Army Hospital (Research and Referral), 110 010, Delhi, India.
Saint Vincent Hospital, Worcester, MA, USA.
Indian J Gastroenterol. 2023 Feb;42(1):17-31. doi: 10.1007/s12664-023-01343-x. Epub 2023 Mar 11.
Abdominal tuberculosis is an ancient problem with modern nuances in diagnosis and management. The two major forms are tuberculous peritonitis and gastrointestinal tuberculosis (GITB), while the less frequent forms are esophageal, gastroduodenal, pancreatic, hepatic, gallbladder and biliary tuberculosis. The clinicians need to discriminate the disease from the close mimics: peritoneal carcinomatosis closely mimics peritoneal tuberculosis, while Crohn's disease closely mimics intestinal tuberculosis. Imaging modalities (ultrasound, computed tomography, magnetic resonance imaging and occasionally positron emission tomography) guide the line of evaluation. Research in diagnostics (imaging and endoscopy) has helped in the better acquisition of tissue for histological and microbiological tests. Although point-of-care polymerase chain reaction-based tests (e.g. Xpert Mtb/Rif) may provide a quick diagnosis, these have low sensitivity. In such situations, ancillary investigations such as ascitic adenosine deaminase and histological clues (granulomas, caseating necrosis, ulcers lined by histiocytes) may provide some specificity to the diagnosis. A diagnostic trial of antitubercular therapy (ATT) may be considered if all diagnostic armamentaria fail to clinch the diagnosis, especially in TB-endemic regions. Objective evaluation with clear endpoints of response is mandatory in such situations. Early mucosal response (healing of ulcers at two months) and resolution of ascites are objective criteria for early response assessment and should be sought at two months. Biomarkers, especially fecal calprotectin for intestinal tuberculosis, have also shown promise. For most forms of abdominal tuberculosis, six months of ATT is sufficient. Sequelae of GITB may require endoscopic balloon dilatation for intestinal strictures or surgical intervention for recurrent intestinal obstruction, perforation or massive bleeding.
腹腔结核病是一种古老的疾病，在诊断和治疗方面存在现代的细微差别。其主要形式有结核性腹膜炎和胃肠道结核病（GITB），而较少见的形式则包括食管、胃十二指肠、胰腺、肝、胆囊和胆道结核病。临床医生需要将该病与类似疾病区分开来：腹膜癌病与腹膜结核病极为相似，而克罗恩病则与肠结核病相似。影像学检查（超声、计算机断层扫描、磁共振成像，偶尔还包括正电子发射断层扫描）可指导评估方法。诊断学（影像学和内镜）的研究有助于更好地获取组织进行组织学和微生物学检查。虽然基于即时聚合酶链反应的检测方法（如 Xpert Mtb/Rif）可能提供快速诊断，但这些方法的敏感性较低。在这种情况下，辅助检查（如腹水腺苷脱氨酶和组织学线索（肉芽肿、干酪样坏死、由组织细胞衬里的溃疡））可能会为诊断提供一定的特异性。如果所有的诊断手段都无法确诊，尤其是在结核病流行地区，可以考虑进行抗结核治疗（ATT）的诊断性试验。在这种情况下，必须进行明确的疗效评估。早期黏膜反应（溃疡在两个月内愈合）和腹水消退是早期反应评估的客观标准，应在两个月时进行评估。生物标志物，特别是粪便钙卫蛋白在肠结核病中的应用也显示出了前景。对于大多数形式的腹腔结核病，六个月的 ATT 治疗即可。GITB 的后遗症可能需要内镜球囊扩张来治疗肠道狭窄，或需要手术干预来治疗反复发作的肠梗阻、穿孔或大出血。
