Gastroenterology Surgery
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TB is a common disease in developing countries, and is reappearing in developed countries as a result of AIDS and migration of population. This is amongst the ten leading causes of death and one of the commonest cause of death in the young. This scenario is not as bad in a case of abdominal TB and more so of colon.
Abdomen is a common site of extra pulmonary TB, but pre-operative diagnosis is difficult. In areas and populations in which TB is uncommon, it is often missed and where TB is common, it is often over diagnosed.
It is very difficult to isolate colonic TB from in general abdominal TB, which can affect the gastro intestinal tract, peritoneum, lymphnodes of mesentery or solid viscera. e.g. liver, spleen, pancreas. The GI tract is involved in 66-75% of cases of abdominal TB, the terminal ileum and ileo-caecal region are commonest sites, followed by jejunum, and colon. Multiple sites are common and most patients with GI lesions also have peritoneum and lymphnodes involvement.
Incidence
The incidence of abdominal TB is increasing globally with the spread of AIDS. Out of this exact incidence of colonic TB is difficult as there is mostly overlapping of all forms of abdominal TB. Incidence is high in Indian subcontinent. The disease may remain quiscent for years, becoming reactivated later, when the host defence mechanism is suppressed because of factors such as old age, poor nutrition, diabetes, alcoholism and corticosteroids or other immune suppressive drugs.
Clinical Features
TB has an insidious onset and most patients have had symptoms for months or even years. In about one third of patients, this chronic course is interrupted by acute attacks, which may lead to presentation. Acute presentations include intestinal obstruction, perforation or peritonitis, also as massive lower GI bleeding.
Usually there are two types of lesion in colon.
A. Ulcero-hypertrophic
B. Hypertrophic
Ulcerative lesions have diarrhoea, malabsorption leading to anaemia, hypoproteinaemia and vitamins deficiency. Small amount of lower GI bleeding is not uncommon.
Subacute intestinal obstruction presents recurrent distension, pain and vomiting which resolves spontaneously or by conservative treatment. Mass is caused by hypertrophic tuberculosis mainly of ileo-caecal region which is palpable at right iliac fossa, and is usually firm, mobile and mildly tender.
There is associated pyrexia, anorexia and weight loss. In patients with miliary TB, there can be tubercular toxaemia, characterised by high grade fever, tachycardia and leucocytosis.
TB should be considered in patient with chronic unexplained abdominal symptoms and pyrexia of unknown origin, specially in areas and population where incidence is high.
Investigations
A.Blood
Haemogram and ESR
B.Imaging
Includes X-ray chest, abdomen.
Barium studies includes meal follow through, enteroclysis and double contrast enema.
Radiological findings are suggestive but not definitive. Chest radiograph should be obtained in a suspected case of colonic TB, as evidence of pulmonary TB supports the diagnosis. Plain X-ray abdomen is useful in intestinal obstruction and perforation.
Ultrasonography and CT may demonstrate thickening of bowel loops or hypertrophic masses and if associated ascites or lymph nodes.
C.Colonoscopy
Colonoscopy is very important to get tissue diagnosis.
D.Histopathology
Though the demonstration of acid fast bacilli is of definite diagnosis, but is difficult to demonstrate so the diagnosis rests on histology. Tissue for histology can be obtained by colonoscopy and percutaneous fine needle aspiration cytology (FNAC) from abdominal mass either direct, ultrasound or CT guided. Characteristic histological picture includes epithelioid cell granulomas with peripheral rim of lymphocytes and plasma cells, Langhan's giant cells and central caseating necrosis. Fibrosis and calcification are seen in healing lesions.
E.Serological Tests
E.g. Tuberculin test, soluble antigen fluorescent antibody, enzyme linked immunosorbent assay may indicate the diagnosis but are not very helpful.
Differential Diagnosis
Most important DD in developing countries is from carcinoma and in developed countries from Crohn's disease and carcinoma.
Management
Antitubercular therapy for abdominal or colonic tuberculosis is the same as that of pulmonary TB. Nowadays short course therapy of 6 to 9 months is recommended which includes rifampicin, isoniazid, pyrazinamide and ethambutol. All four drugs for two months and rifampicin-isoniazid for rest of the period.
It is important to complete the course in proper doses and duration to prevent multidrug resistance TB. Surgery is indicated in colonic TB only if diagnosis is in doubt to rule out carcinoma or there is obstruction or perforation. Surgery is also restricted to limited segmental resection.
Prognosis
Over all prognosis has markedly improved as a result of advances in diagnostic methods, better antitubercular drugs and safer surgical procedures. Still there are mortality and morbidity. Recurrence of disease is a major problem.
Tubercular Proctitis
This is nearly always associated with active pulmonary TB, and is often complicated by a tubercular fistula in ano, or tuberculous ulceration of the anus. Submucous rectal abscesses burst and leave ulcers with an undermined edge.
A hypertrophic type of tubercular proctitis occur in association with tuberculous peritonitis or salpingitis and this requires biopsy for confirmation of diagnosis.
Tuberculous Fistula In Ano
If induration around a fistula is lacking, if the opening is ragged and flushed with surface, if surrounding skin is discoloured and the discharge is watery, it strongly suggests that the fistula is due to the tuberculous infection. In more than 30% of patients suffering from pulmonary TB virulent tubercle bacilli are present in rectum. About 2-3% of fistula in ano are tuberculous, but in sanatoria and settlements for tuberculosis patients, the incidence is higher. Histology is the only diagnostic criteria, other than microscopic demonstration of Acid fast bacilli, and will respond to anti TB drugs alone most of the time.
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