Pediatr Surg Int (1990) 5:392-396
Pediatric
Abdominal tuberculosis in children - surgical management
A 10-year review of 95 cases
A. J. W. Millar, H. Rode, and S. Cywes
Department of Paediatric Surgery, University of Cape Town, Institute of Child Health and Red Cross War Memorial Children's Hospital, 7700 Ronde-
bosch, Cape Town, Republic of South Africa.
Abstract. During the period 1 9 8 0 - 1 9 8 9 , 95 patients,
mean age 5 years, with abdominal tuberculosis (ATB)
were seen at the Red Cross Children's Hospital. Eighty per
cent were malnourished. Apart from fever, loss o f weight,
and failure to thrive, symptoms of abdominal pain, vomit-
ing, and diarrhoea predominated. Abdominal distension
(86%) and a palpable mass (57%) were the most c o m m o n
physical findings. Sixty-three per cent had radiological
evidence o f chest disease. Abdominal ultrasound was use-
ful in identifying ascites and distribution of lymph node
masses. Fifty of the 95 patients were managed on the surgi-
cal unit and the predominant involvement was: peritoneal
21, nodal 15, enteric 11, and undetermined 3. Thirteen of
this group developed one or more complications - perfora-
tion (4), obstruction (7), abscess or fistulae (5), and
haemorrhage (1). Surgery involved diagnostic laparotomy,
extra-abdominal biopsy, and management of the complica-
tions. Emergency surgery was conservative. Definitive sur-
gery for stricture-plasty, resection, and stoma closure was
delayed at least 8 weeks to allow for chemotherapeutic
effect. Uncomplicated TB responded rapidly to therapy.
There were no deaths in this group. Thirty-seven of the 45
"medical" cases made an uncomplicated recovery on anti-
TB therapy. Three died due to generalised disease, 5 had
complications (chylous ascites 2, protein-losing enter-
opathy 3) and 3 had relapse of disease due to poor compli-
ance. The morbidity and mortality of this ubiquitous dis-
ease can be greatly reduced by timely diagnosis, which
often requires early recourse to diagnostic laparotomy, and
appropriate surgery and supportive care for complicated
disease.
Key words: Abdominal tuberculosis - Complications -
Surgical management
Offprint requests to: A. J. W. Millar
ur ery International
© Springer-Verlag 1990
Introduction
Abdominal tuberculosis (ATB) is still an important disease
in developing countries and immigrant populations
[1, 4, 7]. Its importance lies not so much in its incidence,
but because the diagnosis is often initially overlooked due
to nonspecificity and variability in clinical presentation
[10]. With delay in instituting antituberculous therapy mor-
bidity can be severe, however early and appropriate treat-
ment yields an excellent response. A T B has been less often
studied in the paediatric population. This paper supple-
ments previous reports on two series of patients with A T B
seen at the Red Cross Children's Hospital since 1961, and
concentrates on the role of the surgeon in the diagnosis and
treatment [2, 5].
Materials and methods
Records of all patients admitted to this hospital with a diagnosis of ATB
over the 10-year period 1980-1989 were reviewed. Patients were either
admitted directly to the surgical wards, referred to the surgeons from the
medical wards because of doubt in diagnosis or development of compli-
cations, or were managed entirely by the paediatricians. The patients
included in the study had the diagnosis established by: (1) histological
evidence from biopsy specimens obtained at laparotomy; or (2) proven
systemic or pulmonary TB with clinical and radiological features consis-
tent with ATB, with subsequent good clinical response to anti-TB drug
therapy. This latter group were almost exclusively managed by our
paediatricians. Patients received oral quadruple therapy of rifampicin,
isoniazid, pyrazinamide, and ethambutol till discharge either home or to
a TB hospital. Subsequent triple therapy was usually continued for a
minimum of 6 months.
Patients requiring surgical intervention were analysed with regard to
indications for surgery, area of residence (urban or rural), clinical presen-
tation, laboratory and radiological investigations, findings at operation,
complications, and surgical management strategies. The clinical features
of those treated by the surgical unit were compared to those treated on the
medical side. The long-term outcome of all patients was not obtained, but
in most cases follow-up hospital notes were available. Assessment of
morbidity of the complicated surgical group was made by noting the
number of days patients required parenteral nutrition and the total num-
ber of days in hospital.
 393

Table 1. Patient characteristics (n = 95) Table 2. Initial clinical presentation

Average age Sex Origin Surgical group Medical group Total

n = 50 (%) n = 45 (%) n = 95 (%)
No. Months M(%) F(%) Rural Urban
Symptoms
Surgical group 50 59 (6-144) 26 (52) 24 (48) 32 18
Anorexia and
Medical group 45 58 (9-144) 16 (36) 29 (64) 37 8 weight loss 30 (60) 31 (69) 61 (64)
Total 95 57 (6- 144) 42 (44) 53 (56) 69 26 Distension 29 (58) 20 (44) 49 (52)
Pain 26 (52) 13 (29) 39 (41)
Vomiting 20 (40) 20 (44) 40 (42)
Fever, night sweats 13 (26) 24 (53) 37 (39)
Results Diarrhoea 13 (26) 15 (33) 28 (29)
Ascaris infestation 10 (20) 5 (11) 15 (16)
During the period January 1980 through December 1989, Extra-abdominal
50 cases were seen in the surgical wards and 45 were symptoms (cough) 9 (18) 29 (64) 38 (40)
Constipation 6 (12) 3 (7) 9 (9)
treated by the paediatricians (Table 1). Ages ranged from
Blood in stools 4 (8) 4 (9) 8 (8)
6 months to 12 years with a mean of 59 months for both
groups. Sex incidence was equal in the surgical cases but Signs
females were more common amongst the medical cases. Abdominal distension 43 (86) 39 (87) 82 (86)
The majority of children in both groups came from rural Mass 28 (56) 26 (58) 54 (57)
areas (73%). Eighty per cent of all patients were under the Extra-abdominal (chest,
nodes, bone, meningitis) 9 (18) 29 (64) 28 (64)
3rd percentile for weight.
Hepatomegaly 8 (16) 22 (49) 30 (32)
Eighty children (85%) had been ill for more than Peritonitis 7 (14) 0 (0) 7 (7)
2 weeks. Thirty-nine (78%) presented to the surgical unit Ascites 4 (8) 15 (33) 19 (20)
as primarily an abdominal problem, compared with only 18 Doughy abdomen 3 (6) I4 (31) 17 (18)
(40%) of those presenting medically. The predominant Investigations
symptoms and signs are listed in Table 2. Abdominal dis-
Mantoux positive 27/33 (82) 27/34 (79) 54/67 (81)
tension was present in most and was often a presenting
Chest-evidenceof TB 24/50 (48) 34/45 (76) 58/95 (61)
complaint. Abdominal masses, present in more than one- Sedimentation rate
half of both groups although more commonly felt in the >30 mm ist h 24/27 (89) 28/33 (85) 52/60 (87)
right iliac fossa (18/54), were widely distributed Haemoglobin g/dl
throughout the abdomen, the second most common site (average) 9.3 8.8 9.0
being the peri-umbilical area. Ascites was an uncommon
finding in the surgical group but was clinically evident in
one-third of the medical group, and a doughy abdomen - a
classical textbook sign although only a clinical interpreta- were classified as predominatly peritoneal, 15 (30%)
tion - was rarely recorded in the surgical group. Extra- nodal, and 11 (22%) enteric. Enteric involvement incuded
abdominal TB - most often chest and nodal - was much all levels of the gastrointestinal tract: duodenum 1, jejunum
more evident in the group managed by the paediatricians alone 1, distal small bowel including multiple sites 7, with
(36/45, 80% with chest radiographic signs) as compared to caecum 3, distal colon 1, and rectum 1. There was consid-
26/50 (52%) in the surgical group. erable overlap and in 3 cases no conclusion could be
The Mantoux test, where recorded, was positive in reached as to emphasis of involvement.
81% and was regarded as diagnostic of active TB in the Seventy-seven of the 95 (81%) made an uncomplicated
under-5-year age group. The abdominal radiograph was recovery, attesting to the efficacy of anti-TB therapy. Com-
considered abnormal in 51 (54%) with non-specific fea- plications in the surgical group included intestinal obstruc-
tures of mass, incomplete obstruction, ileus, distended tion not responding to therapy in 7 (3 adhesive, 4 multiple
loops, and calcification being present. In 3 cases subdia- strictures), perforation with peritonitis in 4, abscess in 2,
phragmatic air was diagnostic of perforation. A barium enterocutaneous fistulae in 5, of which 3 followed laparot-
meal (n = 16) or enema (n = 9) was rarely used to confirm omy and biopsy, and fresh bleeding from colonic TB in
the diagnosis, but was considered suggestive of TB in 1 patient with factor V deficiency.
16 cases identifying areas of rigidity and stricture. Ultra- Ali but 6 of the 50 referred to the surgical unit under-
sound (US), however, was used with increasing frequency went some form of surgical intervention (Table 3).
and with other clinical evidence of active TB was used as The 13 patients presenting with complications, particu-
confirmation of the diagnosis of ATB by the paediatrici- larly perforation, abscess or fistulae, required multiple pro-
ans, nodal involvement being the positive feature in cedures and in this group the average hospital stay was
33/55 cases. Colonoscopy was used in 1 recent case of 67 days (range 11-205). Eleven of these patients received
colonic TB. Low weight, findings of anaemia (Hb <10 g/dl an average of 36 days of parenteral nutrition because of
in 60%), and low serum albumin (<35 mg/100 ml in either near-total obstruction, high-output fistulae, or fol-
60/70,) confirmed the generally poor condition of these lowing recovery from surgery. Where major complications
children at the time of presentation. existed a minimum of 8 weeks anti-tuberculous therapy
Of the 50 surgical cases where visual as well as clinical was felt necessary before definitive surgery was attempted.
confirmation of the pathology could be made, 21 (42%) Only 1 patient developed a further complication after
394

Table 3. Surgical management (n = 50)~ Discussion

No surgery
Extra-abdominal biopsy
Diagnostic laparotomy and peritoneal or node biopsy
Laparotomy and abscess drainage
Laparotomy and bowel resection and/or stricture plasty
Resuture wound dehiscence
Total
a Five patients required several procedures
definitive surgery (recun'ence of an enterocutaneous fistula
with subsequent spontaneous closure). Patients presenting
with perforation suffered the greatest morbidity, as sum-
marised in Table 4. In the surgical group all made a
complete recovery with none requiring readmission. Sig-
nificant complications encountered in the medically treated
group were chylous ascites in 2 and protein-losing enter-
opathy in 3. Three of the medical group died of diffuse
systemic disease (1 o f TB meningitis and 2 of pneumonia)
and 3 returned with some relapse of symptoms that was
thought to be due to poor compliance with therapy. They
responded well to appropriate medication.
6
4 Although programmes of bacille Calmette-Gudrin (BCG)
33 inoculation together with diligent contact follow-up have
4 nearly eliminated TB in developed countries, in immigrant
6 communities and developing countries, particularly in
1 rural populations, the disease is all too c o m m o n [8, 13].
54
Most childhood TB is spread through adult open pulmo-
nary TB, however a history of contact is only obtained in a
minority o f cases [13]. A T B presenting as distinct from
either diffuse systemic disease or pulmonary disease is
relatively rare, being more c o m m o n l y found in the 3rd and
4th decades [4, 10]. All ages are at risk and the incidence
in Cape T o w n is increasing, viz. 55 cases referred in a
19-year period and 50 in the following 10 years [2]. In
addition, an almost equal number o f patients were man-
aged entirely by our paediatricians. In this group local
histological confirmation of the diagnosis was not
routinely obtained, but when clinical, radiological, and US
evidence was very suggestive a trial of drug treatment was
considered justified, most patients responding within a
week o f c o m m e n c i n g therapy.
Abdominal and chest radiographs or occasional con-
trast examinations were helpful in diagnosis, especially of
associated pulmonary TB. In most instances US proved

Table 4. Features of 4 cases of abdominal tuberculosis with perforation

Case Sex Age Clinicalfeatures
(months)
1. M 60 Known TB contact, 3 days
pain and bloody stools.
Soft, tender, distended abdomen,
Radiology: subdiaphragmatic air
2. F 20 Known TB contact. Failure to Mid-ileum
thrive, fever, cough,
diarrhoea and vomiting,
abdominal distension, 3 weeks
in hospital treatment for TB.
Sudden onset peritonitis.
3. M 6 Abandoned child. Gross
malnutrition, miliary TB.
Established peritonitis.
Radiology: subdiaphragmatic
air
4. F 33 Miliary TB. 'Gastroenteritis'.
Treated for TB × 3 months.
Failed to thrive but no
symptoms. Sudden onset
acute abdomen.
Radiology: subdiaphragmatic
air.
Perforation Operative Findings Surgery Outcome
(days in hospital)
Ileal x 2 1. Faeculent peritonitis. 1. Excision of Well (36)
Perforated ulcers and ulcer perforations
suppurating nodes, with simple 2-layer
AFB on culture closure and chain,
and microscopy. Faeculent discharge
x 14 days
1. Gross faeculent 1. Simple closure.
peritonitis. Bowel very PeritonealIavage.
friable, matted together 2. Peritoneal toilet.
2. Wound infection. Drainage. Well (156)
3. Multiple fistulae. 3. Resection of segment
Multiple faecal collections, of ileum with multiple
Adhesions. F r i a b l e entero-cutaneous
but healthy bowel fistulae
Ileo-caecal 1. Gross faeculent 1. Ileo-caecal resection
peritonitis, and ileostomy.
Caseating nodes.
2. Wound dehiscence. 2. Re-suture. Well (205)
3. Adhesions ++. 3. Closure of ileostomy.
Caseating nodes. 4. Drainage of faecal
4. Anastomotic leak collection with
spontaneous closure,
19 days
Mid-ileum 1. Multiple fibrotic 1. Small-bowel resection Well (39)
small bowel strictures with anastomosis x 4.
with perforation at Stricture-plasty × 2.
most proximal stricture. Formal jejunostomy.
Gross proximal hyper- 2. Closure of stoma
trophy of bowel.
Internal fistula at
ileo-caecal junction

AFB = acid-fast bacillae


helpful in management decisions, especially in the pres-
ence of extra-abdominal TB.
Contrary to previous reports, most of the Mantoux tests
were positive. Where recorded, the erythrocyte sedimenta-
tion rate was raised and anaemia was present in nearly all
cases. Low serum albumin in 86% also confirms the poor
nutritonal state of these patients, which probably indicates
both a population at risk and the effects of a debilitating
disease.
Colonoscopy and biopsy has been advocated as a diag-
nostic modality, but its use is restricted to suspected enteric
TB of the colon and ileo-caecal region [12]. Laparoscopy
has been recommended for diagnosis, but because of mul-
tiple adhesions and bowel matting laparotomy and open
biopsy have been preferred [15].
In the surgical group with abdominal disease histologi-
cal confirmation should be obtained before embarking on
long-term anti-TB therapy. To emphasize this point, the
records of 30 cases of abdominal lymphoma seen at our
hospital during the same 10-year period were reviewed. In
7 of these ATB was the initial clinical diagnosis; 3 received
anti-TB therapy for 1, 2, and 1.5 months before crescendo
symptoms prompted referral for laparotomy and open bi-
opsy. All 3 had massive tumour load at the time of diagno-
sis. Similarly, of the 50 surgical cases seen lymphoma
could not be confidently excluded on clinical grounds in
most, as the presenting symptoms of both diseases are
variable and non-specific and were only helpful in localis-
ing the disease to the abdomen.
Thus, indications for surgery were: (1) to obtain tissue
for histopathological diagnosis, either by extra-abdominal
nodal biopsy or the smallest possible laparotomy to obtain
a representative sample of involved peritoneum or lymph
node; (2) exploratory laparotomy for acute complications;
and (3) definitive management of complications, e.g.
fistulae, stricture, and obstruction.
One-half of the patients had a purely diagnostic lapa-
rotomy and biopsy. In this situation one must be particu-
larly careful on entering the abdomen, as the peritoneum is
thickened and oedematous and adherent to the abdominal
wall. On two occasions bowel was inadvertently opened
during a diagnostic laparotomy; 1 patient developed an
enterocutaneous fistula. No other complications were
noted in this group and all responded rapidly to drug ther-
apy.
Great care must be taken at laparotomy in separating
bowel loops or obtaining representative lymph node biop-
sies. Two referred cases following exploratory laparotomy
done elsewhere for non-specific symptoms developed mul-
tiple entero-cutaneous fistulae. Once a fistula or faecal
collection is apparent, management is along established
lines with adequate drainage of intra-abdominal collec-
tions, parenteral nutritional support, antibiotics for abdom-
inal wall cellulitis and peritonitis, as well as anti-TB drug
therapy. These are usually high-output fistulae because of
distal bowel obstruction. As oral medication was initially
precluded in this group, we used intravenous rifampicin
and intramuscular streptomycin initially. Quadruple oral
drug therapy was instituted as soon as possible and strepto-
mycin discontinued. The patients developing complica-
tions (perforation/obstruction) were all very ill, with many
395
requiring weeks to months of intensive care and parenteral
nutritional support as well as multiple operative pro-
cedures. Definitive surgery for the fistulae and strictures
was delayed until nutritional parameters had been restored
and at least 8 weeks of anti-TB drug therapy had been
given.
Abdominal TB is classically divided into peritoneal
(wet and dry, lymph node) and enteric forms according to
the predominent pathology [1]. However, there is often
significant overlap in any one patient. In the surgical group
of peritoneal TB (22 cases), all made a rapid recovery after
diagnostic biopsy except 1) where bowel was entered and a
fistula developed, and 2) with complete bowel obstruction
who required lysis of serosal tuberculomatous adhesions.
In those patients presenting to the paediatricians peritoneal
TB was more common, although clinical differentiation
between the ascitic form and the adhesive form was indis-
tinct. Ascites was present in 33% and in 2 cases was chy-
lous in nature. Predominantly nodal TB (16 surgical cases)
was not associated with complications in this series, al-
though adhesive obstructions are commonly described
[3, 7].
Enteric TB was found throughout the gastro-intestinal
tract. In the acute phase perforation, haemorrhage, or pro-
tein-losing enteropathy were the predominant presenta-
tions. Although many patients initially had incomplete ob-
stuction, nearly all healed completely without sequelae,
strictures requiring surgery in only 4 cases. In 2 of these, 6
and 13 strictures were identified respectively and required
multiple resections and stricture-plasties [6, 9]. Perforation
of the bowel occurred in the acute phase in only 2 cases and
was delayed in a further 2, but resulted in the greatest
morbidity (Table 4). The perforation may be localised and
confined by matted bowel loops, the resulting abscess pre-
senting as an area of inflammatory oedema of the abdomi-
nal wall initially. If untreated, it may discharge either into
adjacent bowel or externally, most commonly adjacent to
the umbilicus [2]. Free perforation with acute peritonitis
was rare and usually implied extensive enteric involvement
and a degree of distal obstruction. At operation in the
untreated child, minimal dissection should be performed.
Although simple closure has been advocated, if there is
extensive involvement it might be wiser to exteriorize the
affected loop [11]; a controlled fistula is then achieved.
Prior to closure of the stoma a distal loopogram is done to
identify strictures that can be dealt with at the same time.
Dissection of bowel loops at initial surgery is likely to
result in fistulae discharging through a dehisced wound -
2 of our cases required months of intensive care and paren-
teral nutrition. Both cases required operative resection of
the fistulae, release of adhesions, and resection of distal
strictured bowel before a satisfactory outcome was
achieved. Bypass procedures are not recommended [7].
Although none of the children presenting to the surgi-
cal unit died and recurrence of disease after full therapy has
not occurred, the resources required to treat complicated
disease are immense. Thus, emphasis must be laid not only
on prevention in the first instance, which is a priority
public health item in most developing countries, but also
on early diagnosis and treatment. The spectrum of presen-
tation is varied, TB being the great mimicker. Any child
396
with a b d o m i n a l symptoms and a distended abdomen, par-
ticularly if showing evidence of m a l n u t r i t i o n or c o m i n g
from an e n d e m i c area or i m m i g r a n t population, should be
j u d g e d to have A T B until proven otherwise. Not only must
other pathology, e.g. l y m p h o m a or C r o h n ' s disease, be
excluded, but to e m b a r k on treatment without a firm diag-
nosis c o n d e m n s the patient to either protracted unneces-
sary treatment or to delay in the true diagnosis [14]. Thus,
no apology is made for early recourse to laparotomy. The
prognosis is excellent if treatment is c o m m e n c e d early in
the course of the disease, mortality b e i n g associated with
generalised disease. With supportive care and appropriate
surgery complications can be successfully managed.
Acknowledgements. The authors thank Ms. J. Melis for correlation of
data and Ms. P. Ball for typing of the manuscript.
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