Evidence-based approach to diagnosis and management of abdominal tuberculosis

Abstract

Abdominal tuberculosis is an ancient problem with modern nuances in diagnosis and management. The two major forms are tuberculous peritonitis and gastrointestinal tuberculosis (GITB), while the less frequent forms are esophageal, gastroduodenal, pancreatic, hepatic, gallbladder and biliary tuberculosis. The clinicians need to discriminate the disease from the close mimics: peritoneal carcinomatosis closely mimics peritoneal tuberculosis, while Crohn's disease closely mimics intestinal tuberculosis. Imaging modalities (ultrasound, computed tomography, magnetic resonance imaging and occasionally positron emission tomography) guide the line of evaluation. Research in diagnostics (imaging and endoscopy) has helped in the better acquisition of tissue for histological and microbiological tests. Although point-of-care polymerase chain reaction-based tests (e.g. Xpert Mtb/Rif) may provide a quick diagnosis, these have low sensitivity. In such situations, ancillary investigations such as ascitic adenosine deaminase and histological clues (granulomas, caseating necrosis, ulcers lined by histiocytes) may provide some specificity to the diagnosis. A diagnostic trial of antitubercular therapy (ATT) may be considered if all diagnostic armamentaria fail to clinch the diagnosis, especially in TB-endemic regions. Objective evaluation with clear endpoints of response is mandatory in such situations. Early mucosal response (healing of ulcers at two months) and resolution of ascites are objective criteria for early response assessment and should be sought at two months. Biomarkers, especially fecal calprotectin for intestinal tuberculosis, have also shown promise. For most forms of abdominal tuberculosis, six months of ATT is sufficient. Sequelae of GITB may require endoscopic balloon dilatation for intestinal strictures or surgical intervention for recurrent intestinal obstruction, perforation or massive bleeding.

Intestinal tuberculosis can masquerade as Crohn’s disease: A teachable moment

“…Though a strong clinical picture, an absence of caseating granuloma in pathologic findings and a negative tuberculin skin test point toward diagnosis of CD; intestinal biopsy sample should have been sent for AFB stain or culture from the first colonoscopy. 17…”

“…It has a good diagnostic accuracy with sensitivity and specificity of 96.7% and 90.7%, respectively. 17…”

Digestive Tract Tuberculosis Guidelines—The Missing Link

“…In this, patients can have probable, possible, or confirmed abdominal TB diagnosis based on certainty of evidence and would help in choosing a strategy for follow-up of these patients. 2 Response assessment to antitubercular therapy in cases with probable TB has been advocated by Logan in establishing the diagnosis of abdominal TB. 3 In cases with peritoneal TB with ascites, authors have supported empirical anti tubercular therapy when the adenosine deaminase (ADA) value is > 30 IU/mL.…”

“…Their findings highlight patient and device-related complications and significantly contribute to our understanding of Hemospray's application in gastrointestinal (GI) bleeding scenarios. 2 The study's strength lies in its comprehensive overview of the adverse events, from continued GI bleeding to device malfunctions. However, a few aspects warrant further consideration.…”

“…It is extremely important to recognize that a microbiologically confirmed diagnosis of abdominal TB is not always possible, hence a hierarchical approach that may be more clinically applicable. In this, patients can have probable, possible, or confirmed abdominal TB diagnosis based on certainty of evidence and would help in choosing a strategy for follow-up of these patients 2 . Response assessment to antitubercular therapy in cases with probable TB has been advocated by Logan in establishing the diagnosis of abdominal TB 3 …”