Role of Surgical Intervention in Acute Presentations of Tubercular Abdomen in Our Setup

Inpharasun, S A (2013) Role of Surgical Intervention in Acute Presentations of Tubercular Abdomen in Our Setup. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION: Strangely visited people, All swoln and ulcerous, pitiful to the eye. The mere despair of surgery, he cures, Hanging a golden stamp about their necks, Put on with holy prayers: and 'tis spoken, To the succeeding royalty he leaves. The healing benediction — Macbeth, Act 4, Scene 3, 171-7 These were the words from Shakespeare's Macbeth which describes the procedure of Royal Touch ceremony performed in medieval ages for treating tuberculosis patients!!!!!!!!!!!. Abdomen is one of the common sites of extra pulmonary involvement (6%). An increase in the incidence of pulmonary tuberculosis has led many to predict that there will be a corresponding increase in abdominal tuberculosis. In developing countries abdominal tuberculosis continues to be a common presentation of extra pulmonary form. However, in developed countries due to increased standards of living the incidence of abdominal tuberculosis has become rare. Since there is an increase in the incidence of Acquired Immuno-deficiency Syndrome (AIDS) recently, the incidence of abdominal tuberculosis and other forms of Extra pulmonary tuberculosis are also expected to rise. Extra pulmonary form of tuberculosis is difficult to diagnose. Abdominal tuberculosis has bizarre, chronic and insiduous type of presentation and difficult to diagnose. Due to advent of laparoscopy, the diagnosis has been possible without laparotomy. Since there are diverse in clinical presentations, often with equivocal reports of the investigations and wide spread complications, often with prolonged morbidity and mortality, we have analyzed our patients to highlight the various aspects of abdominal tuberculosis in our setup. The purpose of this study is to find out the commonly encountered causes for emergency laparotomy in known tuberculosis patients presenting as acute abdomen and most frequently performed surgical interventions for the same in our setup. Rationale behind the study: Tuberculosis is one of the leading cause of morbidity and mortality all over the world, particularly in a developing country like India. Hence it is not only a health concern to tackle this deadly & disabling disease but also a major social responsibility. Among the various clinical presentations of Tuberculosis, most require only medical management. But few, including Abdominal Tuberculosis definitely requires surgical intervention. Abdominal tuberculosis is like a Pandora’s box with a variety of clinical presentations ranging from vague nonspecific abdominal pain to subacute obstruction to characteristic acute abdomen. If the pathology is diagnosed early, intervention could be done at an earlier stage by ATT thereby avoiding development of acute abdomen or the need for an emergency procedure. But again, early diagnosis of abdominal tuberculosis is virtually impossible. Patients present only when the disease advances. Most times, they present to the emergency, with obstruction, perforation or abscess. This is the place, where surgical intervention comes into play. Not only these interventions relieve the patients of their symptoms, but also they provide tissue for diagnosis, thereby prompting the initiation of ATT. AIMS AND OBJECTIVES: 1. To evaluate the role of surgical interventions in cases of abdominal tuberculosis presenting as emergency 2. To find out the most common surgical presentation of tubercular abdomen as acute abdomen in our setup 3. To find out the most commonly performed surgical intervention in emergency presentations of tubercular abdomen. Inclusion criteria: • Known tuberculosis patient presenting as acute abdomen. • Patients presenting as acute abdomen who are found to have tuberculosis after biopsy report. Exclusion criteria: • Acute abdomen of all other etiologies. MATERIALS AND METHOD: This study was conducted in RGGGH & Madras Medical College, Department of General Surgery during the period of August 2012 – December 2012. Informed written consent was obtained from all the patients. All the base line investigations comprising haematological and biochemical parameters had been done. About 60 patients who were admitted to the emergency department between May 2010 and June 2012 with acute abdominal complaints were taken for the study. The diagnosis of abdominal tuberculosis were made by clinical findings and investigational reports including histo pathological report of the specimen. All the patients underwent emergency X ray chest PA view, X ray abdomen erect view, USG abdomen. Some selected patients were subjected to CECT abdomen. The surgical procedures done were, laparotomy and mesentric node biopsy/ omental/ peritoneal biopsy, limited resection of ileum, cecum and ascending colon with ileo colic anastomosis with & without proximal diversion, resection and anastomosis of ileum with or without proximal diversion, stricturoplasty, adhesiolysis with peritoneal biopsy. With consent patients were subjected to HIV 1 & 2 ELISA. All the patients underwent sputum AFB post operatively to look for pulmonary foci and patients were subjected to Cat 1 or Cat 2 ATT as per pulmonary involvement. Patients were followed up post operatively till the completion of ATT. Data Collected: Preoperative demographic and clinical data, details of the surgical procedure, postoperative course, and complications were collected prospectively. Various presentations of tubercular abdomen along with the procedure done were analyzed. Post operatively patients were followed up to look for development of complications. All the patients were discharged after starting ATT. Complications included wound infection, development of adhesions, anastomotic leak, respiratory complications, duration of hospital stay. RESULTS: Sixty two cases of acute abdomen were taken up for study. • All cases were taken up for emergency laparotomy on the day of admission. • Stricture of ileum was the most common presentation in emergency followed by ileo cecal tuberculosis (46%). • Most commonly performed procedure was resection anastomosis (31%). • All the patients were started on ATT on a average of 15th post operative day. CONCLUSION: Ileal stricture was the most common presentation of the acute abdominal tuberculosis. • Prior thorough investigations for Pulmonary Tuberculosis with sputum AFB in patients chronic abdominal pain and early initiation of the treatment will definitely decrease the progression into abdominal tuberculosis a significant number of patients. • Performing a proximal diversion, along with the definitive procedure, significantly decreases the incidence of anastomotic leaks.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Surgical Intervention ; Acute Presentations ; Tubercular Abdomen.
Subjects: MEDICAL > General Surgery
Depositing User: Devi S
Date Deposited: 26 Mar 2018 13:48
Last Modified: 26 Mar 2018 13:48

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