Dr.Terencia. Dr. Praveena Bhaskaran.Dr.Bhanu Vikraman Pillai DrC Jayakumar
Fifteen year old male boy presented with altered bowel habits, abdominal pain and weight loss x 6 months
At the beginning symptom was suggestive of acid peptic disease. This was followed
a mltered bowel habits-2-3 episodes of semisolid stools/day followed 2-3 days of no stools.In addition He had Generalised myalgia with difficulty in doing daily activities, poor appetite weight loss(10kg over 6 to 7 months), evening rise of temperature associated with night sweats
. Due to worsening of symptoms and decreased food intake child was evaluated in a near hospital
Labs ESR-95, CRP-35, TC-6000, N/L-69/22, PLT-531. He was admitted for 7 days duration and received IV antibiotics,(Ceftriaxone, Metrogyl, Amikacin) probiotics and other supportive measures.
After discharge he was asymptomatic for 2 -3 days after which developed similar complaints with severe abdominal discomfort.
USG Abdomen-Mild dilated bowel loops with sluggish peristalsis
CT Abdomen done and showed
Severe effacement of mesenteric and peritoneal fat pad diffusely. Appendix appear adherent to thickened adjacent mesentry. Mild diffuse thickening of peritoneum, mesentry and mesocolon with severe crowding of small bowel loops and colon within the peritoneal cavity, appearing almost adherent to each other. No obvious intestinal obstruction.Significant mesentericlymphadenopathy.
Differentials
Idiopathic encapsulating peritoneal sclerosis,
Infectious peritonitis including TB,
Sequelae of IBD with peritonitis
Clinically the boy was thin builtBMI13.9kg/M2 less than 3rd centile and except for pallor no other findings no HSM, BS were present. Other systems were normal
OGD scopy showed Small sliding hiatus hernia with mild gastritis.
Colonoscopy done was Normal.
TB GOLD done was +ve .
In view of Persisting symptoms mini laparotomy was done and omental biopsy showed Necrotizing granulomatous inflammation suggestive of TB.
Gene Xpert-Positive and Rifampicin sensitive.
ATT was started
He improved symptomatically with no post operative complications. He started tolerating normal diet and ambulating well. He was discharged with the advise of regular follow up with hemodynamically stable vitals.
ABDOMINAL TUBERCULOSIS
Includes involvement of GI tract, peritoneum, lymph nodes and/or solid organs. Abdominal TB comprises of 5% of all TB cases worldwide.
RISK FACTORS-Cirrhosis, HIV, DM, underlying malignancy, malnutrition, treatment with anti tumour necrosis factor, corticosteroids, use of ambulatory peritoneal dialysis.
• Spread- Reactivation of latent TB infection, Ingestion of TB bacteria(unpasteurized milk or undercooked meat),
Active pulmonary TB/Miliary TB-Abdominal involvement via contiguous or hematogenous spread or via lymphatic spread.
Clinical features of abolish tuberculosis are Fever, anorexia, weight loss, abdomen pain/distension, altered bowel habits.
Doughy abdomen, omental mass, organomegaly, ascites.
• Diagnosis- Clinical, laboratory, radiology, endoscopy, microbiology, HPE is needed to reach a definite diagnosis of abdominal TB. Tissue diagnosis –Most reliable. IGRA(Interferon gamma release assay)-based on quantification of IFN-gamma released from sensitized lymphocytes in whole blood.
• Treatment- ATT for abdominal TB is the same as that for pulmonary TB. Success of therapy in children is due to Paucibacillary nature of disease. Short course chemotherapy for 6 months has become standard practice. Daily regimen is superior to twice a week intermittent regimen. NTEP has introduced Fixed Drug Combinations (FDCs) incorporating multi-drug therapy for TB.
FDCs are preferred due to safety, simplified treatment, and avoiding errors in missing one or more of the combination drugs, thus reducing the risk of emergence of drug-resistant strains
Take over message- Abdominal TB must be anticipated and ruled out in children with chronic abdomen pain, altered bowel habits and weight loss even in the absence of respiratory complaints and normal CXR as early ATT treatment helps in preventing further complications.
