ABDOMINAL TUBERCULOSIS diarrhoea attacking a person with phthisis is a mortal symptom Hippocrates The origins of tuberculosis are hunched

ed in the mists of antiquity. Images of hunchbacks dated c.5000 BC and signs of spinal tuberculosis in Egyptian mummies provide the earliest evidence of the disease in man. Symptoms of pulmonary tuberculosis were described by early Hindu physicians 3000 years ago, and abdominal tuberculosis was probably first recognized by the Persians and Hippocrates c.400 BC. The ancient East was not only the cradle of Civilization. Tuberculosis apparently spread across Europe to the Western hemisphere and, in the latter part of the nineteenth century, to Black Africa. In Shakespearian London, tuberculosis was outranked only by the plague as the main cause of death and, in the wake of the Industrial Revolution, was perhaps the major one. With improvements in the standard of living, there has been a steady fall in the tuberculosis death rate from 440 per 100 000 persons in 1840 to <4 per 100 000 at present. This decline was paralleled in other developed countries such as the USA where, until 1912, tuberculosis was the most common cause of death. The decline has been more modest in countries in which the problems of low resistance from malnutrition and heavy exposure from overcrowding have not been contained, and death rates of the order of 80 per 100 000 are still being reported from central India . The Captain of all the men of Death continues to haunt underdeveloped countries and underprivileged communities. The incidence of tuberculosis shows corresponding wide variations ranging from about 15 per 100 000 in the UK and USA to 400-500 per 100 000 in Bolivia and Swaziland. The incidence in certain developed countries, however, is undoubtedly influenced by the high incidence in recent immigrants from developing countries. In the UK, the annual notification rate among immigrants from the Indian subcontinent exceeded the rate for the white population by 38 times in 1978. Although only 4 per cent of the population, patients from the Indian subcontinent account for 35 per cent of the total number of notifications, over half the cases of extra-pulmonary tuberculosis and about 60 percent of the cases of abdominal tuberculosis. Data from various centers in India suggest that abdominal tuberculosis is indeed one of the more important forms of extra-pulmonary tuberculosis in the subcontinent. Definition For the purposes of this presentation, the term abdominal tuberculosis will refer to tuberculosis of the bowel, mesenteric and retroperitoneal lymph nodes and peritoneum as described under number 014 of the International Classification of Diseases. The definition will be broadened to include tuberculosis of the oesophagus and stomach, but tuberculosis of the liver, spleen, pancreas and genito-urinary system will not be considered.

Classification Abdominal tuberculosis may be classified according to the site of the lesion or its gross morphological appearance. Site of lesion The commonest site for tuberculous involvement of the gastrointestinal tract is the distal ileum and ileo-caecal region. This is ascribed to local factors such as increased stasis with freer contact with the tubercle bacillus and the abundance of lymphoid tissue in the area, and to the fatty coat of the acid-fast bacilli (AFB) which resists gastric digestion. However, any part of the gastrointestinal tract may be involved, the ileum caecum, ascending colon, jejunum, appendix, sigmoid colon, rectum, duodenum, stomach and oesophagus being affected in a decreasing order of frequency. Lesions may be present in more than one site in the bowel and diffuse jejuno-ileal or colonic ulceration may occur. The distribution reported from three different centers is depicted in Fig. 13.1 shows that the small bowel, ileo-caecal and, to a lesser extent the colon remain the most commonly involved sites in gastrointestinal tuberculosis and the latter accounts for about 40 percent of cases of abdominal tuberculosis. Tuberculosis ascites and peritonitis account for about 50 percent of such patients mesenteric tuberculous lymphadenitis (Tabes mesenterica) for remaining 10 percent. The proportion of the peritoneal and no.. forms would appear to be somewhat lower in other Indian series the ascitic form is reportedly uncommon in Britain. Gross morphologic appearance Three pathological varieties of bowel involvement are recognized ulcerative, hypertrophic and mixed, and to these may now be added form manifesting essentially as fibrous stricture of the bowel. The final picture probably depends upon an interplay three factors the magnitude of the mycobacterial insult, the immunological response of the host and the effect of chemotherapy. Histopathology The characteristic microscopic lesion in tuberculosis is the confluent epithelioid cell granuloma with giant cells and central caseation and the demonstration of AFB in biopsy or surgical specimens. However, the bowel wall may show an entirely non-specific picture and the caseating granulomas may be seen only in the regional lymph nodes. AFB may be demonstrated in the bowel wall in such patients and provide the only conglomerate granulomas are suggestive but not diagnostic of the disease. Pathogenesis The traditional classification of abdominal tuberculosis into primary and secondary varieties allowed for certain differences in the pathogenesis of the disease. The primary

variety was linked with the ingestion of milk contaminated by Mycobacterium bovis, the bovine strain of the tubercle bacillus, and this was thought to be largely responsible for the hypertrophic form of the disease. The secondary variety followed the swallowing of infected sputum in patients with open pulmonary tuberculosis a view supported by the results of studies from various tuberculosis sanatoria. Autopsy data prior to 1942 showed a 65-80 percent incidence of bowel tuberculosis in patients dead of the disease and radiological studies showed that the incidence of bowel tuberculosis was directly proportional to the severity of the pulmonary lesion. The incidence in patients with minimal, moderate and far advanced pulmonary tuberculosis in these studies was 1-2.8 percent, 4.5-7.7 percent and 24.7-25.4 percent, respectively. More recent experience necessitates modification of the traditional concept of primary and secondary abdominal tuberculosis: 1. The virtual elimination of infected cattle and the very infrequent finding of the bovine strain in patients with abdominal tuberculosis, and in particular the hypertropic form the disease, throws considerable doubt on the traditional concept, and on the current status of M.bovis in alleged primary forms of the disease. A small number of bovine strains continue to be isolated from new cases of tuberculosis in England but the involve both pulmonary and extrapulmonary forms of the disease. Collins et al. (1981) have postulated that some bovine strains may be transmitted from person to person by pulmonary route and, indeed, that man may now constitute small reservoir for M.bovis. Despite this, there is little doubt that the ingestion of human or bovine AFB may occasionally cause primary intestinal tuberculosis . 2. Recent studies suggest that less than 50 percent of patients presenting with intestinal tuberculosis have radiographic incidence of active pulmonary disease and the incidence in patients with the mesenteric and peritoneal form of the disease is even lower. This, cou. with rarity of M.bovis, suggests that isolated abdominal tuberculosis may be due to the factors other than the swallowing of infected milk or AFB-laden sputum. One can but speculate on the large proportion of patients with abdominal tuberculosis unassociated with active lung disease. haematogenous spread to the submucosa and lymph nodes of the bowel may be a legacy of the silent bacillemia which may. Despite the almost inevitable immune response to the AFB which follows shortly after, a few remain . but dormant. Subsequent reactivation of dormant bacilli in the .. rather than the lung may help explain the relatively low incidence of active pulmonary lesions in patients with abdominal tuberculosis. Alternatively, active pulmonary disease with secondary bowel involvement may be followed, after successful anti-tuberculous therapy, by the eventual development of bowel strictures. Both postulates presuppose that the bowel involvement is secondary to previously active occult or overt lung disease a pseudo-primary type abdominal tuberculosis. The more obvious form of haematogenous spread from the distant site, miliary tuberculosis, may account for a proportion of patients with tuberculosis of the bowel

associated with active disease in the lungs or elsewhere. Less commonly, the bowel may become involved by direct extension or retrograde spread from caseating lymph nodes. Clinical Features Age and sex incidence The disease may occur at any age, from early infancy to old age, with peak incidences during infancy and early childhood, late adolescence and early adulthood, and old age. However, the disease is most frequently encountered between the second and fourth decades, depending on the collection bias in any particular series. The mean age of 40 years in our series compares favourably with the higher mean age in the Western world but our data were biased by exclusion of patients from the childrens hospital. a slight female preponderance is sometimes noted, particularly in reports from the Indian subcontinent. Racial incidence In South Africa the disease is found almost exclusively in the non-white population, particularly in the Blacks, while in the UK patients from the Indian subcontinent predominate. The clinical features of abdominal tuberculosis are varied, dec.. and generally nonspecific. The wide spectrum of presentation ranging from relatively mild abdominal symptoms to an acute life threatening emergency, reflect differences in the site, severity and extent of the disease, the nature of the pathological process and the amount of constitutional upset. The clinical presentation my also be influenced by the age and the immunological response of the patient and the severity of possible associated disease in the lung. Our 20-year Groote Schuur Hospital experience of 242 patients showed weight loss, abdominal pain and fever to be the most frequent findings, occurring in some 60-80 percent of patients. Diarrhoea was a symptom in about 30 percent of patients, while vomiting and constipation occurred in about 20 percent. An abdominal mass was palpable in 25 percent and ascites was a feature in almost 50 percent of patients. Routine investigations were equally non-specific. Anaemia and an ESR of >40 mm were found in about 60 per cent of patients, and a leucocytosis was present in 35 per cent. The ESR was normal in 22 per cent, however, and a leucopaenia was present in 17 per cent. It should be stressed that the Mantoux test was pulmonary disease and/or pleural effusion was demonstrated in <40 per cent of patients subjected to a chest X-ray. Peripheral lymphadenopathy was noted in 18 per cent.

Dominant Clinical Presentations Oesophageal tuberculosis This is perhaps the rarest form of gastrointestinal tuberculosis and, when it occurs, is almost invariably secondary to caseating para-oesophageal glands. Active pulmonary tuberculosis is usually present, but the disease is sometimes secondary to mediastinal tuberculosis unassociated with overt lung disease. dysphagia is usually the presenting symptom, but chest pain, coughing and, very rarely, lethal haemorrhage from an oesophago-aortic fistula may occur. Barium studies may show stricture and ulceration of the involved area, extrinsic compression and, occasionally, oesophago-bronchial fistula formation. These findings may be confirmed on oesophagoscopy, but biopsy is not always helpful. The lesion may mimic a benign stricture or tumour and, in particular, oesophageal carcinoma. Gastric tuberculosis Tuberculosis of the stomach is also excessively rare and is usually found in association with pulmonary or other extrapulmonary forms of the disease. The antrum and lesser curvature aspect of the stomach are preferentially involved, and the lesion may be either ulcerative or infiltrative. Gastroscopy may show the presence of characteristic undermining of the edge of the ulcer, a serpiginous lesion with a violaceous edge or superficial tubercles in the vicinity of the ulcer. Despite this, the clinical, radiological and even gastroscopic features simulate peptic or malignant ulceration or linitis plastica. Gastric tuberculosis is seldom considered except perhaps in patients with pulmonary tuberculosis presenting with non-healing gastroduodenal ulceration with an associated fistula. Pyloroduodenal obstruction Although unusual, tuberculosis is the commonest cause of pyloroduodenal obstruction in the South African Black. The obstruction is almost invariably due to extrinsic compression by a mass of caseating glands in the region, and may simulate a carcinoma of the pancreas at laparotomy. Small Bowel Tuberculosis In our experience, tuberculosis confined to the small bowel is the commonest form of gastrointestinal tuberculosis and accounts for 36 per cent of such cases. It may conveniently be subdivided into two subgroups.

Malabsorption Syndrome Tuberculosis is one of the more important causes of the malabsoprtion syndrome in India and in black South Africans which, in India, occurs in about a third of patients with intestinal tuberulosis. The disease tends to occur in early adulthood, and the clinical picture is dominated by weight loss, diarrhoea and, to a lesser extent, abdominal pain. Hypoalbuminaemic oedema is sometimes a feature. Tests of small bowel absorption are usually abnormal and a jejunal biopsy specimen frequently shows evidence of partial villous atrophy or abnormal cellular infiltrate. Barium studies show a non-specific malabsorption pattern, a localized abnormality or a combination of both findings. Malabsorption in these patients is probably on the basis of extensive bowel involvement with villous atrophy, lymphatic and lymph node obstruction, stagnation as a result of stricture and, rarely, fistula formation. Small Bowel Obstruction Apart from malabsorption, the majority of patients with small bowel disease present with postprandial abdominal discomfort, nausea, vomiting, constipation or colicky abdominal pains due to varying degrees of bowel obstruction. The latter may be caused by stricture following the healing of chronic ulcers, hyperplastic lesions or external compression by glands or adhesions. Less commonly, the patient may manifest with persistent or even acute abdominal pain due to a localized or free perforation of the small bowel. The plain X-ray examination of the abdomen is helpful in establishing the presence of subacute obstruction or free perforation and barium studies of the small bowel help define the site of obstruction and the lesion itself. Ileo-caecal tuberculosis The ileocaecal area is traditionally the commonest site of involvement but the frequency of this location may be declining. In our series, ileocaecal disease accounted for 24 per cent of cases with gastrointestinal disease and compares favourably with the 16-44 per cent reported in recent studies from India. A tender abdominal mass is often present, making differentiation from Crohns disease, caecal carcinoma and even amoeboma or appendix abscess difficult. The ileo-caecal involvement is typically of the hypertrophic type and as a result of subsequent fibrosis and shortening, the caecum is pulled up with loss of the normal ileo-caecal angle. The finding of a stiff, involved terminal ileum emptying directly through a gaping ileo-caecal valve into a shortened, rigid or obliterated caecum forms the classic Stierlins sign of intestinal tuberculosis. Tuberculous Appendicitis Rarely, patients may present with acute appendicitis or an appendix abscess due to obstruction of the appendix by the tuberculous process. The caecum in such patients is not necessarily involved.

Colonic tuberculosis Apart from tuberculosis of the caecal region, colonic tuberculosis was considered to be a rarity. This is no longer true and, in our studies, the frequency of colonic disease now appears to be similar to the ileo-caecal form of the disease. The classification of colonic tuberculosis was rather arbitrary, however, since associated small bowel disease was demonstrated in some patients and not carefully sought in others. The majority presented with features of a dysenteric illness, a colonic mass or an ano-rectal lesion, but there is a wide overlap between these presentations. Dysenteric Syndrome Diffuse and patchy ulceration of the colon usually manifests with diarrhoea associated with the passage of blood and mucus, and radiologic features indistinguishable from Crohns disease or indeed ulcerative colitis. Punched out ulcers are occasionally noted. Rectal or colonoscopic biopsies may be diagnostic in this as in other forms of colorectal tuberculosis. Colonic Mass Lesion These patients usually present with a tender mass associated with radiological evidence of a localized stenosis, an annular ulcerating lesion or, indeed, a so-called apple-core lesion of the bowel. More than one segment of the colon may be involved. Presumptive diagnoses in these patients include carcinoma, amoebiasis, complicated diverticular disease and Crohns disease. Ano-Rectal Lesions Patients with this comparatively rare form of the disease present with lower abdominal pain associated with proctitis or an ulcerative or hyperplastic lesion of the rectum. Sigmoidoscopic biopsies usually provide a definitive diagnosis. Tuberculous fistula-inano is less common than previously reported. Tuberculous Mesenteric Adenitis Massive lymphadenopathy without obvious evidence of bowel involvement may be the dominat feature in abdominal tuberculosis. In the Sudan, it would appear to be the most common form of the disease. The lymph nodes are large, fleshy and usually matted together and, in order pf frequency, are found in the center of the mesentery, the ileocaecal and the pyloroduodenal region. These patients usually present with weight loss, abdominal pain, variable constitutional symptoms and, in about, right iliac fossa or epigastrium. This may cause pyloroduodenal, intestinal or even inferior vena cava obstruction and may simulate a variety of conditions such as pancreatic carcinoma, abdominal lymphoma, appendiceal and liver abscesses or present as a pyrexia of unknown origin.

Tuberculous Peritonitis Tuberculous peritonitis, perhaps the most frequently encountered form of abdominal tuberculosis in South Africa, manifests either with clinical ascites or a so-called fibrinous, dry, chronic or plastic variety of the disease. The dominant presentation is weight loss, distention and abdominal pain, present in about 70-80 per cent of patients, but vomiting, diarrhoea or constipation is sometimes a feature. The abdomen is frequently tender and a mass is palpable in about 20 per cent of patients. Widespread peritoneal involvement with caseating glands, adherent loops of bowel and caseous thickening of the omentum, a childhood variant of the disease, may give rise to the characteristic doughy abdomen or cotton-wool sign. The diagnosis in our patients with obvious ascites was usually considered at presentation but in a few the ascites was linked with known cirrhosis or chronic pancreatitis and others were thought to have a gynaecological or disseminated malignancy. This clinical impression was strengthened by the finding of a uniformly blood-stained fluid in the occasional patient. The diagnosis may be established by means of an abdominal tap, peritoneoscopy or peritoneal biopsy. Complications Apart from malabsorption, most complications of abdominal tuberculosis are related to the effects of obstruction and/or perforation of the bowel. These include the following: 1. Acute and subacute bowel obstruction, pyloroduodenal stenosis and, very rarely, oesophageal or inferior vena cava obstruction. 2. Acute perforation of the bowel with peritonitis, localized or confined perforations with abscess and/or intrinsic or extrinsic fistula formation. A tracheo-oesophageal fistula may complicate the rare oesophageal lesion. 3. massive gastrointestinal haemorrhage due to to ulceration of the bowel, which occurs uncommonly. 4. enterolithiasis and amyloid are now historical curiosities, but pulmonary embolus related to contiguous vena caval involvement may rarely occur. Diagnosis The diagnosis of abdominal tuberculosis should not be difficult in patients with florid pulmonary tuberculosis, or in patients with suggestive symptoms and radiological features in the correct geographical, socio-economic and racial setting. The accuracy of clinical diagnosis is of the order of 50 per cent in India but recent reports from N. America and Britain indicate that the diagnosis is suspected in less than 20 per cent of patients prior to surgery. Surprisingly, the diagnosis in these non-endemic areas may even be overlooked in patients with active or previously treated pulmonary tuberculosis. This failure to consider tuberculosis in the differential diagnosis of inflammatory and obstructive bowel disorders is probably due as much to the alienation of tuberculosis control programmes from the teaching hospital milieu as to the dominance of Crohns disease and malignancy in current gastrointestinal thinking.

Radiology Despite its limitations, radiology remains the primary investigation for patients with abdominal tuberculosis. The chest X-ray provides and important clue to the diagnosis in about 40 per cent of the patients and a plain X-ray examination of the abdomen may confirm a clinical impression of small bowel obstruction. Calcified mesenteric nodes are of little diagnostic significance. Barium small bowel and large bowel studies are essential in establishing the presence, site and extent of bowel involvement. Good quality negative studies tend to exclude the latter, but it does not exclude enlarged mesenteric nodes or early ascites. Nowadays these features may be demonstrated by ultrasonography, computed tomography or radionuclide studies. In the majority of patients, the barium studies will establish the presence of a disease process in the ileum, ileocaecal region or large bowel. The radiological changes are usually a conglomerate of ulceration, swollen folds, wall thickening and encasement by hyperplastic changes, thickened mesentery and enlarged nodes. The latter may produce displacements or luminal indentations. Ascites may be radiologically apparent. Apart from obstruction due to the conglomerate inflammatory mass, clinical and radiological features of obstruction may be due simply to a localized segment of hyperplastic tuberculosis or to later development of a fibrotic stricture. Although certain radiological features may be highly suggestive of tuberculosis it is probably unwise to regard any of them as pathognomonic of the disease. These changes are often indistinguishable from Crohns disease and in the case of localized or segmental obstruction of the colon, from carcinoma or amoeboma as well. Other Diagnostic Leads Routine haematological and biochemical tests are of no diagnostic value in abdominal tuberculosis, although the finding of a markedly raised ESR with a leucopaenia is sometimes helpful. A strongly positive Mantoux test increases the Likelihood, but a negative test does not exclude the diagnosis, and radiological evidence of healed pulmonary tuberculosis is no more than a possible pointer to active bowel disease. active pulmonary disease, proven peripheral adenopathy or the finding of granulomata on liver biopsy provides strong inferential evidence of coexisting disease in patients presenting with bowel symptoms but even the finding of AFB in the sputum, gastric contents, pleural fluid aspirate or stools in such patients does not establish the diagnosis of abdominal tuberculosis. Diagnostic Procedures The diagnosis of tuberculosis can only be confirmed by the finding of the typical histopathological picture or the demonstration of acid-fast bacilli on appropriate staining, culture or guinea-pig inoculation. This usually necessitates laparotomy, but the diagnosis may be established with recourse to operation in patients with clinical ascites and those in whom the colon or anorectal region is involved.

Diagnostic Abdominal Tap in Clinical Ascites The fluid is typically straw coloured, occasionally blood stained or chylous, and very rarely purulent. A high protein concentration and lymphocytosis is suggestive, and the diagnosis is confirmed by the demonstration of AFB on direct smear of the centrifuged deposit or on culture. Failing this, peritoneoscopy or peritoneal biopsy are necessary to establish, the diagnosis. Peritoneoscopy Coupled with appropriate histological and bacteriological examination of fluid and suspect biopsies obtained during the procedure, this will be diagnostic in about 90 per cent of patients with clinical ascites. Random peritoneal biopsy in the right iliac fossa is sometimes preferred, but both procedures carry a risk of bowel perforation in patients without free fluid. Open peritoneal biopsy has been claimed to be of value in such patients. Colonoscopy The diagnosis of colonic or even ileocaecal tuberculosis may be made by means of colonoscopic biopsies, thus obviating the need for possible surgical intervention. Sigmoidoscopic Biopsies These are sometimes of value in the diagnosis of ano-rectal tuberculosis and upper gastrointestinal endoscopy may have a place in patients with oesophageal or gastroduodenal disease. Laparotomy Despite these recent diagnostic advances, laparotomy remains the definitive investigation in most patients with gastrointestinal mesenteric and non-ascitic forms of peritoneal tuberculosis. Lymph gland and, if warranted, omental or peritoneal biopsies should always be taken for histology and culture in preference to biopsies of the bowel wall because of the risk of subsequent fistula formation with the latter. It should be stressed that there are in fact no diagnostic features of abdominal tuberculosis on nkaed eye examination. The classic findings in Crohns disease may mimic the findings in ileocaecal tuberculosis, and even tubercle-like lesions are occasionally seen on the bowel surface in Crohns disease. On the other hand, peritoneal tubercles may be mistaken for peritoneal seedlings in patients with an operative diagnosis of an extensive malignancy. Surgical iopsies for histology and culture are mandatory.

Diagnostic Criteria The hallmark of diagnosis is the caseating granuloma and/or the demonstration of AFB on histology or culture. These rigid criteria have been extended to include an unequivocal response to antituberculous therapy in patients with strong circumstantial evidence of the disease. At present, the diagnosis is acceptable on the basis of at least one of the following criteria: 1. 2. 3. 4. Histological evidence of caseating granulomas Histological demonstration of AFB in the lesion or in ascitic fluid The growth of AFB on culture of tissue or ascitic fluid Typical macroscopic findings at operation with mesenteric node biopsy showing caseating granulomas and/or AFB on staining or culture 5. Good therapeutic response to chemotherapy in patients with clinical, radiological and/or operative evidence of abdominal tuberculosis associated with proven tuberculosis elsewhere 6. Response to chemotherapy without subsequent recurrence in patients with only clinical and radiological features of the disease Diagnostic Problems with Crohns Disease The distinction between tuberculosis and Crohns disease is usually easy, sometimes difficult and occasionally impossible. None of the so-called characteristic features of Crohns disease are pathognomonic, and there is a variable overlap in the clinical and radiological features of the two diseases. In practice, diagnostic difficulties arise less frequently if race, religion and socio-economic status of the patient are taken into account, but they still occur particularly in areas where the incidence of Crohns disease is high, and abdominal tuberculosis seemingly non-existent, and vice versa. Apart from a possible history of pulmonary tuberculosis, the clinical history is usually unrewarding. The finding of peripheral adenopathy, ascites and a strongly positive Mantoux test suggest tuberculosis. Succulent, violaceous perianal lesions, eruthema nodosum and arthritis favour Crohns disease but the latter two may also complicate bowel tuberculosis. Laboratory findings are unhelpful. Radiological evidence of relative caecal sparing in patients with ileo-caecal disease or ileocolitis would point to Crohns disease. caecal obliteration is more characteristic of tuberculosis, while deep ulcers and bowel fistulae are perhaps more common in Crohns disease. aphthoid ulcers have not yet been described in tuberculosis, and post-inflammatory filiform polyps, if they occur, are rare. Macroscopically, the classic circumferential tubeculous ulcer is seen more often in the text-book than in the bowel but the finding of peritoneal nodules points strongly to tuberculosis. In the majority of difficult cases, however, the diagnosis leans heavily on histology, AFB staining and culture of biopsy or other tissue. Large confluent granulomas are highly suggestive, and central caseation diagnostic of tuberculosis. These features may be found only in the lymph nodes and a little central necrosis is rarely seen in what is otherwise Crohns disease. The presence of AFB is also diagnostic.

Since tuberculosis is so eminently curable, it should be seriously considered in the differential diagnosis in every case of apparent Crohns disease before embarking on a potentially hazardous course of long-term steroids or immunosuppressives. Treatment The therapeutic approach to abdominal tuberculosis is currently in a state of flux. The old order, dominated by the need for laparotomy to establish the diagnosis and the seemingly irresistible desire to carry out extensive resections of affected bowel is slowly being displaced by a more medically-oriented discipline. This is due largely to the efficacy of the newer anti-tuberculous chemotherapeutic regimens and to the growing realization that the may, in fact, be curative in patients with diffuse and even hypertrophic and partially obstructive lesions in the bowel. More than ever, the management of abdominal tuberculosis requires close teamwork between the physician and the surgeon. Medical Treatment Patients presenting with abdominal tuberculosis may be desperately ill, requiring vigorous treatment to correct dehydration, electrolyte disturbances, nutritional deficits and blood loss, and immediate investigation to exclude a surgical emergency and establish the diagnosis. Ideally, the diagnosis should be established before the commencement of specific anti-tuberculous therapy, but this is not always possible, or desirable. A delay of even a few days may be lethal. In some, particularly those with proven disease elsewhere and strong circumstantial evidence of bowel involvement, parenteral anti-tuberculous therapy i.v. rifampicin and isoniazid and i.m. streptomycin may be commenced forthwith. In others, the difficult decision regarding diagnostic laparotomy will have to be made. Given the right socio-economic and racial setting, a therapeutic trial with antituberculous agents may be considered preferable to laparotomy in the gravely ill patient with typical radiological findings on emergency barium studies. Chemotherapeutic trials in questionable cases may avoid the need for diagnostic laparotomy or curative surgery. However the majority of patients, will tolerate the necessary delay of a few days or weeks needed to obtain confirmation of the diagnosis, by means of laparotomy or otherwise. Treatment with one of the newer chemotherapeutic regimens should be started as soon as after diagnosis as possible and continued for a long period of time. The duration of treatment using one of the highly effective rifampicincontaining regimens is uncertain, but may be used as short as six to nine months. Longterm follow up is necessary to monitor the healing process and to exclude recurrence. Patients with diffuse bowel involvement may benefit from a period of treatment with parenteral chemotherapy and intravenous hyper-alimentation before going onto an oral chemotherapeutic regimen. A low fat diet and vitamin and mineral supplements are usually advisable in such patients.

Surgical Treatment Emergency surgery is obviously required in patients presenting with an acute abdomen due to bowel perforation, acute intestinal obstruction or acute appendicitis or, rarely, to uncontrollable gastrointestinal bleeding. Surgery in other patients can usually be delayed to await the outcome of investigations aimed at defining the nature of the complication. Localized abscess and internal fistula formation, gross pyloroduodenal obstruction and subacute intestinal obstruction due to probable stricture formation invite surgical correction. Laparotomy is frequently necessary to establish the diagnosis in abdominal tuberculosis. The procedure should be restricted to obtaining the appropriate biopsies and culture, and should not be regarded as a mandate to resect bowel unless this is clearly indicated on obstructive or other grounds. The decision to carry out extensive resections in patients with subacute attacks of pain and obstruction associated with fairly diffuse disease poses a problem in clinical judgement. A limited small bowel resection or right hemicolectomy is almost certainly justified in some patients. We cannot agree with Elhence that anti-tuberculosis drugs are of no value in this setting and would be inclined to reconsider the question of surgery after assessing the response to a therapeutic trial. The temptation to resect diseased bowel during the initial laparotomy must be tempered by the knowledge that the majority of patients with diffuse or localized lesions of the small or large bowel will improve dramatically on the newer chemotherapeutic regimens. In any event, surgery can be carried out at a later stage, and with greater safety, if symptoms persist. Prognosis Despite the advent of safe and highly effective anti-tuberculous drugs there is still an appreciable mortality in patients with abdominal tuberculosis. This is due to serious complications such as a perforated bowel, late presentation of desperately ill patients, delays in establishing the diagnosis and instituting appropriate chemotherapy after admission to hospital, and over-enthusiastic surgery. Predisposing conditions such as cirrhosis, alcoholism, diabetes, immunocuppression and gross debility may also be pertinent. Patients with uncomplicated abdominal tuberculosis usually show a dramatic response to anti-tuberculous therapy and often become symptom-free within a few days or weeks of starting such therapy. Complete resolution of radologically demonstrable changes may be noted after a few months, but there is some evidence that the healing process may occasionally lead to eventual stricture formation. This apart, the long term prognosis is uncomplicated abdominal tuberculosis would appear to be good in patients given the benefit of timely chemotherapy.

Diarrhoea attacking a person with phthisis need not be a mortal symptom