39]
. ROLE OF SURGERY
Furthermore, the granulomas associated with intestinal TB Surgery is essentially reserved for those with acute
are more frequent and confluent and larger than those surgical complications including free perforation, confined
associated with Crohn’s disease. As tissue samples are perforation with abscess or fistula, massive bleeding,
positive for acid-fast bacilli in only 25% to 30% of cases complete obstruction, or obstruction not responding
of intestinal TB, the use of molecular techniques such to medical management
[6,11,26,27]
. Obstruction is the
as PCR assays of fresh biopsy specimens, can improve most common complication with multiple and/or long
[28,40] [38]
the diagnostic yield . Makharia et al interestingly strictures less likely to respond to medical therapy
[40,43]
.
developed a scoring system for differentiation of CD and The obstruction may also be exacerbated during anti-
intestinal TB based on clinical endoscopy and histology tuberculous therapy due to healing by cicatrisation .
[40]

using the findings of sigmoid colon involvement, blood About 20%-40% of patients with abdominal TB present
in stools, weight loss and focally enhanced colitis. Other with an acute abdomen and need surgical mana­
differential diagnoses are carcinoma, lymphoma, Yersinia [44]
gement . Chronic patients with subacute obstruction
[3]
infections and, in some parts of the world, amoeboma . are managed conservatively and surgery is planned after
[45]
Peritoneal TB must be differentiated from carcinomatosis, suitable work-up . Being a systemic disease surgical
talc peritonitis, bacterial peritonitis, and from ascites due resection should be conservative. Multiple small bowel
to heart failure or liver disease (Table 1). Although ascites strictures may be treated by strictureplasty to avoid
[46-48]
due to cardiac failure is usually easy to distinguish, it is major resection . An alternative is colono­scopic
important to realize that there is an increased incidence balloon dilatation of readily accessible, short and fibrous
of abdominal TB in alcoholics, and that liver disease with tuberculous ileal strictures causing subacute obstructive
ascites may coexist with peritoneal TB and the ascites symptoms. Although the experience is very limited, this
[5,19]
may not have the characteristics of an exudate . technique appears safe and may obviate the need for
[49]
Some patients may therefore warrant a laparoscopy or surgery in this setting . Acute tubercular peritonitis

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 Weledji EP et al . Abdominal tuberculosis: Is there a role for surgery?

and mesenteric lymphadenitis need to be managed on surgical emergencies of tubercular abdomen in

with caution. If a laparotomy is carried out only a biopsy developing countries. Abdominal pain, vomiting, and
needs to be performed with peritoneal toilet and the constipation were commonest presenting symptoms.
[50]
abdomen closed without a drain . About 20% patients had history of pulmonary TB and
The surgery performed in gastrointestinal TB are 16% patients presented with ascites. PCR for blood and
[14]
essentially of three types . The first type is the surgery ascitic fluid was positive in 72% and 87.5% patients,
which is done to bypass the involved segments of bowel respectively. As in the low prevalence developed country,
such as an enteroenterostomy or an ileotransverse the indications and principles of management were
colostomy. As in Crohn’s disease, these surgeries are the same. About 24% of patients were managed non-
usually complicated by blind loop syndrome, fistula operatively and responded to anti-tuberculous therapy.
formation and recurrent disease in the remaining Seventy-six percent needed surgery among which
segments and hence usually not performed routinely. 20% were operated as emergency. Adhesiolysis of gut
The second type are segmental resections such as the (47.3%), strictureplasty (10.5%), resection anastomosis
limited ileo-caecal resection for obstructing ileo-caecal (5.2%), right hemicolectomy (5.2%), and ileotransverse
TB with adjuvant anti-tuberculous therapy to eradicate anastomosis (7.8%) were performed and peritoneal
[47,51]
the disease completely . However, these surgeries biopsy and lymph node biopsy in 21% of patients. The
are hindered by the malnourished status of most of the tuberculous bowel perforations were usually treated
patients which make them poor surgical candidates. Also with resection of involved segments with primary
[17,18]
the lesions can be widely placed and extensive resection anastomosis . Generally, emergency surgery in
may not be possible in all the cases. Postoperative those severely ill patients presenting late carried high
complications include anastomotic leak, faecal fistula, mortality from toxaemia, hypoproteinaemia, anaemia
peritonitis, intraabdominal sepsis, persistent obstruction, and immunosuppression. The mortality rate ranged
[47,48,52] [10,30]
wound infection and dehiscence . Re-operation between 14%-50% in developing countries , and
[11,16]
may be required for recurrent obstruction. The third 6%-37% in developed countries . Morbidity included
type of surgery is bowel conserving strictureplasty of delayed wound healing with occurrence of incisional
[18,47,48] [14,47]
those stenotic lesions with obstructive symptoms . hernia, recurrent obstruction and faecal fistula . Both
Strictureplasty for cases with multiple strictures was medically and surgically managed patients responded
introduced as a better technique than multiple resections dramatically to anti-tuberculous therapy with increase in
[28-30]
and enteroanastomoses, as it does not sacrifice any part haemoglobin level and fall in ESR .
of the small bowel and avoids the risk of short-bowel
[53]
syndrome or blind loops . Long strictures with active
inflammation or multiple strictures in a segment may CONCLUSION
require resection unless there is concern about bowel Abdominal TB is generally responsive to medical
[18]
length . With adjuvant anti- tuberculous therapy, treatment, and early diagnosis and management can
microscopic disease at the resection margin should not prevent unnecessary surgical intervention. However,
[14,18-20,54]
influence recurrence of disease . The Heineke- abdominal TB should be considered a surgical problem
Mikulicz pyloroplasty technique is usually used. In a in the acute and chronic abdomen. Laparoscopy is
small number of cases with longer strictures where emerging as the gold standard for diagnosis since
bowel conservation is required, a Finney or a Jaboulay diseases such as Crohn’s disease, lymphoma and
[17-19]
strictureplasty may be used . Strictures of recent malignancy can mimic TB. Due to the challenges of early
onset that are not very tight may be left alone, or dilated diagnosis, patients should be managed in collaboration
[53,54]
via an enterotomy . Tubercular perforations are with a physician familiar with anti-tuberculous therapy.
mostly ileal and proximal to a stricture. If they are close An international expert consensus should recommend
to one another, resection of the segment is performed. an algorithm for the diagnosis and multidisciplinary
If the stricture is not close, the perforation can be closed management of abdominal TB.
in layers and the stricture dealt with by strictureplasty
or resection, depending on the length of the narrowed
segment. Delayed diagnosis and injudicious treatment REFERENCES
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P- Reviewer: Aggarwal D, García-Elorriaga G, Parwat I, Pani SP,

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