Meltem ERGÜN, Bilge TUNÇ, Aysel ÜLKER, Nurgül ŞAŞMAZ

Doktorlar için bir klinik zorluk: Abdominal tüberküloz 24 olgunun derlemesi

Amaç:Abdominal tüberküloz halen gelişmekte olan ülkelerde immun yetmezliği olmayan bireylerde görülebilen bir hastalıktır. Kesin tanı öncelikle bu hastalıktan şüphelenilerek ve farklı tanı metotlarını bir arada kullanarak mümkündür ve uzun zaman alabilir. Gereç ve Yöntem: Ocak 2000 ile Aralık 2011 tarihleri arasında kliniğimizde abdominal tüberküloz tanısı konulan 24 hastanın kayıtları retrospektif olarak analiz edildi. Demografik özellikler, laboratuar kayıtları, radyolojik, endoskopik ve cerrahi bulgular değerlendirildi. Takipler hastalara randevu verilerek veya telefonla yapılan görüşmelerle sağlandı. Bulgular: Toplam 24 hasta çalışmaya dahil edildi (10 bayan, ortalama yaş: 40, dağılım: 2168). Hastaların en sık klinik semptomu ateş (20, %83), karın ağrısı (19, %79), iştahsızlık (17, % 71), kilo kaybı (16,%66), gece terlemesi (12,%50), ishal (10,%42), asit (8, %33) olarak saptandı. Subakut/akut intestinal obstrüksiyon olguların 5'inde (%21) saptandı. Hastaların 4'ünde (%16) geçirilmiş pulmoner tüberküloz hikâyesi, 5'inde (%21) ailede tüberküloz hikâyesi mevcuttu. Hastaların 12'sinde (%50) intestinal tutulum saptanırken, 8'inde (%30) peritoneal ve 4'ünde nodal tutulum saptandı. ‹ntestinal tutulum gösteren hastaların 9'unda (%75) ileoçekal bölgede lezyon saptandı. Abdominal tüberküloz tanısı 8 (33%) hastada endoskopik/ kolonoskopik biopsilerin histopatolojik incelemesiyle, 5 (21%) hastada abdominal ultrason/tomografi rehberliğinde yapılan biyopsilerle, 7 (29%) hastada laparoskopik/cerrahi girişimle, 2 (8%) hastada da asit incelemeleri ile kondu. Mikrobiolojik incelemelerde pozitişik sadece 4 (17%) hastada saptandı. Sonuç: Abdominal tüberküloz spesifik olmayan semptomatolojisi ile karmaşık bir hastalıktır. Tanısını koymak için öncelikle şüphelenmek ve bir çok tanı metotlarını bir arada kullanmak gerekir.

Anahtar Kelimeler:

Gastrointestinal tüberküloz, abdominal tüberküloz, intestinal tüberküloz

Clinical challenge for physicians - abdominal tuberculosis: review of 24 cases

Background and Aims:Abdominal tuberculosis is still seen in immunocom-petent adults in developing countries. The accurate diagnosis of abdominal tuberculosis requires a high index of suspicion and combination of diagnos-tic modalities in clinic practice and is time-consuming. Materials and Met-hods: The records of 24 patients (10 females, mean age: 40 years, range: 21-68 years) diagnosed with abdominal tuberculosis between January 2000 and December 2011 were analyzed retrospectively. Patients' characteristics, labo-ratory investigations, and radiological, endoscopic and surgical findings we-re evaluated. Follow-up information was obtained by telephone contact and scheduled visits. Results: 24 patients were enrolled in the study. The most frequent symptoms were abdominal pain (n=19, 79%), fever (n=20, 83%), ascites (n=8, 33%), diarrhea (n=10, 42%), and weight loss (n=16, 66%). Su-bacute/acute intestinal obstruction was found in 5 cases. Past history of treat-ment for tuberculosis and family history of tuberculosis were present in 4 (16%) and 5 (21%) patients, respectively. The basis of diagnosis of abdomi-nal tuberculosis were histopathology obtained by endoscopic/colonoscopic biopsies in 8 (33%), ultrasound/computed tomography-guided biopsies in 5 (21%), laparoscopic/surgical interventions in 7 (29%), and ascites examinati-ons in 2 (8%) patients. Microbiological tests were positive in only 4 (17%) patients. The predominant site of involvement by abdominal tuberculosis was intestinal in 12 (50%), peritoneal in 8 (33%), and solid viscera/nodal in 4 (16%) cases. Conclusions: Abdominal tuberculosis is a complex disease with non-specific symptomatology. Combination of a high index of clinical suspi-cion and use of multiple adjuvant diagnostic tools is required to make the correct diagnosis.

Keywords:

Gastrointestinal tuberculosis, abdominal tuberculosis, intestinal tuberculosis,

PDF

___

Raviglione MC, Snider DE Jr, Kochi A. Global epidemiology of tubercu- losis: morbidity and mortality of a worldwide epidemic. JAMA 1995; 273:220-6.
World Health Organization. Global Tuberculosis Control 2011. Availab- le at: http://www.who.int/tb/publications/global_report/2011/gtbr11 _full.pdf
Braun MM, Byers RH, Heyward WL, et al. Acquired immunodeficiency syndrome and extra-pulmonary tuberculosis in the United States. Arch Intern Med 1990;150:1913-6.
Ihekwaba FN. Abdominal tuberculosis: a study of 881 cases. J R Coll Surg Edinb 1993;38:293-5.
Talwar BS, Talwar R, Chowdhary B, Prasad P. Abdominal tuberculosis in children: an Indian experience. J Trop Pediatr 2000;46:368-70.
Pulimood AB, Amarapurkar DN, Ghoshal U,et al. Differentiation of Crohn's disease from intestinal tuberculosis in India in 2010. World J Gastroenterol 2011;17:433-43.
Chou CH, Ho MW, Ho CM, et al. Abdominal tuberculosis in adult: 10- year experience in a teaching hospital in central Taiwan. J Microbiol Im- munol Infect 2010;43:395-400. 8.
Khan R, Abid S, Jafri W, et al. Diagnostic dilemma of abdominal tuber
culosis in non-HIV patients: an ongoing challenge for physicians. World
J Gastroenterol 2006;12:6371-5.
Bölükbaş C, Bölükbaş FF, Kendir T, et al. Clinical presentation of abdo- minal tuberculosis in HIV seronegative adults. BMC Gastroenterol 2005;5:21.
Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis--presen- ting features, diagnostic strategies and treatment. Aliment Pharmacol Ther 2005;22:685-700.
Dulger C, Adali E, Avcu S, Kurdoglu Z. Large mesenteric cyst mimicking tuberculous ascites. Case Report Med. 2010;2010:725050. doi: 10.1155/2010/725050.
Yönal O, Hamzaoğlu HO. What is the most accurate method for the di- agnosis of intestinal tuberculosis? Turk J Gastroenterol 2010;21:91-6.
Pulimood AB, Ramakrishna BS, Kurian G, et al. Endoscopic mucosal bi- opsies are useful in distinguishing granulomatous colitis due to Crohn's disease from tuberculosis. Gut 1999;45:537-41.
Amarapurkar DN, Patel ND, Rane PS. Diagnosis of Crohn's disease in In- dia where tuberculosis is widely prevalent. World J Gastroenterol 2008;14:741-6.
Leung VK, Law ST, Lam CW, et al. Intestinal tuberculosis in a regional hospital in Hong Kong: a 10-year experience. Hong Kong Med J 2006;12:264-71.
Gan H, Ouyang Q, Bu H, et al. Value of polymerase chain reaction assay in diagnosis of intestinal tuberculosis and differentiation from Crohn's disease. Chin Med J (Engl) 1995;108:215-20.
Chow KM, Chow VCY, Szeto CC. Indication for peritoneal biopsy in tu- berculous peritonitis. Am J Surg 2003;185:567-73.
Chow KM, Chow VCY, Hung LCT, et al. Tuberculous peritonitis-asso- ciated mortality is high among patients waiting for the results of myco- bacterial culture of ascitic fluid samples. Clin Infect Dis 2002;35:409-13.