Abdominal tuberculosis is now rare in the industrial world, but is common in developing countries. In India and Nepal it is responsible for about 10% of gut obstructions. You are most likely to see it when you are expecting something else.
There are three main types, and several less common ones. In Africa the order of their frequency in adults is: (1) The type which presents as ascites. (2) The plastic type, which causes intestinal obstruction. (3) The glandular type, which involves the mesenteric nodes. In India the order of frequency of these types in adults is (2), (3), (1). In children in Africa their order of frequency is (3), (1), (2).
These three types are described in detail in later sections. Less commonly, you may also see:
(4) Tuberculous strictures anywhere in a patient's gut, but usually in his caecum and distal small gut, where they are caused by the shrinkage of a tuberculous ileocaecal mass to form a fibrous constriction.
(5) Tuberculous ulcers (unusual) can occur anywhere in his gut, but are most often seen in his ileum, caecum, rectum, or sigmoid colon. In his small gut, a tuberculous ulcer can cause diarrhoea. On the rare occasions when the ulcer is in his stomach or duodenum, it can closely mimic a peptic ulcer, or a carcinoma. Caseating lymph nodes will lead you to the correct diagnosis. A tuberculous ulcer may perforate his gut, or bleed; because it usually occurs distally, he usually bleeds from his rectum.
(6) Tuberculous fistulae form occasionally.
All this pathology can present in so many ways, and with so few distinguishing signs, that diagnosis is difficult. With all forms of tuberculosis he loses his appetite, he loses weight, and he feels ill, just as he does with tuberculosis elsewhere. He has vague abdominal pain and tenderness, and may vomit. Depending on the type of tuberculosis he has, he may have the symptoms of abdominal swelling (the ascitic type), obstruction (the plastic type), abdominal masses (the glandular type), or bleeding or perforation (tuberculous ulcers).
If he is not obstructed, or bleeding, you can treat him medically. But you will have to operate if his gut obstructs completely (the plastic type) or, rarely, if he bleeds (tuberculous ulcers).
Fig. 29-5 MORE ABDOMINAL TUBERCULOSIS. A, an adhesion causing obstruction. B, tuberculous ulcers. C, coils of gut matted together. Adapted from a drawing by Frank Netter, with the kind permission of CIBA-GEIGY Ltd, Basle (Switzerland).