Diagnosing abdominal tuberculosis in the acute abdomen

Kerry A. Burke a,*, Ashish Patel b, Ajitha Jayaratnam c, Kumaran Thiruppathyc, Steven J. Snooks c
a Barts and The London School of Medicine and Dentistry, Queen Mary University of London, Student Office, Garrod Building, Turner
Street, Whitechapel, London E1 2AD, UK
b University of Southampton, Medical School, Builging 85, Life Sciences Building, Highfield Campus, Southampton SO17 1BJ, UK c

King George Hospital, Barley Lane, Goodmayes, Essex IG3 8YB, UK

M. Fadhly (1210070100133)

Pembimbing:
Dr. Erina Outry Siregar Sp. B (k) BD
Abstrak

 Latar belakang: Meskipun telah tedapat kemajuan terbaru dalam

penatalaksanaan medis, insidensi tuberkulosis abdominalis (TB) di
Inggris telah meningkat selama dua dekade terakhir. Serial kasus ini
meneliti kesulitan yang ditemukan dalam mendiagnosis infeksi ini
dengan tepat.
 Pasien dan metode: Dilakukan sebuah penelitian retrospektif, dengan
meninjau catatan 36 pasien yang didiagnosis dengan ATB dari tahun
2000 hingga 2012 di rumah sakit umum daerah di Outer East London.
Pendahuluan

 Tuberkulosis (TB) merupakan suatu penyakit infeksius yang insidensinya

semakin meningkat di Inggris, dengan sekitar 8000 kasus pada tahun
2005, yang bertambah menjadi 8693 kasus di tahun 2011.
Mycobacterium tuberculosis didapat melalui jalur aerosol dan paling
sering mengenai paru.
 TB abdominalis (ATB) diyakini menyusun sebesar 4.9% kasus TB dan
dapat terbukti memperlihatkan tantangan diagnostik, karena dapat
terlihat dengan gejala yang samar dan nonspesifik dan menyerupai
patologi intaabdomen lain yang lebih sering ditemukan.
Metode
Patient Age Sex Birth place Occupation Presenting symptoms Impression at
presentation
Case 1 37 Female Uganda Health care worker Ascites Unclear
Case 2 47 Female Pakistan Unemployed Pyrexia of unknown origin Unclear
Case 3 34 Male Bangladesh Shop worker Change in bowel habit Crohn’s disease
Case 4 28 Female Morocco Unemployed Abdominal pain Unclear
Case 5 29 Female India Microbiologist Ascites and abdominal pain Unclear
Case 6 30 Male India Software engineer Abdominal pain Unclear
Case 7 32 Female Pakistan Health care worker Abdominal pain Unclear
Case 8 25 Female Kenya Health care worker Abdominal pain and change in bowel habit Unclear
Case 9 30 Male India Pharmacy technician Abdominal pain Unclear
Case 10 30 Male United Kingdom IT consultant Abdominal pain Unclear
Case 11 62 Female Pakistan Retired Ascites Unclear
Case 12 85 Female Mauritius Retired Abdominal pain Unclear
Case 13 31 Female Kenya Student midwife Ascites and change in bowel habit Unclear
Case 14 37 Male United Kingdom Accountant Right groin swelling Unclear
Case 15 37 Male United Kingdom Cab driver Abdominal pain and weight loss Crohn’s disease or
lymphoma
Case 16 39 Female Pakistan Housewife Ascites, change in bowel habit and weight loss Crohn’s disease
Case 17 24 Female Pakistan Shop worker Ascites and change in bowel habit Unclear
Case 18 19 Male Sri Lanka Student Ascites and change in bowel habit Crohn’s disease
Case 19 39 Female Philippines Health care worker Abdominal pain and ascites Unclear
Case 20 22 Male United Kingdom Student Abdominal pain and ascites Unclear
Case 21 22 Male Pakistan Student Abdominal pain Unclear
Case 22 59 Female India Retired Abdominal pain, weight loss and tiredness Ileitis
Case 23 36 Male Germany Health care worker Abdominal pain and ascites Unclear
Case 24 25 Female Unknown Health care worker Abdominal pain and ascites Unclear
Case 25 77 Female India Retired Unknown Unclear
Case 26 34 Female India IT developer Abdominal pain Crohn’s disease
Case 27 34 Male Eritrea Asylum seeker Weight loss, fever and dyspnoea Unclear
Case 28 25 Female India Housewife Ascites and change in bowel habit Unclear
Case 29 26 Female Sri Lanka Student Abdominal pain Unclear
Case 30 29 Female Sri Lanka Housewife Night sweats, cough and ankle oedema Unclear
Case 31 27 Female Pakistan Housewife Unknown Unclear
Case 32 19 Male Sri Lanka Student Abdominal pain, weight loss and rectal bleeding Unclear
Case 33 31 Male Gambia Unemployed Ascites Unclear
Case 34 28 Male India Software engineer Abdominal pain, change in bowel habit and weight loss Crohn’s disease
Case 35 33 Male India Civil engineer Abdominal pain Unclear
Case 36 35 Male India Construction worker Abdominal pain Unclear
Diskusi

 Insidensi tuberkulosis di Inggris (UK) telah mennjukkan tidak adanya

tanda-tanda penurunan selama dua dekade terakhir, dengan
peningkatan insidensi pada kelompok dengan sosioekonomi rendah dan
masyarakat migran dari anak benua Asia dan Afrika subsahara
 Serial kasus ini menyoroti masalah penting yang muncul ketika
berupaya untuk mengidentifikasi TB dengan tepat.
Tampilan pasien
Pemeriksaan pasien
Case 1 Laparoscopy biopsy of Normal Normal CT Abdomen: large volume of ascitic fluid and Not done
peritoneum thickening of the greater omentum and
peritoneum
Case 2 Mediastinoscopy Not done Not done CT Chest and Abdomen: mediastinal Not done
lymphadenopathy, hepatosplenomegaly and enlarged
para-aortic lymph nodes
Case 3 Not available Normal Normal Not available Ulceration and irregular edges
in the rectal region
Case 4 Laparoscopy Not done Not done CT Abdomen: para-aortic lymphadenopathy with Not done
central necrosis, several prominent mesenteric lymph
nodes
Case 5 Laparoscopy (in India) Not done There is a small CT Abdomen: gross ascites with several enlarged Not done
Ultrasound and aspiration left pleural effusion lymph nodes in a left para-aortic location
Case 6 N/A Normal Normal Not available Ileocaecal inflammation
Case 7 Laparoscopy Not done Not done CT Abdomen: thickening of the ileocaecal junction Not done
Case 8 CT guided retro-peritoneal biopsy Not done Not done CT chest and abdomen: Abdominal free fluid and Normal bronchoscopy
and abdominal aspiration lymphadenopathy
Case 9 Appendicectomy and ileocolic Not done Not done Ultrasound of abdomen: normal. Not done
resection
Case 10 Laparoscopic removal of abdominal Not done Bilateral apical CT Chest and Abdomen: gross ascites and Not done
mass pleural thickening extensive infra-diaphragmatic lymphadenopathy
Case 11 Laparotomy and ileocolic resection Not done Not done Not available Not done
Case 12 Laparotomy Not done Not done CT Abdomen: diffuse moderate ascites is noted with Not done
diffuse mesenteric and omental fat stranding
Case 13 N/A Not available Not done CT Chest and Abdomen: mediastinal Not done
lymphadenopathy. Free fluid in the abdomen and
several prominent lymph nodes
Case 14 Exploration of right groin lump Not done Not done CT Abdomen: diffuse lymphadenopathy with necrotic Not done
nodes involving the abdomen
Case 15 Laparoscopy Not done Not done Not done Inflamed terminal ileum,
patchy inflammation of the colon
Case 16 N/A Not done Not done Not done Caecal lesion
Case 17 Right groin lymph node biopsy Not done Not done CT Abdomen: large volume ascites and diffuse Gastric ulcer
thickening of the proximal small bowel
Case 18 N/A Not done Not done CT Chest and Abdomen: extensive cavitating Normal colonoscopy
consolidation in the left upper lobe and extensive
mediastinal and bilateral hilar lymphadenopathy
Case 19 Laparoscopy Not done Not done CT Chest and Abdomen: calcified soft tissue nodule Not done
in the left lung apex, significant ascites
Case 20 N/A Not done Not done CT Chest and Abdomen: mild inflammatory changes Normal colonoscopy
in the left lung base. Mucosal thickening of the small
bowel with para aortic lymphadenopathy
 lymphadenopathy. Significant free fluid in
the abdomen
CT Chest and Abdomen: multiple
retroperitoneal lymphadenopathy,
peritoneal thickening and large ascites
CT Chest and Abdomen: bilateral basal
atelectasis and small bilateral pleural
effusions.
Ascites and small bowel dilatation. CT
Chest and Abdomen: diffuse
lymphadenopathy in the mediastinum
and multiple focal lesions within the
spleen. CT Chest and Abdomen: diffuse
nodularity in both lungs in a military
pattern, small left pleural effusion
CT Chest and Abdomen: inguinal lymph
node and left axilla lymph node
enlargement. CT Chest and Abdomen:
small bowel thickening, free ascitic fluid
and lymphadenopathy Not available Not done
Laparoscopy Not done
Case 28 Not done CT Chest and Abdomen:
Not done
Not done lymphadenopathy in the epigastrium and
Laparoscopy and
Case 29 Not done retroperitoneum
appendicectomy Normal bronchoscopy.
CT chest and abdomen: tuberculous
Not done Gastroscopy: duodenal
Case 30 N/A Not done peritonitis
strictures
Not done Not done
Case 31 N/A Not done

Not done Normal colonoscopy

Case 32 N/A Not done
Large bilateral Not done
Case 33 Laparoscopy Not done
pleural effusion
Necrotising granulomas
Case 34 N/A Not done Not done
and inflammation on
Case 35 Laparotomy Not done Not done colonoscopy Not done

Case 36 Laparotomy Not done Not done Not done

Patient Histology: report Microbiology: site Microbiology: TB Site of ATB
report
Case 1 Non-specific chronic inflammation Ascitic fluid Positive Large bowel
Case 2 Caeseating granulomas Bronchial washing Negative Liver, skin, mediastinal lymph nodes
Case 3 Rectal ulcer Rectal biopsy Negative Rectum
Case 4 Multiple necrotising and non-necrotising Lymph node and pus Negative Omentum
granulomas
Case 5 Not taken Ascitic fluid Positive Peritoneum
Case 6 Not taken Not available Negative Ileocaecal junction
Case 7 Not taken Not available Negative Ileocaecal junction
Case 8 Normal Abdominal fluid aspirate and Positive Retro-peritoneum
bronchial washing
Case 9 Necrotising granulomatous ileus Not available Negative Ileocaecal junction
Case 10 Multiple necrotising and non-necrotising Not available Negative Peritoneum
granulomas
Case 11 Caeseating granulomas Ascitic fluid Positive Ileocaecal junction
Case 12 Caeseating granulomas Ascitic fluid Negative Peritoneum
Case 13 Not available Sputum culture Positive Peritoneum and lungs
Case 14 Caeseating granulomas Tissue biopsy and pus Positive Lymph node
Case 15 Crohn’s disease Tissue biopsy Negative Ileocaecal junction
Case 16 Crohn’s disease Ascitic fluid Positive Ileocaecal junction
Case 17 Reactive hyperplasia Ascitic fluid and lymph node Positive Ileocaecal junction
biopsy
Case 18 Granulomas Bronchial washings and tissue Positive Ileocaecal junction
biopsy
Case 19 Normal Ascitic and peritoneal fluid Negative Peritoneum
Case 20 Not taken Not available Negative Ileocaecal junction
Case 21 Not taken Bronchial washings and sputum Positive Ileocaecal junction
culture
Case 22 Granulomas Tissue biopsy Positive Ileocaecal junction
Case 23 Chronic inflammation and tissue necrosis Tissue Biopsy Positive Peritoneum
Case 24 Not available Ascitic fluid Normal Peritoneum
Case 25 Abscess Not available Negative Unknown
Case 26 Not available Bronchial washings Positive Ileocaecal junction
Case 27 Caeseating granulomas Pleural fluid Positive Ileocaecal junction
Case 28 Granulomas Pleural fluid Positive Peritoneum
Case 29 Caeseating granulomas Tissue Biopsy Positive Peritoneum
Case 30 Non-specific chronic inflammation Bronchial washings Positive Pulmonary
Case 31 Caeseating granulomas Tissue and peritoneal biopsy Positive Unknown
Kesimpulan
 Gambaran klinis yang paling sering terlihat adalah nyeri abdomen, diikuti
dengan asites dan penurunan berat badan
 Gambaran lain mencakup perdarahan per rektal, perubahan kebiasaan buang
air besar, batuk, letargis atau sesak napas. Tampilan akut abdomen relatif
nonspesifik
 Sifat tampilan klinis ATB menunjukkan bahwa ini dapat menyerupai penyakit
lainnya seperti penyakit Crohn, karsinoma kolorektal, sarkoma, dan abses
periapendiks
 Tempat tersering untuk ATB adalah tautan ileosekal
 Radiologi tampak sangat tidak membantu karena non-spesifisitas temuan
pencitraan yang positif, dan terdapat kurangnya pemeriksaan tindakan
diagnostik dan mikrobiologi dengan spesifisitas dan sensitivitas yang tinggi.
 Laparotomi diagnostik telah terbukti merupakan prosedur diagnostik yang
paling efektif untuk ATB