Abdominal tuberculosis in children

02/19/15 Moustapha Mounib 1

Abdominal Abdominal tuberculosis in tuberculosis in

childrenchildrenMoustapha MounibMoustapha Mounib

Cosultant of Chest DiseasesCosultant of Chest Diseases

Military Medical AcademyMilitary Medical Academy

02/19/15 2Moustapha Mounib

Presenting symptoms & signs in Presenting symptoms & signs in children with abdominal tuberculosischildren with abdominal tuberculosis


Abdominal tuberculosis is an insidious and rare Abdominal tuberculosis is an insidious and rare manifestation of childhood tuberculosis and occurs in manifestation of childhood tuberculosis and occurs in less than 1-5% of cases of pulmonary tuberculosis. It is less than 1-5% of cases of pulmonary tuberculosis. It is still common in tropical countries and its incidence is still common in tropical countries and its incidence is gradually increasing in industrialized countries due to gradually increasing in industrialized countries due to immigration from developing countries, the increasing immigration from developing countries, the increasing incidence of human immunodeficiency virus ( HIV ) incidence of human immunodeficiency virus ( HIV ) infection and the emergence of atypical mycobacteriainfection and the emergence of atypical mycobacteria..


Aetiology and Aetiology and pathogenesispathogenesis

It was originally thought that abdominal TB was the It was originally thought that abdominal TB was the result of consuming milk infected with result of consuming milk infected with Mycobacterium Mycobacterium bovis. bovis. However , the practice of boiling milk, routine However , the practice of boiling milk, routine pasteurization and the eradication of infected cattle has pasteurization and the eradication of infected cattle has considerably reduced the number of cases caused by considerably reduced the number of cases caused by M.bovis M.bovis and the majority of the cases seen in present-day and the majority of the cases seen in present-day practice are caused by the human strain of practice are caused by the human strain of M. M.

TuberculosisTuberculosis..


Atypical mycobacteria may be encountered in a Atypical mycobacteria may be encountered in a minority of cases. Most present-day cases result minority of cases. Most present-day cases result from swallowing infected sputum and from swallowing infected sputum and haematogenous spread or peritoneal seeding from haematogenous spread or peritoneal seeding from the rupture of infected mesenteric lymph nodes. In the rupture of infected mesenteric lymph nodes. In females, tuberculous salpingitis may occur with females, tuberculous salpingitis may occur with subsequent abdominal spreadsubsequent abdominal spread..


Types of abdominal TBTypes of abdominal TB

The following are encountered : peritoneal, in The following are encountered : peritoneal, in which there is adhesive peritonitis with or without which there is adhesive peritonitis with or without ascites ;nodal, in which there are adhesions with ascites ;nodal, in which there are adhesions with mesenteric lymph node enlargement; intestinal, mesenteric lymph node enlargement; intestinal, in which there is either hypertrophic ileocaecal TB in which there is either hypertrophic ileocaecal TB and/or small bowel stictures; ulceration may also and/or small bowel stictures; ulceration may also be encountered and can lead to perforationbe encountered and can lead to perforation..


Unsual presentations include gastroduodenal Unsual presentations include gastroduodenal tuberculosis with extrinsic compression by enlarged tuberculosis with extrinsic compression by enlarged mesenteric lymph nodes causing obstruction and mesenteric lymph nodes causing obstruction and intrinsic lesions causing peptic symptoms, acute intrinsic lesions causing peptic symptoms, acute enterocolitis, diffuse pancolitis, splenomegaly and enterocolitis, diffuse pancolitis, splenomegaly and hypersplenismhypersplenism..


Presenting symptoms and Presenting symptoms and signssigns

The most common symptoms are abdominal pain The most common symptoms are abdominal pain and low grade fever. Clinical diagnosis has been and low grade fever. Clinical diagnosis has been reported to be accurate in less than 50% cases reported to be accurate in less than 50% cases even in endemic countries such as India. even in endemic countries such as India. Intestinal TB presents with abdominal pain which Intestinal TB presents with abdominal pain which may mimic appendicitis or a right-lower quadrant may mimic appendicitis or a right-lower quadrant mass and can be confused with Crohn’s disease mass and can be confused with Crohn’s disease which may rarely be present in the paediatric which may rarely be present in the paediatric population. In such cases, only histology and population. In such cases, only histology and culture can establish the final diagnosisculture can establish the final diagnosis..


Peritoneal TB presents with insidious onset of ascites. Peritoneal TB presents with insidious onset of ascites. Sometimes patients present with acute abdominal pain Sometimes patients present with acute abdominal pain secondary to bowel perforation. Constitutional secondary to bowel perforation. Constitutional symptoms such as fever, anorexia and weight loss are symptoms such as fever, anorexia and weight loss are common in 60-70 % of casescommon in 60-70 % of cases..


It is evident, therefore, that the clinical It is evident, therefore, that the clinical manifestations of abdominal TB are protean, non-manifestations of abdominal TB are protean, non-specific and can mimic a variety of abdominal specific and can mimic a variety of abdominal disorders. Early diagnosis is important because 90 % disorders. Early diagnosis is important because 90 % of patients with uncomplicated abdominal TB will of patients with uncomplicated abdominal TB will respond to medical therapy alone if begun early and respond to medical therapy alone if begun early and laparotomy and thus be avoidedlaparotomy and thus be avoided..


Presenting symtoms and signs in Presenting symtoms and signs in children with abdominal tuberculosischildren with abdominal tuberculosisSymptomSymptomAdominal pain 80%Adominal pain 80%Fever 74%Fever 74%Failure to thrive 58%Failure to thrive 58%Loss of appetite 54%Loss of appetite 54%Abdominal distention 38%Abdominal distention 38%Mobile lump 32%Mobile lump 32%Alternative diarrhoea and Alternative diarrhoea and constipation 20%constipation 20%History of cough 16%History of cough 16%

Loose stools 14%Loose stools 14%

SignSignFree fluid 44%Free fluid 44%Visible peristalsis 36%Visible peristalsis 36%Doughy feel 12%Doughy feel 12%Lump right iliac fossa 12%Lump right iliac fossa 12%Palpable liver 6%Palpable liver 6%Palpable spleen 4%Palpable spleen 4%Succussion splash 2%Succussion splash 2%


InvestigationsInvestigations


AnaemiaAnaemia : mild normochromic anaemia is present in 10- : mild normochromic anaemia is present in 10-25% of patients and may be secondary to bone barrow 25% of patients and may be secondary to bone barrow suppression as a result of chronic diseasesuppression as a result of chronic disease..

LeucocytosisLeucocytosis : is found in less than 30% of patients and : is found in less than 30% of patients and without lymphocytosiswithout lymphocytosis. .

Raised Raised erythrocyte sedimentation rateerythrocyte sedimentation rate..Mantoux- positiveMantoux- positive : use of the Mantoux test as a : use of the Mantoux test as a diagnostic aid is controversial. Some have stressed a diagnostic aid is controversial. Some have stressed a positive Mantoux as a good diagnostic aid ; however, positive Mantoux as a good diagnostic aid ; however, others state that a negative tuberculin reaction is others state that a negative tuberculin reaction is common in these patients due to immunological common in these patients due to immunological hyporesponsiveness related to the severity of the illness hyporesponsiveness related to the severity of the illness and consequent malnutritionand consequent malnutrition..


Various non – invasive tests, includingVarious non – invasive tests, including adenosine adenosine deaminase activitydeaminase activity of the ascitic fluid, of the ascitic fluid, enzyme-linkedenzyme-linked immunosorbent assayimmunosorbent assay and and soluble antigen fluorescentsoluble antigen fluorescent antibody testantibody test, have been reported for confirmation of , have been reported for confirmation of diagnosis. However, their use is limited due to their poor diagnosis. However, their use is limited due to their poor predictive value, cost and lack of availability in developing predictive value, cost and lack of availability in developing countriescountries..

RadiographyRadiography ; ; Chest radiographsChest radiographs are abnormal in less than are abnormal in less than a quarter of cases. Radiological findings are non-specific, a quarter of cases. Radiological findings are non-specific, but may be useful. There may be evidence of pulmonary but may be useful. There may be evidence of pulmonary tuberculosis on chest radiographs which may support the tuberculosis on chest radiographs which may support the diagnosisdiagnosis..


Plain radiographs of the abdomenPlain radiographs of the abdomen may show calcified may show calcified nodes. nodes. Barium contrast studiesBarium contrast studies may be useful in the may be useful in the intestinal of the disease, showing areas of small bowel intestinal of the disease, showing areas of small bowel narrowing and a deformed ileocaecal regionnarrowing and a deformed ileocaecal region..

Abdominal ultrasonographyAbdominal ultrasonography and and computed tomographycomputed tomography may show lymphadenopathy, peritonitis and ascites, may show lymphadenopathy, peritonitis and ascites, mesenteric and omental inflammation with associated mesenteric and omental inflammation with associated mass hepatosplenomegalymass hepatosplenomegaly..


Diagnostic criteria for childhood Diagnostic criteria for childhood abdominal tuberculosisabdominal tuberculosis

Histological evidence of caseating granulomas or Histological evidence of caseating granulomas or acid-fast bacilli in the lesion or ascitic fluid.acid-fast bacilli in the lesion or ascitic fluid.

Growth of Growth of Mycobacterium tuberculosis Mycobacterium tuberculosis from tissue from tissue or ascitic fluid.or ascitic fluid.

Good therapeutic response to chemotherapy Good therapeutic response to chemotherapy with evidence of TB elsewhere.with evidence of TB elsewhere.

Response to chemtherapy without susequent Response to chemtherapy without susequent recurrence in patients with clinical features of recurrence in patients with clinical features of the disease.the disease.


Final diagnostic criteriaFinal diagnostic criteriaIn a significant number of patients, the diagnosis of In a significant number of patients, the diagnosis of abdominal TB is presumptive and based on a good abdominal TB is presumptive and based on a good therapeutic response to antituberculosis chemotherapy therapeutic response to antituberculosis chemotherapy in patients who have suggestive clinical features and in patients who have suggestive clinical features and come from areas where tuberculosis is very common. come from areas where tuberculosis is very common. This could be in the form of a past history of This could be in the form of a past history of completely treated pulmonary TB, a positive family completely treated pulmonary TB, a positive family history of TB, active pulmonary tuberculosis on chest history of TB, active pulmonary tuberculosis on chest X-ray or a past history of treated tuberculous cervical X-ray or a past history of treated tuberculous cervical adenitis. In the remainder, diagnosis may have to be adenitis. In the remainder, diagnosis may have to be based on suspicion. However, in many cases, the based on suspicion. However, in many cases, the diagnosis is still difficult and many patients require diagnosis is still difficult and many patients require laparotomy.laparotomy.


ManagementManagement


The majority of patients respond to conservative The majority of patients respond to conservative treatment with antituberculosis drugs alonetreatment with antituberculosis drugs alone..

Antituberculosis chemotherapy is recommended Antituberculosis chemotherapy is recommended postoperatively for 9-12 months. For the initial 2 postoperatively for 9-12 months. For the initial 2 months, patients should receive combination months, patients should receive combination chemotherapy consisting of isoniazid, rifampicin, chemotherapy consisting of isoniazid, rifampicin, pyrazinamide and ethambutol, following which pyrazinamide and ethambutol, following which isoniazid and rifampicin should be administered for 7-isoniazid and rifampicin should be administered for 7-10 months10 months..

A positive response to antituberculosis A positive response to antituberculosis chemotherapy is shown by increased well-being, chemotherapy is shown by increased well-being, disappearance of fever, weight gain, reduction of disappearance of fever, weight gain, reduction of ascites and disappearance of abdominal massesascites and disappearance of abdominal masses..


Laparotomy is usually reserved for the relief of bowel Laparotomy is usually reserved for the relief of bowel obstruction, severe acute abdominal pain with peritonitis obstruction, severe acute abdominal pain with peritonitis of undiagnosed aetiology and in the presence of of undiagnosed aetiology and in the presence of abdominal masses to establish a definitive histological abdominal masses to establish a definitive histological diagnosis. Laparotomy findings include ascites, scattered diagnosis. Laparotomy findings include ascites, scattered tubercles over the abdominal organs, thickened tubercles over the abdominal organs, thickened oedematous omentum, small bowel strictures and oedematous omentum, small bowel strictures and hypertrophic ileocaecal lesionshypertrophic ileocaecal lesions..


The role of definitive surgery in these patients is for The role of definitive surgery in these patients is for the management of bowel obstruction or bowel the management of bowel obstruction or bowel perforation. In the past, bypass procedures or radical gut perforation. In the past, bypass procedures or radical gut resection was recommended. This frequently resulted in resection was recommended. This frequently resulted in blind loop syndrome and short gut syndrome, blind loop syndrome and short gut syndrome, respectively. With a better understanding of the respectively. With a better understanding of the pathology of the disease, it was appreciated that the pathology of the disease, it was appreciated that the affected bowel in TB heals well and conservative surgical affected bowel in TB heals well and conservative surgical procedures were advocatedprocedures were advocated..


For an ileocaecal mass, a limited ileocaecal resection For an ileocaecal mass, a limited ileocaecal resection should be carried out. Strictures with minimal narrowing should be carried out. Strictures with minimal narrowing may be left alone, as they trend to resolve with may be left alone, as they trend to resolve with chemotherapy. For significant strictures, stricturoplasty chemotherapy. For significant strictures, stricturoplasty may be done. If strictures are long and multiple, may be done. If strictures are long and multiple, resection and end-to-end anastomosis should be carried resection and end-to-end anastomosis should be carried outout..

Free perforation of a tuberculous ulcer is uncommon Free perforation of a tuberculous ulcer is uncommon because of peritoneal thickening and adhesions to because of peritoneal thickening and adhesions to adjacent tissues. The reported incidence is 0-11% and, adjacent tissues. The reported incidence is 0-11% and, when it occurs, perforations are multiple in 10-40% of when it occurs, perforations are multiple in 10-40% of cases, limited resection or freshening of the edges and cases, limited resection or freshening of the edges and transverse closure is requiredtransverse closure is required..


PrognosisPrognosis

The overall mortality for abdominal TB varies from 6% The overall mortality for abdominal TB varies from 6% to 8%. In patients undergoing elective surgery it is 0.5-to 8%. In patients undergoing elective surgery it is 0.5-2%. However, in the setting of emergency surgery with 2%. However, in the setting of emergency surgery with intestinal obstruction, it may be as high as 25%. In the intestinal obstruction, it may be as high as 25%. In the presence of intestinal perforation, it may be up to 40%. presence of intestinal perforation, it may be up to 40%. Thus abdominal TB is a potentially lethal disease which Thus abdominal TB is a potentially lethal disease which should be diagnosed and treated earlyshould be diagnosed and treated early..


ConclusionConclusionAbdominal tuberculosis in children is a disease Abdominal tuberculosis in children is a disease that is non-specific in nature and defies easy that is non-specific in nature and defies easy diagnosis. A high index of suspicion is required diagnosis. A high index of suspicion is required for early diagnosis and treatment in order to for early diagnosis and treatment in order to prevent complications, reduce mortality and avoid prevent complications, reduce mortality and avoid an unnecessary laparotomyan unnecessary laparotomy..


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Abdominal tuberculosis in children