P Kishore, T Chandrsekhar, S Palaian
abdominal tb, diagnosis, nepal
P Kishore, T Chandrsekhar, S Palaian. Diagnosing Abdominal Tuberculosis: A Retrospective Study From Nepal. The Internet Journal of Gastroenterology. 2007 Volume 6 Number 2.
According to World Health Organization (WHO) nearly one-third of the world's population is under the risk of acquiring tuberculosis (TB) and more than 30 million deaths occurred due to TB in the 1990's, especially in Africa and Asia.1 In 1993, WHO declared TB as a global emergency and started Directly Observed Treatment Short course (DOTS) Programme in countries all over the world.2 Nepal is a high-burden country for TB with an estimated 6,000-8,000 deaths annually. 3 The National Tuberculosis Programme (NTP) in Nepal was reviewed in 1994 and DOTS was adopted as national policy for TB control in 1995 and was implemented in early 1996.3 TB can affect any part of the body and abdominal TB accounts for nearly 2% of the total cases of TB.4 Though
The clinical presentation of abdominal TB is non-specific and requires confirmatory evidence for accurate diagnosis.6 A study from United Kingdom reported that laparoscopy may be an investigation of choice among patients from high-burden countries with a suspected abdominal TB clinical history. 7 However, a study from Turkey has reported that none of the diagnostic modalities used could be used as gold standard for diagnosis of gastrointestinal TB.8 Insidious onset and non-specific clinical and radiological findings of abdominal TB mimics several diseases, such as crohn's disease, carcinoma, sarcoma, amebiasis,
1. To describe the clinical presentation and the diagnostic and treatment methods of the patients diagnosed with abdominal TB in Nepal.
2. To determine the accuracy of abdominal TB diagnosis in Nepal.
Based on 2003-2006 records retrieved from MTH-DOTS clinic, 32 cases of abdominal TB were identified out of the 302 cases of extra pulmonary TB.
Tuberculosis is one of the most common infectious diseases in developing countries like Nepal.3 TB can affect any part of the gastrointestinal tract including anus, peritoneum and pancreato-biliary system. 13Abdominal TB is the sixth most common form of extra-pulmonary site of infection after lymphatic, genitourinary, bone and joint, miliary and meningeal TB. 14
In our study, we found a slightly higher female preponderance in the number of abdominal TB patients. The male: female ratio was 1:1.13. A previous study from Nepal identified a slightly high male preponderance, male: female was 1.08:1. In a study from Turkey, the male: female ratio was 1.2:1. 8 In general, the sex distribution in abdominal TB is almost equal.15 However, there is an evidence suggesting that the male preponderance in Britain and in third world countries a female preponderance. 16
The mean SD of the age of the patients in our study was 39.62 21.18 years. In general it was reported that abdominal TB occurs in the fourth decade of life. 17 A previous study from Nepal reported 64% of the patients with in the age group of 12 to 35. 12It is also known that two thirds of the patients with abdominal TB are 21-40 years old. 18In our study we did not find such an observation.
The presenting symptoms of the patients with abdominal TB are not specific for the condition. 11The common symptoms reported by our patients are weight loss, loss of appetite, fever, ascites, vomiting, abdominal pain and diarrhoea. In a study from Taiwan, the common symptoms reported by the patients were abdominal pain, distension, fever, general weakness, and progressive weight loss. 19 A previous study from Nepal reported the common symptoms to be abdominal pain (88%), anorexia (40%), vomiting (36%), diarrhoea or constipation (52%), weight loss (52%). 12 Moreover the clinical presentations may be acute, chronic or acute on chronic. 15These observations made by different studies suggest that the symptoms of abdominal TB are not specific enough to issue the diagnosis.
Laboratory tests were suggested to have only limited value in the diagnosis of abdominal TB. Elevated ESR is seen in majority of the cases but may be normal in some histologically proven case of abdominal TB. 4 In our study we found majority of the patients with elevated ESR level. Since our study was a retrospective one, further laboratory testing was not possible.
Since the symptoms of abdominal TB are very general, one must be careful when issuing such diagnosis. A study from Turkey recommended the need for an algorithm of various diagnostic methods such as clinical signs, laboratory, radiological and endoscopic methods etc., to have a higher precision in the diagnosis of abdominal TB.8 In our study, we attempted to categorize the patients into different groups which aided in our diagnosis of abdominal TB. The ultrasonological abnormalities observed in our patients included peritonitis with ascites, hepatomegaly, mesenteric lymphadenopathy and intestinal
The management of abdominal TB requires conventional ATT for at least 6 months including initial l2 months of rifampicin, INH, Pyrazinamide and Ethmabutol . 15In our study though all the patients were diagnosed as abdominal TB, they differ in the treatment because 15 patients were considered to be severe extra pulmonary TB and started on Category I, the rest with category III as per the standard guidelines. A study from Bangladesh used conventional ATT with Isoniazid, Rifampicin and Pyrazinamide for 9 months and all the patients improved. 11In our study, one patient died during the treatment due to drug toxicity.
Our study had following limitations: The number of the patients in the study was low. Moreover, our study being a retrospective one thus, it was not possible to corroborate original diagnosis.
Since the clinical presentations of abdominal TB are very general and specific for the condition, diagnosis has to be supported by additional tests. If diagnosed early, it can be treated successfully with the conventional anti tubercular drugs. Similar studies done in different region of Nepal will provide more insights.
The authors acknowledge the New Zealand Medical Journal for sending us an important reference article for writing the manuscript.