ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)

SURGERY | ORIGINAL ARTICLE
ABDOMINAL TUBERCULOSIS (STUDY OF 50 CASES)
Ketan Vagholkara,∗,1, Meghal Sanghavib,∗ and Suvarna Vagholkarc,∗
a Professor , b Senior Resident , c Research Assistant , ∗ Department of Surgery. D.Y.Patil University School of Medicine. Navi Mumbai 400706. MS. India
ABSTRACT Background: The incidence of abdominal tuberculosis is increasing. Preoperative diagnosis continues to
be the biggest challenge. Diagnosis is established only after histopathological examination. The modes of presentation
and therapeutic options need to be assessed. Objectives: To study the patterns of presentations, the extent of organ
involvement and therapeutic options. Materials and methods: Fifty histopathologically proven cases of abdominal
tuberculosis were studied. In addition, epidemiologic data, clinical patterns of presentation, diagnostic and various
surgical options, including outcomes, were studied. Results: The mortality in the study was 8%. The disease was
commonly seen in 21 to 40 years old and commonly seen in females. HIV positivity, anaemia and hypoproteinaemia
were associated with poor outcomes. Four types of presentations were observed. Diagnostic laparoscopy enabled early
histopathological diagnosis of biopsy specimens. Chemotherapy is the mainstay of treatment Surgery is a significant
adjunct in diagnosing and managing complications. Patients presenting with perforative peritonitis had a poor prognosis
Conclusion: Critical evaluation of chronic abdominal pain is essential. Supportive evidence such as the history of TB or
contact with a patient suffering from TB is highly suggestive of abdominal tuberculosis. Radiological tests are highly
suggestive but not diagnostic. Diagnostic laparoscopy enables tissue diagnosis. Chemotherapy accompanied by surgical
intervention for complications is the mainstay of treatment.
KEYWORDS Abdominal, Intestinal, tuberculosis, diagnosis treatment
Introduction
Abdominal tuberculosis is one of the common sites of extra-
pulmonary tuberculosis. [1, 2] The increasing incidence of
pulmonary tuberculosis has led to a corresponding increase
in the incidence of abdominal tuberculosis. In some patients,
abdominal tuberculosis is a primary disease wherein there is
no involvement of any other organ system, either in past or
present. [3] Despite the dramatic decrease in mortality and mor-
bidity for pulmonary tuberculosis, after discovering effective
anti-tuberculosis drugs, there is still a steady increase in the
incidence of abdominal tuberculosis in the developing world.
With the advent of HIV, there is a significant change in the pre-
Copyright © 2022 by the Bulgarian Association of Young Surgeons
DOI: 10.5455/ijsm.AbdominalTuberculosisStudyof50cases
First Received: February 6, 2021
Accepted: March 7, 2021
Associate Editor: Ivan Inkov (BG);
1
Corresponding author: Dr. Ketan Vagholkar, E mail: kvagholkar@yahoo.com, Mobile:
+91 9821341290
sentation of abdominal tuberculosis. The disease has become
more lethal with great variability in presentation and response
to treatment. The medical line of treatment continues to be the
mainstay of treatment. However, surgery plays a pivotal role
once complications supervene and is instrumental in reducing
the morbidity and mortality in such patients. [3]
Objectives
1. To study the epidemiological aspects of abdominal tuber-
culosis concerning age, sex, previous or past history of
pulmonary tuberculosis and HIV status.
2. To study the various patterns of clinical presentations of the
disease and correlate them to intraoperative findings.
3. To study the nature of surgical procedures performed for
various presentations.
4. To evaluate the morbidity and mortality in these patients
following surgical interventions.
Ketan Vagholkar et al./ International Journal of Surgery and Medicine (2022) 8(1):56-70

Materials and methods
Fifty histopathologically proven cases of abdominal tuberculosis
treated in a single surgical unit, of a tertiary care hospital, in
the period from January 2017 to December 2019 were studied.
Institutional Ethics committee approval was sought prior to
commencing the study.
Inclusion criteria
• Cases with a proven diagnosis of abdominal tuberculosis on
histopathological examination. (Caseation and epithelioid
granulomas)
• Cases of abdominal tuberculosis in which diagnostic or
therapeutic, surgical interventions were done.
Exclusion criteria
• Cases diagnosed as abdominal tuberculosis on radiolog-
ical or biochemical investigations alone, with no proven
histopathological evidence of tuberculosis.
• Cases with tuberculosis involving the genitourinary system.
Fifty cases fulfilling the inclusion criteria were selected for
the study, and a detailed proforma was completed for each of
these patients. The following factors were studied:
A. Personal details: Included age and sex of the patient.
B. Clinical presentation: The 50 cases selected were grouped
into one of the four types of presentations based on their
clinical features:
1. Acute presentation: All cases presenting for the first time
as an acute abdomen with symptoms and signs of acute
intestinal obstruction or perforative peritonitis and not on
any previous medical treatment for abdominal complaints
for more than one month were categorised as acute presen-
tation in the study.
2. Chronic presentation: All cases not responding to any form
of a conservative or medical line of treatment for abdominal
complaints for more than six months were categorised as
chronic presentation.
3. Acute on chronic presentation: Cases on treatment for ab-
dominal complaints about a period less than six months
and in whom a provisional diagnosis of abdominal tubercu-
losis was made clinically, radiologically, biochemically and
in whom anti-tuberculosis therapy was not started, and yet
presented with an acute abdomen.
4. Incidental presentation: Elective cases that underwent
surgery for other indications and proved to be abdominal
tuberculosis on histopathological examination were cate-
gorised as incidental presentation.
C. The general condition and immunological status of the 50
cases were studied based on four factors:
1. Past/Present history of pulmonary tuberculosis or tubercu-
lous contact
2. HIV status
3. Absence or presence of anaemia
4. Absence or presence of hypoproteinaemia
D. Each of the 50 cases underwent one or more of the following
four radiological investigations preoperatively, and their
findings were studied and noted.
1. X-ray chest
2. X-ray abdomen
3. Ultrasonography
4. CT scan
E. Surgical factors: The surgical interventions carried out in
50 cases were grouped into four categories.
1. Exploratory laparotomy
2. Diagnostic laparoscopy with exploratory laparotomy
3. Diagnostic laparoscopy with tissue biopsy and adhesiolysis
4. Laparoscopic surgery
The intraoperative findings included the site of involvement,
type of pathology and the surgical procedure carried out in each
individual case.
All the aforementioned surgical factors were studied and cor-
related with the type of presentation. All the observations and
results were tabulated. Other factors like wound infection, septi-
caemia, and pulmonary complications causing morbidity and
mortality were also studied in relation to each type of presenta-
tion and results obtained. No immunological and mycobacterial
culture testing was done due to limitations in cost and the non-
availability of facilities.
Frequency tables were charted for age, sex and type of pre-
sentation.
Statistical analysis was done for various factors influencing
morbidity and mortality in abdominal tuberculosis and its as-
sociation with each clinical presentation using the chi-square
test and Pearson chi-square value. A value less than 0.05 was
considered significant to conclude statistical significance or as-
sociation between two factors. A P-value greater than 0.05 was
considered not significant.
Results
The total number of cases studied were 50 (n =50).
1. Age
The age varied from 10 years to a maximum of 55 years
(Table 1)
2. Sex
19 patients were male, and 31 patients were female. The
male by female ratio was 1:1.06 (Table 1).
3. Type of clinical presentation
20 patients presented in the acute form (40%), 10 patients
presented in chronic form (20%), 15 patients presented in
acute on the chronic form (30%), and 5 patients presented it
incidentally (10%) (Table 2).
4. HIV status
5 out of 50 patients had HIV positive status (10%). Out of
these, four had an acute presentation (80%), and 1 out of
5 had a chronic presentation (20%). This finding was not
statistically significant (p = 0.217, p> 0.05) (Table 3).

5. Past or present history of pulmonary tuberculosis or tu-
berculous contact
19 out of 50 patients had a history of pulmonary tuberculo-
sis or tuberculous contact (38%). 5 out of these 19 patients
had an acute presentation (26.3%), 9 patients had a chronic
presentation (26.3%), and 9 had an acute-on-chronic presen-
tation (47.4%). This finding was statistically significant (p =
0.042, p<0.05) (Table 4).
6. Anaemia
Patients were categorised into 4 grades. Grade 0 greater
than 12 gm% of haemoglobin, Grade 1 with 10.1 to 12 gm%,
Grade 2 with 7.1 to 10 grams and Grade 3 less than 7 gm%
of haemoglobin. 8 patients belonged to grade 0, 17 patients
belonged to Grade 1, 22 patients belonged to Grade 2, and
3 patients belonged to Grade 3. This finding was not statis-
tically significant (p = 0.073, p>0.05) (Table 5).
7. Hypoproteinaemia
Total protein concentration less than 6 gm/dl was consid-
ered hypoproteinaemia. 38 patients had hypoproteinaemia
(78%). Out of these 16 patients belonged to acute presen-
tation, 9 belonged to chronic presentation, 11 were acute
on chronic presentation, and 2 were incidental presenta-
tion. This finding was not statistically significant (p = 0.182,
p>0.05) (Table 5).
8. Chest X-ray
Patients were categorised into four groups based on x-ray
findings. Group 1 was pulmonary tuberculosis, group 2
permanently healed tuberculosis, group 3 was a gas under
the diaphragm, and group 4 had no abnormality. 29 out of
50 patients studied had a normal chest x-ray (58%), 4 out of
50 patients studied had pulmonary tuberculosis (8%), 3 out
of 50 patients studied had healed pulmonary tuberculosis
(8%), and 14 out of 50 patients studied had to gas under the
diaphragm (28%). This finding was statistically significant
(p<0.001) (Table 6).
9. X-ray abdomen
Patients were categorised into three groups based on find-
ings on the x-ray abdomen. Group one had multiple air-
fluid levels, group 2 had gas-filled dilated loops, and group
3 had no abnormality on the x-ray abdomen. 36 out of 50
patients had normal x-ray abdomen (72%), 10 out of 50 pa-
tients had multiple air-fluid levels (20%), and 4 out of 50
patients had gas-filled dilated loops (8%). This finding was
not statistically significant (p = 0.182, p>0.05) (Table 7).
10. Ultrasonography
Patients were categorised into 7 groups depending upon
ultrasonography findings (Table 8).
More than one finding was positive in each case, and there-
fore each of the groups was analysed individually. 19 out of
50 had oedematous, clumped or dilated loops (38%). This
finding was not statistically significant (p = 0.96, p>0.05).
3 out of 15 patients had a right iliac mass. This finding
was not statistically significant (p = 0.674, p>0.05). 8 out
of 50 patients had lymphadenopathy (16%). This finding
was statistically significant (p = 0.010, p<0.05). 21 out of
50 patients had fluid-filled loops or free fluid (42%). This
finding was not statistically significant (p = 0.669, p>0.05).
9 out of 50 patients had appendicitis (18%). This finding
was statistically significant (p <0.01). 1 out of 50 patients
had a pneumoperitoneum (2%). This finding was not statis-
tically significant (p = 0. 675, p>0.05). 7 out of 50 patients
did not undergo ultrasonography (14%). This finding was
statistically significant (p = 0.007, p<0.05).
11. CT scan
27 out of 50 patients did not undergo CT scan (54%), 7 out
of 50 patients had structures (14%), 7 out of 50 patients had
features suggestive of ileocaecal tuberculosis (14%), and 9
out of 50 patients had a normal scan (18%). This finding
was statistically significant (p = 0.007, p<0.05) (Table 9).
12. Surgical option
32 out of 50 patients underwent exploratory laparotomy
(64%), 4 out of 50 patients underwent diagnostic la-
paroscopy with exploration (5%), 10 out of 50 patients un-
derwent diagnostic laparoscopy plus tissue biopsy (20%),
and 4 out of 50 patients underwent laparoscopic surgery
(8%). This finding was statistically significant (p<0.001)
(Table 10).
13. Site of involvement
More than one site was involved in certain cases. (Table 11)
The majority of patients had ileal and mesenteric involve-
ment.
14. Pathology and extent of involvement
The majority of patients had lymphadenopathy and stric-
tures of the small intestine. (Table 12)
15. Surgical procedure
a) Resection anastomosis
16 patients underwent resection anastomosis. Out of these,
14 had an acute presentation, 2 patients had acute on chronic
presentation. This observation was statistically significant
(p <0.001, p<0.05) (Table 13).
b) Right hemicolectomy
4 patients underwent right hemicolectomy. Out of these, 3
patients had an acute presentation, and one had an acute-on-
chronic presentation. This observation was not statistically
significant (p =0.445, p>0.05) (Table 13).
c) Stricturoplasty
8 patients underwent stricturoplasty. Out of these, two
patients had an acute presentation, five patients had an
acute-on-chronic presentation, and one patient had an inci-
dental presentation. This observation was not statistically
significant (p =0.119, p>0.05) (Table 13).
d) Adhesiolysis/tissue biopsy
Thirty-nine patients underwent adhesiolysis. Out of these,
12 patients had an acute presentation, 10 patients had a
chronic presentation, 12 patients had acute on chronic pre-
sentation, and five patients had an incidental presenta-
tion. This observation was statistically significant (p =0.045,
p<0.05) (Table 13).
e) Incision and drainage

Table 1 Age and sex distribution
Age Group Frequency Percentage (%)
0-20 15 30
21-40 30 60
41-60 05 10
Sex Frequency Percentage (%)
Male 19 38
Female 31 62
Table 2 Pattern of clinical presentation
Presentation Frequency Percentage (%)
Acute 20 40
Chronic 10 20
Acute on Chronic 15 30
Incidental 05 10
Table 3 HIV status
Presentation Status + Status -
Acute 04 (20%) 16 (80%)
Chronic 01(10%) 09 (90%)
Acute on Chronic 00 (0%) 15 (100%)
Incidental 00 (0%) 05 (100%)
Total 05 45
Table 4 Past/Present History of Pulmonary Tuberculosis/Tuberculous Contact
Presentation Positive Status Negative Status
Acute 05 (25%) 15 (75%)
Chronic 05(50%) 05 (50%)
Acute on Chronic 09 (60%) 06 (40%)
Incidental 00 (0%) 05 (100%)
Total 19 31

Table 5 Anaemia & Hypoproteinaemia
Incision & drainage Not Performed - Incision & drainage Not Performed -
>12 No Anaemia Gr-0
10.1-12.0 Mild Anaemia Gr-1
7.1-10.0 Moderate Anaemia Gr-2
<7 Severe Anaemia Gr-3
Presentation Gr-0 Gr-1 Gr-2 Gr-3
Acute 04(20%) 05(25%) 10(50%) 01(05%)
Chronic 01(10%) 03(30%) 04(40%) 02(20%)
Acute on Chronic 03(20%) 04(26.7%) 08(53.3%) 00(0%)
Incidental 00(0%) 05(100%) 00(0%) 00(0%)
Total 08(16%) 17(34%) 22(44%) 03(06%)
Presentation Hypoproteinaemia Total protein (<6gm/dl) Total Protein >6gm/dl
Acute 16(80%) 04(20%)
Chronic 09(90%) 01(10%)
Acute on Chronic 11(73.3%) 04(26.7%)
Incidental 02(40%) 03(60%)
Total 38 12
Table 6 Chest x ray findings
Group Finding
Group 1 Pulmonary tuberculosis
Group 2 Healed pulmonary tuberculosis
Group 3 Gas under diaphragm
Group 4 No abnormality detected
Presentation Group 1 Group 2 Group 3 Group 4
Acute 01(05%) 00(0%) 14(70%) 05(25%)
Chronic 01(10%) 00(0%) 00(0%) 09(90%)
Acute on Chronic 02(13.3%) 03(20%) 00(0%) 10(66.7%)
Incidental 00(0%) 00(0%) 00(0%) 05(100%)
Total 04 03 14 29
Table 7 X ray abdomen findings
Group Finding
Group 1 Multiple air fluid levels
Group 2 Gas filled dilated loops
Group 3 No abnormality detected
Presentation Group 1 Group 2 Group 3
Acute 06(30%) 01(05%) 13(65%)
Chronic 00(00%) 01(10%) 09(90%)
Acute on Chronic 04(26.7%) 02(13.3%) 09(60%)
Incidental 00(0%) 00(0%) 05(100%)
Total 10 04 36

Table 8 Ultrasonography of abdomen
Group Finding
Group 1 Oedematous/clumped/dilated loops
Group 2 Rt. Iliac mass/lump
Group 3 Lymphadenopathy
Group 4 Fluid filled loops/free fluid
Group 5 Appendicitis
Group 6 Pneumoperitoneum
Group 7 Not done
Presentation Group 1 Group 2 Group 3 Group 4 Group 5 Group 6 Group 7
Acute 09 (45%) 02(10%) 00 (0%) 10(50%) 01(05%) 01(05%) 07(35%)
Chronic 02 (20%) 00 (0%) 02(20%) 04(40%) 01(10%) 00 (0%) 00 (0%)
Acute on Chronic 08 (63.3%) 01(6.7%) 06(40%) 06(40%) 02(13.3%) 00 (0%) 00 (0%)
Incidental 00 (0%) 00 (0%) 00 (0%) 01(20%) 05(100%) 00 (0%) 00 (0%)
Total 19 03 08 21 09 01 07
Table 9 CT scan of the abdomen
Group Finding
Group 1 Stricture
Group 2 Ileo-caecal tuberculosis
Group 3 Normal Study
Group 4 Not done
Acute 01(05%) 01(05%) 00(0%) 18(90%)
Chronic 00(0%) 03(30%) 07(70%) 00(0%)
Acute on Chronic 06(40%) 03(20%) 01(6.7%) 05(33.3%)
Incidental 00(0%) 00(0%) 01(20%) 04(80%)
Total 07 07 09 27
Table 10 Surgical options
Group Finding
Group 1 Exploratory Laparotomy
Group 2 Diagnostic laparoscopy + Exploration
Group 3 Diagnostic laparoscopy + Tissue Biopsy
Group 4 Laparoscopic Surgery
Acute 19(95%) 01(05%) 00(0%) 00(0%)
Chronic 02(20%) 00(0%) 07(70%) 01(10%)
Acute on Chronic 07(46.7%) 03(20%) 03(20%) 02(13.3%)
Incidental 04(80%) 00(0%) 00(0%) 01(20%)
Total 32 04 10 04

Table 11 Site of Involvement: More than one site was involved in certain cases and each site was separately analysed
Presentation Ileocaecal Involvement + Ileocaecal Involvement -
Acute 04(20%) 16(80%)
Chronic 00(0%) 10(100%)
Acute on Chronic 01(6.7%) 14(93.3%)
Incidental 00(0%) 05(100%)
Total 05(10%) 45(90%)
Presentation Ileal Involvement + Ileal Involvement -
Acute 18(90%) 02(10%)
Chronic 00(0%) 10(100%)
Acute on Chronic 06(40%) 09(60%)
Incidental 01(20%) 04(80%)
Total 25(50%) 25(50%)
Presentation Jejunal Involvement + Jejunal Involvement -
Acute 05(25%) 15(75%)
Chronic 00(0%) 10(100%)
Acute on Chronic 02(13.3%) 13(86.7%)
Incidental 00(0%) 05(100%)
Total 07(14%) 43(86%)
Presentation Mesenteric Involvement + Mesenteric Involvement -
Acute 09(45%) 11(55%)
Chronic 06(60%) 04(40%)
Acute on Chronic 07(46.7%) 08(53.3%)
Incidental 04(80%) 01(20%)
Total 26(52%) 24(48%)
Presentation Peritoneal Involvement + Peritoneal Involvement -
Acute 00(0%) 20(100%)
Chronic 01(10%) 09(90%)
Incidental 01(20%) 04(80%)
Total 03(06%) 47(94%)
Presentation Appendix Involvement + Appendix Involvement -
Acute 00(0%) 20(100%)
Chronic 00(0%) 10(100%)
Incidental 02(40%) 03(60%)
Total 02(04%) 48(96%)
Presentation Stomach Involvement + Stomach Involvement -
Acute 00(0%) 20(100%)
Chronic 01(10%) 09(90%)
Incidental 00(0%) 05(100%)
Total 02(04%) 48(96%)
Presentation Omental Involvement + Omental Involvement -
Acute 01(05%) 19(95%)
Chronic 04(40%) 06(60%)
Incidental 00(0%) 05(100%)
Total 05(10%) 45(90%)

Presentation Colonic Involvement + Colonic Involvement -
Acute 03(15%) 17(85%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 03(06%) 47(94%)
Presentation Liver Involvement + Liver Involvement -
Acute 00(0%) 20(100%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 01(02%) 49(98%)
Table 12 Extent of pathological involvement
Presentation Mass Present + Mass Absent -
Acute 04(20%) 16(80%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 07(14%) 43(86%)
Presentation Stricture Present + Stricture Absent -
Acute 15(75%) 05(25%)
Chronic 00(0%) 10(100%)
Acute on Chronic 08(53.3%) 07(46.7%)
Incidental 01(20%) 04(80%)
Total 24(48%) 26(52%)
Presentation Bowel perforation Present + Bowel perforation Absent -
Acute 11(55%) 09(45%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 11(22%) 39(78%)
Presentation Lymphadenopathy Present + Lymphadenopathy Absent -
Acute 09(45%) 11(55%)
Chronic 09(90%) 01(10%)
Incidental 05(100%) 00(0%)
Total 37(74%) 13(26%)

Table 13 Surgical procedure performed
Presentation Resection anastomoses of bowel Performed + Resection anastomoses of bowel Not Performed -
Acute 14(70%) 06(30%)
Chronic 00(0%) 10(100%)
Acute on Chronic 02(13.3%) 13(86.7%)
Incidental 00(0%) 05(100%)
Total 16(32%) 34(68%)
Presentation Right hemicolectomy Performed + Right hemicolectomy Not Performed -
Acute 03(15%) 17(85%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 04(08%) 46(92%)
Presentation Stricturopasty Performed + Stricturoplasty Not Performed -
Acute 02(10%) 18(90%)
Chronic 00(0%) 10(100%)
Acute on Chronic 05(33.3%) 10(66.7%)
Incidental 01(20%) 04(80%)
Total 08(16%) 42(84%)
Presentation Adhesiolysis &tissue biopsy Performed + Adhesiolysis & tissue biopsy Not Performed -
Acute 12(60%) 08(40%)
Chronic 10(100%) 00(0%)
Incidental 05(100%) 00(0%)
Total 39(78%) 11(22%)
Presentation Incision & drainage Performed + Incision & drainage Not Performed -
Acute 00(0%) 20(100%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 01(02%) 49(98%)
Presentation Appendicectomy Performed + Appendicectomy Not Performed -
Acute 03(15%) 17(80%)
Chronic 02(20%) 08(80%)
Incidental 05(100%) 00(0%)
Total 11(22%) 39(78%)
Presentation Exteriorization Performed + Exteriorization Not Performed -
Acute 04(20%) 16(80%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 04(08%) 46(92%)
Presentation Fistulectomy Performed + Fistulectomy Not Performed -
Acute 01(05%) 19(95%)
Chronic 00(0%) 10(100%)
Acute on Chronic 02(13.3%) 13(86.7%)
Incidental 00(0%) 05(100%)
Total 03(06%) 47(94%)

Table 14 Complications
Presentation Surgical site infection Present + Surgical site infection Absent -
Acute 06(30%) 14(70%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 06(12%) 44(88%)
Presentation Septicaemia Present + Septicaemia Absent -
Acute 06(30%) 14(70%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 07(14%) 43(86%)
Presentation Pulmonary complications Present + Pulmonary complications Absent -
Acute 05(25%) 15(75%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 05(10%) 45(90%)
Table 15 Mortality
Presentation Mortality + Mortality -
Acute 04(20%) 16(80%)
Chronic 00(0%) 10(100%)
Incidental 00(0%) 05(100%)
Total 04(08%) 46(92%)

Only one patient who underwent incision and drainage had
an acute on chronic presentation. This observation was not
statistically significant (p =0.497, p>0.05) (Table 13).
f) Appendicectomy
11 patients underwent appendicectomy. Out of these, three
patients had acute presentation, 2 patients had a chronic
presentation, one patient had acute on chronic presentation,
and five patients had an incidental presentation. This obser-
vation was statistically significant (p <0.001, p<0.05) (Table
13).
g) Stoma creation (exteriorization)
4 patients who had acute presentation underwent exterior-
ization. This observation was not statistically significant (p
=0.089, p>0.05) (Table 13).
h) Fistula tract excision
3 patients out of 50 had these procedures performed. Out of
these, one patient had an acute presentation, and 2 patients
had acute on chronic presentation. This observation was
not statistically significant (p =0.489, p>0.05) (Table 13).
16. Complications
a) Wound infection
6 patients had wound infections postoperatively. All six
patients had an acute presentation. This observation was
statistically significant (p =0.017, p<0.05) (Table 14).
b) Septicaemia
7 patients developed septicaemia. Out of these, 6 had an
acute presentation, and one patient had acute on chronic
presentation. This observation was not statistically signifi-
cant (p =0.061, p>0.05) (Table 14).
c) Pulmonary complications
5 patients developed pulmonary complications. All five
statistically significant (p =0.040, p>0.05) (Table 14).
17. Mortality
4 patients expired, yielding a mortality of 8%. All four
not statistically significant (p <0.001, p<0.05) (Table 15).
Discussion
Abdominal tuberculosis is a disease that can affect any age group
of patients. [1] The age of the patients in the present study
ranged from 10 years to 55 years, with a mean age of 27.44
years. However, most of the cases were in the age group 21 to 40
years. Abdominal tuberculosis has a predilection for females for
unknown reasons. [1, 2] 31 (62%) of the patients in the present
study were females, while only 19 (38%) were male.
The present study revealed 4 patterns of clinical presentation:
1. Acute presentation 20 (40%) cases,
2. Chronic presentation 10 (20%) cases,
3. Acute on chronic presentation 15 (30%) cases and
4. Incidental presentation 5 (10%) cases.
Surgery was mainly performed, either to confirm the diag-
nosis of abdominal tuberculosis or to manage complications. It
was also observed that the number of patients with acute presen-
tation who underwent surgery was more than any other group.
This was because patients belonging to this group had advanced
disease. The primary mode of presentation and disease were
detected and confirmed only after surgery in certain cases. [1, 2]
HIV status and tuberculosis are closely linked to each other.
In the present study, 5 (10%) cases were HIV positive, out of
which 4 cases had an acute presentation. The mortality among
HIV-positive patients with the acute presentation was 100%.
Nevertheless, due to the small number of HIV positive cases in
the study, a statistical analysis substantiating a positive associa-
tion could not be achieved. The impact of AIDS is reflected in the
increased prevalence of systemic or multiple site involvement
and poor response to surgical intervention. [2, 3] The present
study showed an association between the modes of presenta-
tion and past or present history of pulmonary tuberculosis or
contact with a patient suffering from tuberculosis. It was also ob-
served that a definite association existed between past or present
history of tuberculosis or tuberculous contact and acute on the
chronic pattern of presentation. Other studies have also conclu-
sively shown the association between pulmonary tuberculosis
and abdominal tuberculosis. [3, 4, 5] In the present study, 42
(84%) cases had anaemia, while 38 (76%) cases had hypopro-
teinaemia. However, the observation did not achieve statistical
significance. Though present in most patients with abdominal
tuberculosis, Anaemia has no diagnostic relevance except for
being a comorbid factor. Many other studies have also reported
similar observations. [4, 5]
The present study revealed the diagnostic efficacy of chest x
rays in various modes of presentation. 14 (70%) of acute cases
had gas under the diaphragm, whereas 1 (10%) chronic cases
had pulmonary tuberculosis, and 3 (20%) of acute on chronic
cases had healed tuberculosis lesions. Hence, it is concluded that
pulmonary tuberculosis, including healed lesions on chest x rays
in chronic cases of pain in the abdomen, is highly suggestive of
abdominal tuberculosis. However, a normal x-ray chest does
not rule out the diagnosis of abdominal tuberculosis. Quite a
few other studies have revealed the presence of active or healed
lesions on chest x rays in patients suffering from abdominal
tuberculosis. [5, 6] 36 (72%) cases had no positive findings on
the x-ray abdomen. Hence an x-ray abdomen has limited rel-
evance in the diagnosis of abdominal tuberculosis. However,
in patients presenting with symptoms of obstruction, multiple
air-fluid levels and dilated bowel loops may be seen. [7] In the
present study, 43 (86%) cases underwent ultrasound evaluation
of the entire abdomen. The following features seen in various
combinations were suggestive of abdominal tuberculosis.
a. Intra-abdominal fluid (free/loculated) with debris and
septa
b. Due to local exudation from inflamed bowel, interloop ad-
hesions are typically described as “Club Sandwich” sign.
c. Discrete or matted lymphadenopathy with caseation and
calcification is highly suggestive of tubercular aetiology.
Ultrasonography findings were analysed statistically but
did not achieve any significance. However, the surgeon
needs to be aware of these findings in order to differen-
tiate tuberculosis from Crohn’s disease or irritable bowel
syndrome. [4] Barium study was a very important diag-
nostic tool, especially in the chronic presentation of abdom-

inal tuberculosis.[7,8] Barium studies were usually done
in patients presenting with chronic abdominal pain, lump,
or recurrent episodes of intestinal obstruction during the
quiescent phase of the disease. A variety of radiological
signs on barium studies diagnostic of intestinal tuberculosis
were described. However, with the advent of CT scanning,
the utilisation of barium studies for diagnosing abdomi-
nal tuberculosis has decreased. CT scan is a commonly
used investigation for documenting features suggestive of
abdominal tuberculosis. Dilated bowel loops, strictures,
adhesions, and features suggestive of an abdominal cocoon
are diagnostic of abdominal tuberculosis. [9, 10]
In the present study, a definite association pattern was ob-
served between the surgical options exercised and the mode of
presentation. Exploratory laparotomy was the procedure per-
formed for an acute presentation. Diagnostic laparoscopy with
tissue biopsy was performed for chronic presentation. (Figure 1)
Figure 1 Laparoscopic omental biopsy
7 (46.7%) patients of acute on chronic presentation underwent
exploratory laparotomy, while 3 (20%) each underwent either
a diagnostic laparoscopy followed by exploratory laparotomy
or a diagnostic laparoscopy with a tissue biopsy. The remain-
ing 2 (13.3%) underwent laparoscopic surgery. The advent of
laparoscopic surgery has greatly helped in the early diagnosis
of abdominal tuberculosis. [11] Formal laparoscopy is usually
performed for complications due to abdominal tuberculosis. The
most common being adhesions of the bowel. [12] Diagnostic
laparoscopy also enables biopsy, thereby allowing a definitive
diagnosis to be made. Such patients, if started on medical ther-
apy, do not need further surgical intervention. [13] Incidental
detection of abdominal tuberculosis is usually associated with
appendicitis, wherein the histopathological evaluation of the
appendectomy specimen reveals tuberculosis. [14]
The site of involvement was evaluated in each of the 50
cases studied. There was no case presenting or diagnosed as
oesophageal tuberculosis in the present study. Oesophageal
tuberculosis is rare and occurs due to spread from pulmonary
tuberculosis, mediastinal lymph nodes, or from the spine. It is
one of the rarest of gastrointestinal tuberculosis. The patient may
present with dysphagia and retrosternal pain. The endoscopic
evaluation may reveal ulceration. [14, 15] In the present study, 2
(4%) cases had involvement of the stomach, whereas there were
no cases with duodenal involvement. Stomach and duodenal
involvement is extremely rare due to the following reasons,
1. Sparcity of lymphoid tissues in the upper GI tract
2. The high acidity of peptic secretions
3. Rapid passage of ingested organisms into the small intestine
The common symptoms include pain and upper GI bleed
besides nausea and vomiting of gastric outlet obstruction. [16] 7
(14%) cases had jejunum involvement in the present study. The
proximal small intestinal disease is more commonly due to atypi-
cal mycobacteria, especially Mycobacterium avium-intracellular
infection. [17] 5 (10%) cases had involvement of the ileocecal
region, whereas 25 (50%) cases had ileal involvement. A statisti-
cally significant association was observed with 18 (72%) cases
belonging to acute presentation, 6 (24%) to acute on chronic pre-
sentation and 1 (4%) incidentally diagnosed. A specific predilec-
tion for the ileocecal region can be attributed to various factors:
1. Increased physiological stasis, thereby increasing the con-
tact time of organism with the blood.
2. Increased rate of fluid absorption.
3. Minimal digestive activity.
4. The abundance of lymphoid tissue.
Various other studies have also found predilection for the
ileocecal region. [17, 18] Tuberculous granulomas are initially
formed in the mucosa or the Payer’s patches. These vary in size
and tend to be confluent. Granulomas are usually seen beneath
the ulcer bed in the submucosal layers. Ulcers are usually super-
ficial and do not penetrate the mucosal layer. They may be single
or multiple and are transversely placed. Cicatrisation of circum-
ferential girdle type ulcers eventually leads to stricture forma-
tion. Occlusion of the vasa recta due to endarteritis may also
contribute to the development of strictures. Such patients usu-
ally present with colicky abdominal pain and vomiting. Physical
examination of the abdomen may reveal a doughy feel, disten-
tion or a lump. Malabsorption is a common accompaniment of
abdominal tuberculosis. This is usually due to bacterial over-
growth in the stagnant loop, bile salt deconjugation, diminished
absorptive surface due to ulceration and lymphatic involvement.
[18] Primary tuberculosis of the appendix is seen in 1% of cases
even though it lies close to the ileocecal junction. In the present
study, the appendix was primarily involved in 2 (4%) cases. It
attained statistical significance with all the cases having an in-
cidental presentation. In most cases, appendicectomy in such
patients is usually performed electively for recurrent attacks of
right iliac fossa pain. [18, 19, 20] In the present study, a statistical
association could not be achieved in 3 (6%) cases with colonic
involvement. Tuberculosis can affect the ascending, transverse,
and sigmoid colon. Isolated cases of distal colonic tuberculosis
presenting as multiple perianal fistulas have been reported. 26
(52%) cases in the present study had mesenteric involvement,
3 (6%) had peritoneal involvement, and 5 (10%) had omental
involvement.( Figure 2)
Figure 2 Peritoneal tubercles with ascites.

A statistically significant association was found in the 5 cases
having omental involvement with the chronic pattern of presen-
tation. Mesentery lymph nodes are usually commonly involved.
Peritoneal tuberculosis assumes different patterns. An ascitic
type is the most common pattern presenting as abdominal full-
ness due to fluid. Purulent type is rare and is usually associated
with tuberculosis of the fallopian tubes, especially in females.
This may also be associated with cold abscesses and internal
fistula formation. Encysted type consists of a localised intra-
abdominal collection leading to obstruction. The fibrous type
presents with widespread adhesions. Omental involvement by
tuberculosis is seen as an omental cake in appearance. (Figure 3)
Figure 3 Omental involvement
Long-standing inflammation can form a fibrous wall covering
the omentum, described as an omental line. This omental line is
rarely seen in malignancy. [21, 22] Only 1 (2%) cases had liver
involvement. This case presented with a subhepatic abscess and
a fistulous track ending onto the anterior wall of the stomach
as an internal fistula. The presenting complaint was chronic ab-
domen pain, low-grade fever, and recurrent attacks of sub-acute
intestinal obstruction. The abscess cavity and fistulous tract
were excised. Histopathologic evaluation of the tract revealed
tuberculosis. Extensive adhesiolysis was also performed. The
overall incidence of tuberculosis of the hepato-biliary-system is
less than 1%. Isolated liver lesions may mimic liver abscesses
and present with pyrexia of unknown origin. [23, 24, 25] 7
(14%) presented with a lump. The average range of 20 to 25% of
cases presenting with lumps has been reported by other studies.
[25, 26] 24 (48%) cases had a stricture. This was a statistically
significant observation. 62.5% of the strictures had an acute pre-
sentation, 33.3% had an acute on chronic presentation, and 2.5 %
had an incident presentation. Stricture formation is a common
manifestation of intestinal tuberculosis and has been reported
in a number of studies. [26, 27, 28] 11 (22%) patients had perfo-
ration. All these patients had an acute pattern of presentation
which was statistically significant. The incidence of abdominal
tuberculosis presenting as perforative peritonitis ranges between
14 to 20%. [29, 30, 31] A significant association was found with
the presentation mode in 37 (74%) cases with lymphadenopathy.
24.3 % had an acute pattern, 24.3 % had a chronic pattern, 36.8%
had an acute, chronic pattern, whereas 13.5% had an incidental
pattern of presentation. Mesenteric lymphadenopathy is a com-
mon manifestation of abdominal tuberculosis. [32, 33, 34, 35]
5 (10%) cases showed extraintestinal tuberculosis evidence. 16
(32%) cases underwent resection anastomosis. These constituted
87.5% of cases with the acute presentation. Various other studies
have also revealed that resection anastomosis is a commonly per-
formed procedure in abdominal tuberculosis. [36, 37, 38] Right
hemicolectomy was performed in 4 (8%) cases. However, this
observation did not achieve statistical significance. As a thera-
peutic procedure for tuberculosis, right hemicolectomy ranges
from 10 to 32%, as revealed by various studies. [39, 40, 41] Stric-
turoplasty was done in 8 (16%) cases. The procedure helps avoid
a major resection anastomosis, thereby preserving the length of
the intestine. However, multiple strictures in a short segment
of the intestine necessitate resection anastomosis. [41, 42] 39
(78%) cases underwent adhesiolysis with tissue biopsy. This
procedure helps in the relief of symptoms and confirmation of
diagnosis. [40] 11 (22%) cases undergoing appendicectomy had a
statistically significant incidental presentation. Appendicectomy
was an ancillary procedure to another type of surgery such as a
hemicolectomy. Only two patients had primary tuberculosis.
All these patients did extremely well after completing a
course of anti-tuberculosis therapy. This observation empha-
sizes that all specimens sent to the pathology after appendicec-
tomy should be carefully evaluated for tuberculosis. Primary
tuberculosis of the appendix can present as either chronic or
acute appendicitis, whereas preoperative diagnosis is extremely
difficult. [39, 40]] In 4 (8%) cases, a stoma was created. All these
patients had an acute presentation with extensive peritonitis.
Though the postoperative morbidity increases in these cases,
the mortality is slightly reduced, improving long-term progres-
sion. A statistically significant association could not be achieved,
which can be attributed to fewer cases having undergone this
procedure. In the present study, all these patients had to undergo
a stoma reversal after 12 weeks, during which they were started
on antituberculosis treatment. A proximal loop ileostomy helps
protect a distally performed anastomosis following resection of
the diseased portion of the gut. [39, 40] 3 (6%) cases underwent
fistulectomy.
6 (12%) patients in the present study developed surgical site
infection and showed a statistically significant association with
the acute mode of presentation. Surgical site infection is a com-
mon accompaniment in patients undergoing surgery for ab-
dominal tuberculosis. [41] 7 (14%) cases developed septicaemia.
Though the observation did not achieve statistical significance, it
was evident that these patients either had acute or acute chronic
presentation patterns. Septicaemia is a common accompaniment
of patients presenting late to the hospital. [42] 5 (10%) cases
developed pulmonary complications. [43] All these patients had
an acute pattern of presentation. 38 (76%) cases in the present
study did not develop any form of complication related to the
surgical procedure.
The mortality rate in the present study was 8%. As seen
in many studies, the mortality rate in abdominal tuberculosis
ranges between 4 to 15%. [1, 2, 4, 40, 41, 44] In the present study,
48% of cases belonged to the acute presentation.
Conclusion
Abdominal tuberculosis is common in age 21 to 40 years with a
predilection for females. The mortality of abdominal tuberculo-
sis in HIV positive patients is high. History of past or present
primary tuberculosis or tuberculous contact serves as an impor-
tant adjunct in diagnosing abdominal tuberculosis in patients
presenting with chronic abdominal pain. Anaemia and hypopro-
teinaemia, which are features of malnutrition, serve as comorbid
factors. The radiological investigation, which includes chest
X-ray, abdominal X-Ray, ultrasonography, and CT scan, help in
arriving at a diagnosis of abdominal tuberculosis, though not
always confirmatory. Exploratory laparotomy is the procedure
of choice for an acute pattern of presentation.
In contrast, a diagnostic laparoscopy with tissue biopsy is
best suited for a chronic pattern of presentation, while an acute

on chronic type of presentation requires an individualized ap-
proach. Stricture, lymphadenopathy, and disseminated peri-
toneal tubercles are common pathological observations. Stoma
creation (exteriorization) reduces mortality, especially in patients
presenting as perforative peritonitis—Adhesiolysis and tissue
biopsy aid in arriving at a definitive diagnosis of tuberculosis.
Appendicitis may be a pattern of presentation of abdominal
tuberculosis, which needs critical histopathologic evaluation.
Post-operative complications are more with an acute mode of
presentation. Mortality in patients suffering from abdominal
tuberculosis who have undergone surgical intervention is 8%.
Acknowledgements
The authors would like to thank the Dean of D.Y.Patil University
School of Medicine, Navi Mumbai. India, for granting permis-
sion to publish the study.
Conflict of interest
None.
Funding
Nil.
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