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ABDOMINAL TUBERCULOSIS PRESENTING AS

INTESTINAL OBSTRUCTION

Article · June 2015

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Ann Biomed Sci. Vol 14, No. 2, June, 2015

ABDOMINAL TUBERCULOSIS PRESENTING AS INTESTINAL

OBSTRUCTION- CASE SERIES

*N.J Nwashilli , O.O Osewengie

Department of Surgery
University of Benin Teaching Hospital, Benin City, Edo state, Nigeria

*Corresponding author
E-mail: namoforever@yahoo.com
Mobile Phone: +2348037214386

ABSTRACT
Abdominal tuberculosis is one of the most common types of extra-pulmonary tuberculosis
and accounts for 3-4% of the extra-pulmonary tuberculosis. Abdominal tuberculosis can
mimic a variety of other abdominal diseases; hence a high index of suspicion is required to
make the diagnosis.
One of the complications of abdominal tuberculosis is intestinal obstruction, which can be
acute, chronic or acute on chronic. Other complications include intestinal haemorrhage,
perforation of the intestine (rare), faecal fistula, cold abscess formation, mal-absorption
syndrome and dissemination of the tuberculosis to other areas of abdomen and extra-
abdominal sites. The presence of intestinal obstruction may be an indication for surgery if the
obstruction is complete. However, in partial obstruction, treatment with anti-tuberculous
drugs may lead to resolution of the obstruction.
We present four cases of abdominal tuberculosis that presented with partial intestinal
obstruction that were successfully treated with anti-tuberculous therapy without recourse to
surgical treatment.

Introduction Abdominal tuberculosis can occur

Abdominal tuberculosis is the 6th most primarily following ingestion of milk or
common type of extra-pulmonary food contaminated with Mycobacterium
1
tuberculosis . Extra-pulmonary bovis or it can occur secondarily due to a
tuberculosis accounts for 11-16% of all tubercular focus elsewhere in the body
patients with tuberculosis, out of which 3- caused by infection with Mycobacterium
4% belong to abdominal tuberculosis2. tuberculosis. It can mimic a variety of
Abdominal tuberculosis comprises other abdominal diseases. A high index of
tuberculosis of gastrointestinal tract, suspicion can help in the diagnosis;
peritoneum, omentum, mesentry, lymph otherwise it is likely to be missed or
nodes and other abdominal organs such as delayed, resulting in high morbidity and
liver, spleen and pancreas. mortality.

* Corresponding Author 1
N.J Nwashilli et al
A complication of abdominal tuberculosis
is intestinal obstruction which can be
acute, chronic or acute on chronic1. Other
complications are intestinal haemorrhage,
perforation of the intestine (rare), faecal
fistula, cold abscess formation, mal-
absorption syndrome and dissemination of
the tuberculosis to other areas of abdomen
and extra-abdominal sites1. The presence
of intestinal obstruction may be an
indication for surgical intervention
especially if obstruction is complete.
However, in the presence of partial
intestinal obstruction, treatment with anti-
tuberculosis may lead to a resolution of the
obstruction.
We present four cases of abdominal
tuberculosis that presented with partial
intestinal obstruction. The purpose of this
study is to emphasize how a high index of
suspicion coupled with laboratory
findings, radiological imaging and
treatment with anti-tuberculous drugs led
to avoidance of surgery for these patients
with a good outcome.
Case presentation
Case 1
O.A, a 21-year old female university
undergraduate presented via Surgical
Outpatient Clinic with a year history of
progressive abdominal swelling, chronic
constipation and recurrent abdominal pain.
Abdominal pain started gradually, located
in the lower abdomen, colicky, mild in
intensity, worsened by intake of meals and
relieved after passing stool. There was a
change in bowel habit in favour of
constipation as she passed hard stool
infrequently. She had an episode of
vomiting a week before presentation.
Ann Biomed Sci. Vol 14, No. 2 June, 2015
Vomitus contained recently ingested
meals, neither bilious nor blood stained.
She had reduced appetite and weight loss.
There was no history of fever, cough, chest
pain or difficulty in breathing. There was
no history of ingestion of unpasteurized
milk. A review of the other systems was
normal. She had a right lower abdominal
pain three years earlier, following which
she had appendicectomy. At operation,
there was a copious straw-coloured fluid
drained which was not sent for laboratory
examination. The removed appendix was
confirmed on histology as normal.
Physical examination revealed a
chronically ill-looking lady, not pale,
afebrile, anicteric, not dehydrated, with
neither pedal edema nor peripheral
lymphadenopathy. Abdomen was
markedly distended with generalized
multiple scarification marks and
tenderness in the lower aspect. Organ
enlargement could not be assessed due to
massive ascites demonstrable by fluid
thrill. Bowel sound was hypoactive.
Rectum contained hard faeces.
Examination of other systems was normal.
The investigations done for the patient are
shown in Tables 1 and 2. She was
commenced on anti-tuberculous therapy
(pyrazinamide, rifampicin, isoniazid and
ethambutol) with remarkable clinical
improvement, evidenced by gradual
regression of abdominal swelling and
resolution of abdominal pain. She is
presently on follow-up in Surgical
Outpatient Clinic; to complete anti-
tuberculous drugs for two years.
2
 Abdominal Tuberculosis Presenting As Intestinal Obstruction- Case Series
Case 2
E.O, a 27-year old female petty trader
presented via Surgical Outpatient Clinic
with 3-month history of progressive
abdominal swelling and constipation. She
noted a central abdominal pain, insidious
in onset, colicky, non-radiating, moderate
in intensity, worsened after intake of meals
and relieved after passing stool. There was
no history of vomiting or passage of
blood/mucus in the stool. There was a
positive history of anorexia, night sweats
and weight loss, but no fever, cough, chest
pain or difficulty in breathing. A review of
other systems was normal.
Physical examination revealed a young
lady, chronically ill-looking, pale, afebrile,
anicteric, not dehydrated, with neither
pedal edema nor peripheral
lymphadenopathy. Abdomen was grossly
distended with no area of tenderness.
Organ enlargement could not be assessed
due to the massive ascites demonstrable by
fluid thrill. Abdominal girth measured at
umbilical level was 93cm. Bowel sound
was hypoactive. Rectum was empty on
rectal examination. Examination of other
systems was normal.
Tables 1 and 2 show the investigations
done for patient. She was placed on anti-
tuberculous drugs (pyrazinamide,
rifampicin, isoniazid and ethambutol).
There was remarkable clinical
improvement within two weeks, evidenced
by improved appetite, resolution of
abdominal pain and gradual regression of
the abdominal swelling. The abdominal
girth reduced remarkably from 93cm to
31cm within six weeks on anti-tuberculous
drugs. She was discharged and followed-
up in Surgical Outpatient Clinic to
Ann Biomed Sci. Vol 14, No. 2 June, 2015
complete anti-tuberculous drugs for two
years.
Case 3
I.A, a 27-year old male university
undergraduate presented at Emergency
Department with 2-month history of
progressive abdominal swelling, recurrent
abdominal pain and constipation.
Abdominal pain started gradually, located
in the left lower abdomen, colicky in
nature, severe in intensity, worsened after
intake of meals and transiently relieved by
analgesics. He noticed a change in his
normal bowel habit. His normal bowel
habit was 2-3 times daily, but reduced to
once a week with onset of symptoms. He
noticed an episode of frank blood in his
stool two weeks before presentation. His
appetite was reduced, but no weight loss
and no history of cough. There was no
history of tenesmus, mucus in the stool,
anal protrusion or perianal itching. Review
of other systems was normal.
Physical examination revealed an acutely-
ill-looking young man, not pale, afebrile,
anicteric, not dehydrated, with neither
pedal edema nor peripheral
lymphadenopathy. Abdomen was
distended and tense with tenderness
elicited in the left lumbar and iliac fossa.
Organ enlargement could not be assessed
because of massive ascites demonstrable
by fluid thrill. Bowel sound was
hypoactive. Digital rectal examination
revealed scanty greenish faeces and no
palpable mass.
The investigations done for the patient are
shown in Tables 1 and 2. He was
commenced on anti-tuberculous drugs
(pyrazinamide, rifampicin, isoniazid and
ethambutol). Abdominal pain resolved
3
N.J Nwashilli et al
with gradual regression of abdominal
swelling after 10 days. He is presently on
Surgical Outpatient Clinic follow-up; to
complete anti-tuberculous drugs for two
years.
Case 4
J. D, a 28-year old female fish farmer
presented via Emergency Department with
a 3- year history of progressive abdominal
swelling. There was associated reduction
in appetite and chronic constipation, but no
vomiting or abdominal pain. There was no
history of blood/mucus in the stool. She
started coughing six months prior to
presentation. Cough was productive of
yellowish sputum with associated fever,
drenching night sweats and weight loss.
There was no history of ingestion of
unpasteurized milk. A review of other
systems was normal.
Physical examination revealed a commencement of anti-tuberculous drugs,
chronically ill-looking young woman,
pale, afebrile, anicteric, dehydrated, with
neither pedal edema nor peripheral
lymphadenopathy. Abdomen was
markedly distended, umbilicus everted and
Fig 1: Picture of Case 2 at presentation with massive ascites causing abdominal swelling
Ann Biomed Sci. Vol 14, No. 2 June, 2015
ulcerated. Organ enlargement could not be
assessed due to the massive ascites
demonstrable by fluid thrill. Digital rectal
examination revealed scanty faeces
brownish in colour. Chest examination
revealed a respiratory rate of 20/min,
reduced air entry in the upper zone of both
lung fields and vesicular breath sound
bilaterally. Other systems examination was
normal.
The results of the investigations are shown
in Tables 1 and 2. She was transfused with
two units of blood on account of
hemoglobin of 8.9g/dl. The infected
umbilical ulcer yielded a growth of
Klebsiella Specie on culture which was
sensitive to the antibiotic Ofloxacin. She
was commenced on Ofloxacin and anti-
tuberculous drugs. The umbilical ulcer was
dressed daily with eusol. She improved
remarkably three weeks after
evidenced by improved appetite and
gradual regression of the abdominal
swelling. She is presently on anti-
tuberculous drugs and being followed-up
in Surgical Outpatient Clinic.
4
Fig 2: Picture of Same the Patient after 4 weeks on anti-tuberculous drugs showing
regression of abdominal swelling

Fig 3: Picture of the same Patient after three months on anti-tuberculous drugs showing
resolution of the abdominal swelling.

Table 1: Results of Laboratory Investigations of the Patients

Investigation Case 1 Case 2 Case 3 Case 4
Full blood
count: 12/35 9.4/33 11.3/41 8.9/31
9 9
Hb 3.6 x 10 7 x 10 5 x 109 5 x 109
(g/dl)/HCT(%)
Total White
blood cell(/μL) 49 8 53 62
Differentials(%) 45 82 35.5 31
Neutrophils 6 10 - 07
9
Lymphocyte - 545 x10 - 277, 000
Ann Biomed Sci. Vol 14, No. 2 June, 2015 5
N.J Nwashilli et al

Monocyte
Platelet (/μL)
Erythrocyte - 20 66 14
Sedimentation
Ratio
Electrolytes, Normal Normal Normal Normal
urea and
Creatinine
Liver function Normal Normal - Normal
test
Serum 7.2 - - -
protein(g/dl)
Mantoux (mm) No reaction 10 (positive) 16 (positive) 7 (positive)
Ascitic fluid:
Colour Straw Straw Straw Straw
Acid fast bacilli +++ ++ None None
Culture No growth No growth No growth No growth
Cytology Reactive - - -
mesothelia
hyperplasia
HIV test Negative Negative Negative Negative
Sputum:
Microscopy - - - Gram + cocci,
Gram – cocci

Acid fast bacilli - - - None seen

Table 2: Radiological Investigations of the Patients

Investigation Case 1 Case 2 Case 3 Case 4
Chest X-ray Normal Normal Bilateral Bilateral
perihilar perihilar
opacities opacities
Abdominal X- Signs of chronic - - -
ray constipation
Abdominal Generalized Generalized Severe Gross ascites
ultrasound scan ascites without ascites generalized
associated ascites
lymphomatous
masses.
Abdominal CT Veil-like opacity - Veil of opacity Massive ascites.
scan overlying the over the No intra-
Ann Biomed Sci. Vol 14, No. 2 June, 2015 6
 abdomen with
centrally
displaced bowel
suggestive of
abdominal
tuberculosis.
Discussion
Abdominal tuberculosis is predominantly a
disease of young adults with two-thirds of
the patients being in the age range of 21-
40 years with equal gender incidence3.
This was noted in the four cases presented.
Kapoor et al4 reported a slight female
predominance similar to what we
observed; three out of the four cases
presented were female.
Abdominal tuberculosis can have varied
presentation, frequently mimicking other
common and rare diseases5. The four cases
presented with features of intestinal
obstruction which may suggest intestinal
tuberculosis. Other systemic
manifestations of abdominal tuberculosis
include low grade fever, malaise, night
sweats, anaemia and weight loss which
occurs in one-third of patients6.
The full blood count showed a reduced
Packed Cell Volume and normal total
white blood cell count in all the four
patients. A patient had lymphocytosis
(82%). Marshall et al7 reported mild
anaemia in abdominal tuberculosis while
Manohar et al8 reported mild leucocytosis.
Erythrocyte sedimentation ratio (ESR) was
elevated in two patients. Erythrocyte
Ann Biomed Sci. Vol 14, No. 2 June, 2015
abdomen with abdominal mass
centrally lesion. No para-
displaced bowel aortic lymph
loops. No organ nodes.
enlargement.
Massive ascites.
No intra-
abdominal mass
lesions or para-
aortic lymph
nodes.
sedimentation is almost always raised in
abdominal tuberculosis but does not
exceed 60mm/hr8. Three patients had a
positive Mantoux/tuberculin test as shown
in Table 1. Mantoux test has high
specificity but low sensitivity and low
predictive value of 50-67%9. A positive
Mantoux is not of much value in
distinguishing between active and inactive
disease10. The incidence of abdominal
tuberculosis is high in human
immunodeficiency virus (HIV) infected
patients1. However, none of the patients
presented had HIV. The ascitic fluid in
abdominal tuberculosis is straw-coloured
with low yield of organisms on smear and
culture1. Ascitic fluid stained positive for
acid- fast bacilli in two out of the four
cases presented. Staining for acid-fast
bacilli is positive in less than 3% of cases3.
This is because at least 5000 bacteria/ml is
required for positive staining11.
Chest radiograph was normal in two
patients, but showed bilateral hilar
opacities in the other two patients. Kapoor
et al12 reported evidence of active or
healed lesions on chest radiograph in 22
(46%) out of 70 cases of abdominal
tuberculosis studied while Tandon et al13
7
N.J Nwashilli et al

reported positive findings of pulmonary non-specific clinical features coupled with

tuberculosis in 25% of their patients. low yield of mycobacterium on smear and
Evidence of pulmonary tuberculosis on a culture. A high index of suspicion is
chest radiograph supports the diagnosis, required to make diagnosis. Anti-
but a normal chest radiograph does not tuberculous drugs without surgery may be
rule it out. Chest radiographs are more sufficient in its treatment.
likely to be positive in patients with acute
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Ann Biomed Sci. Vol 14, No. 2 June, 2015 9

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