In Young adults abdominal tuberculosis is common. 2/3rdof patients are
in the age group of 21-40 yrsand there is no gender difference in incidenceof abdominal TB, but female predominance was seen in few Indian studies. A study conducted in South Africa, showed that the association of abdominal with pulmonary Tuberculosis increases (62%) only under low socioeconomic conditions.[40]Conversely, increased severity of pulmonary tuberculosis
increases the severity of abdominal disease.
Abdominal tuberculosis clinically present either in acute or chronic form.Common symptoms found are constitutional. Fever in 40-70%, pain among 80-95%, diarrhoea seen in 11 20%cases, constipation, alternate constipation and diarrhoea, weight loss in about 40-90% of patients, malaise and anorexia. Continuous and dull Pain is felt if the mesenteric nodes are involved and in case of luminal compromise colicky pain is felt. Specific clinical features are seen depending upon the nature, site and extent of involvement.
Table 2: Clinical features
Site Type Clinical features
Small intestine
Ulcerative Diarrhoea,malabsorption
Stricturous Obstruction
Large intestine
Ulcerative,Rectal bleeding Rectal bleeding Hypertrophic Lump obstruction
Peritoneal
Ascitic Pain, distension Adhesive Obstruction
Bhansali[12]found frank malabsorption in about 21% of patients, while
Tandon et al [41] reported biochemically that 75% of patients with intestinal
obstruction had malabsorptionand 40% without it. Mass in patients with abdominal tuberculosis is firm, mobile and only slightly tender. Rectal bleeding has been reported in 4% [42] to 6% [43] of patients; massive lower
gastrointestinal bleeding is rare.[44]
Subacute intestinal obstruction is described as colicky abdominal pain, distension, vomiting, gurgling, feeling of a ‘ball of wind’ moving in the
abdomen, and visible loops and peristalsis; these symptoms are relieved spontaneously after passage of flatus. Ano-rectal tuberculosis presents as stricture,[45] fistula-in-ano [46, 47] or fissure-in-ano. [48] Tubercular fistulae
are usually multiple; as many as 12 out of 15 multiple flstulae but only four out of 61 single peri-anal fistulae were tubercular.[49]
Tuberculous Peritonitis:
Tuberculous peritonitis, the common form of abdominal tuberculosis presenting as ascitic type in about 97% of cases[50, 51].Localised or Generalised
ascites with fine strands of adhesions and filmy membranes are seen. The tubercles are studded on the peritoneum - on parietal as well as visceral peritoneum.
Remaining 3% of cases are of plastic or fibroadhesivetype,here bowel loops are matted due to adhesion of masses of tubercles. These matted loops of bowel are then stuck to the mesentery and to peritoneum so peritoneal space will be obliterated due to adhesions.[52]Omentummay be palpable, rolled up or
thickened. This illness generally develops slowly over months.
Tuberculosis of oesophagus:
A rare variety, Oesophageal tuberculosis constitutes 0.2 per cent of cases of abdominal tuberculosis.[39] Patient withOesophageal tuberculosis presents
with difficulty and pain during swallowing, fever – low gradeand an
midoesophagealulcer. This disease can be misdiagnosedas oesophageal carcinoma and there will be no evidenceforextraoesophageal focus of tuberculosis.[53].
Gastroduodenal tuberculosis:
In this type , Stomach and duodenum each contribute for about 1% of cases of abdominal tuberculosis.Patients presents as peptic ulcer disease of short duration with decreased or no response to treatment.[54]
Infected sputum, contaminated food, hematogenous spread and direct spread from adjacent organs result in Tuberculous enteritis. Ulcerative type is the most common followed by hypertrophic or ulcero-hypertrophic type of intestinal lesion. Patient complaints are fever, pain abdomen, diarrhea with weight loss. Rectal bleeding and tenderness over the abdomen are seen. A palpable mass is seen in 25 to 50% of cases in right lower quadrant.
Common sites involved areileocecal area and jejunoileum.Complications include obstruction, fistula formation and perforation. Anal fissures, fistulas or perirectal abscess are the rectal lesions seen in Gastro duodenal tuberculosis.
Hepatic and pancreatic tuberculosis
The liver is frequently affected in association with miliary tuberculosis. In 41 patients with hepatic tuberculosis from South Africa, the liver was found to vary in size and consistency. [55]Hepatic involvement tends to be diffuse;
macronodular forms are rare.[56]Pancreatic tuberculosis can mimic pancreatic
occasionally with obstructive jaundice due to a mass at the head of the pancreas. Tuberculous pancreatic abscess has been reported in patients with AIDS[57].
Splenic Involvement:
In abdominal tuberculosis,spleen may be involved that presents as splenic enlargement–hypersplenism , abscess formation and fever. Along with
medical management Splenectomy is mandatory.HIV – positive drug abusers
presents with multiple abscesses.[58]
Ileocaecal tuberculosis
Typical features of Ileocaecal tuberculosis are abdominal pain –colicky
with borborygmi and vomiting. Abdominal examination may reveal a well defined, mobile mass, firm in the right lower quadrant. Sometimes examination reveals no abnormality or a doughy feel. Lymphadenitis may be associated that present as multiple lumps on palpation. Mobility of the lump also depends upon the node involved ,if mesenteric nodes are involved the lump is mobile and para-aortic or iliac nodes are involved the mass is fixed.[59]
Segmental colonic tuberculosis
Segmental also called isolated colonic tuberculosis is the involvement of the colon without ileocaecal region. This type constitutes 9.2 % of cases of abdominaltuberculosis. Sigmoid, ascending and transverse colon are commonly involved.[60]78–90% of patients presents with pain and less than
1/3rd of patients presents with hematochezia.[61, 62] Fever, weight loss,
anorexia, change in bowel habits are other features of segmental tuberculosis.
Anorectal lesions
These are rare. Four types have been described: ulcerative being the most common, varicose (warty-like), lupoid (nodular) and miliary. They are often confused with rectal carcinoma.[63] Elderly men with anorectal lesions may
present with abscesses and fistulas with concomitant pulmonary disease [64].
Glandular tuberculosis
This affects mesenteric or retroperitoneal nodes as well as nodes in the neck, axilla and/or groin. It may rarely present with a psoas abscess due to retroperitoneal lymphadenopathy, in the absence of bony affection [65].
Tuberculosis and HIV Infection
Extrapulmonary-tuberculosis(pericardial,pleural,meningeal,lymphadenopathic, disseminated, bone and joint infections) incidence increases with increase in incidence HIV infection. There is proportionate increase in extrapulmonary tuberculosis with increase in HIV infection. The diagnosis of intra abdominal tuberculosis is difficult, so the contribution of abdominal infection is higher. Manifestation of abdominal infection is altered by HIV infection but the extent is unknown. A study relates this to Immunosupression. Thus, in HIV infected patients weight loss , fever and extra abdominal lymphadenopathy are
common and CT findings suggests visceral lesions. In HIV negative individuals ascites and Jaundice are seenand CT scan commonly reveal ascitis and omental thickening in these patients.Aspirates from abdominal lymph nodes revealedrapid diagnosis in 8 HIV-infected patients showing acid-fast bacilli in the smear.
93% of HIVinfected patients, showed disseminated tuberculosis whereas only 31% of HIV negative cases had disseminated TB .Tuberculosis caused death in HIV-infected patients (23%) and about 31% in patients without HIV infection. Thus, in HIV-infected patients, abdominal tuberculosis is a manifestation of disseminated disease and therefore results in significant mortality.[114]
Tuberculosis is one of the common ‘HIV-related opportunistic infection
in India’, patients with both diseases should be cared properly which is a
major public health challenge. In India, annually about 1.8 million new cases of tuberculosis are reported, that accounts for a fifth of new cases in the world. Patients with latent Mycobacterium tuberculosis infection are at higher risk for progression if they are coinfected with HIV. The response to treatment in HIV patients is similar when compared with Patients without HIV infection but HIV patients have higher risks of recurrence and death. The influence of tuberculosis co-infection on the progression of HIV disease is controversial.
A study conducted in Malawi reported that 74.6% of patients with
tuberculosis are HIVpositive.[66] 6% of patients with acquired
immunodeficiency syndrome (AIDS) had tuberculosis in London.[67]
Tuberculosis infection in AIDS patients increases the mortality in HIV patients.[68]
Cryptic Miliary Tuberculosis
This type is common in Elderly people. So occult malignancy, should be ruled out while diagnosing Cryptic miliary tuberculosis. It occurs due to decreased immunity which may be related to reactivation of previous disease.[69]patient presents with features like: malaise, weight loss, fever, an
raised erythrocyte sedimentation rate (ESR) andwith normal chest X ray.