The plastic peritonitis type of abdominal tuberculosis

This is the result of a tuberculous granuloma, which causes a patient's omentum, and the other structures in his abdomen, particularly loops of his distal small gut, his caecum, and his ascending colon, to mat together with many adhesions. The affected coils of his gut are thick and rubbery, with characteristic transverse lesions on his small gut. Loops of his small gut may obstruct, and be difficult to separate. Carcinoma, amoeboma, and Crohn's disease can all cause a plastic peritonitis; but in the developing world tuberculosis is more common than all these others combined. Amoebiasis makes loops of small gut stick to the descending colon, without causing a true plastic peritonitis.

The obstruction in his gut is commonly incomplete, so that his symptoms are subacute or chronic, and may have lasted months or years. The adhesions which mat the loops of his gut together are extensive and difficult to separate, so manage him non- operatively if you can. Give him chemotherapy, a light diet, or fluids only, if necessary intravenously, for a few days. A tuberculous granuloma of the small gut usually resolves without a stricture; but in the ileocaecal area fibrosis and stenosis often follow.

Occasionally, you may have to operate for persisting complete obstruction. Even then, if you know tuberculosis is the cause, you will be wise to try non-operative treatment for a few days first[md]if there is no strangulation. When you do operate, you may find that there is no stricture in the wall of his gut, and that you can relieve the obstruction by dividing adhesions only. This is much preferable, if it is possible, because, if you open his gut, there is always a danger that a fistula may follow. If you have to open his gut, you have a choice between: (1) A ''stricturoplasty', if there is a narrow stricture in his his small gut, as in A, Fig. 29-8. (2) A local small-gut bypass (D, 29-8). (3) A bypass (ileotransversostomy) between his ileum and his transverse colon (9.6). This will relieve his obstruction, and you can refer him for definitive surgery later. (4) A right hemicolectomy (66-20). If you are skilled enough to do it, this will remove the focus of infection, and is better than an ileotransversostomy.

Avoid these common mistakes: (1) Don't try to make a diagnosis without understanding the nature of the disease. Make it by weighing up the signs and symptoms carefully. (2) Don't be too eager to start a therapeutic trial without confirming the diagnosis: he may have some other disease. He will almost certainly be well enough for a ''minilap' under local anaesthesia (29-6). (3) If you cannot make a diagnosis, don't wait too long before exploring his abdomen. (4) If he has subacute obstruction, which does not respond to non-operative treatment, you will have to relieve it surgically. (5) If he is desperately ill, don't make meddlesome and dangerous attempts to resect grossly scarred gut, or to free difficult adhesions.

PLASTIC ABDOMINAL TUBERCULOSIS SYMPTOMS. The pattern of signs and sypmtoms described here applies to abdominal tuberculosis as it presents in India and Nepal, where the plastic type of the disease predominates. The different presentation of the ascitic type is described elsewhere (29.6).

Weight loss (all cases), the patient may have lost much weight.

Weakness, malaise, fatigue, and anorexia (75%) are common. He may also have nausea and vomiting, fever and night sweats (60%).

Abdominal pain (90%) is usually constant, central, and not severe. If it is in his right lower quadrant, it suggests ileocaecal tuberculosis. In the ascitic type pain is often mild, and may be absent.

Symptoms of obstruction (30%) include alternating constipation and diarrhoea, cramps, and gurglings. Typically, he describes a ''ball of wind' moving in his abdomen.

Rectal bleeding is rare, but may be severe.

Steatorrhoea with pale, bulky, and offensive stools is sometimes seen.

A chronic cough and blood-stained sputum are rarer than you might expect.

SIGNS [s7]OF ABDOMINAL TUBERCULOSIS Abdominal tenderness (60%) is ill-defined, and is usually maximal in the middle of his abdomen. It is absent in about half the cases. Experts say that they can recognize a peculiar ''doughy' feeling in a tuberculous abdomen.

An abdominal mass (40%) may be present. He may have one or two well-defined tender rubbery masses, either in his ileocaecal region, or at the base of his mesentery. A mass is unusual in the ascitic type.

Signs of obstruction to his lower small gut may be acute or subacute.

He is usually moderately anaemic, and he may have dependent oedema as the result of hypoproteinaemia.

X-RAYS. If you suspect acute or subacute bowel obstruction, take films in the erect and supine positions (10-6, 10-7). Avoid a barium follow through in the acute stage: it may make an incomplete obstruction complete.

SPECIAL TESTS. Measure his haemoglobin and his ESR, and examine his stools. X-ray his chest, and examine his sputum. Do

a tuberculin test (29.1). If he has palpable ascites, examine it as described earlier.

Examine him carefully for enlarged axillary or cervical lymph nodes; if you find one, biopsy it. An inguinal node is less likely to be diagnostic, unless it is very large.

THE DIFFERENTIAL DIAGNOSIS [s7]OF PLASTIC ABDOMINAL TUBERCULOSIS Suggesting ascaris infection[md]he is a child with vague abdominal pain, and subacute obstruction but no weight loss or fever. Tenderness is not constant, and palpable masses of worms are unusual. See Section 10.6.

Suggesting an appendix abscess[md]a short history, and an acute onset.

Suggesting amoebiasis[md]a history of passing blood and mucus rectally, and trophozoites in his stools.

Suggesting carcinoma of the colon[md]a Western life style. It does occur in villagers but is unusual.

Suggesting cirrhosis or a liver tumour[md]an iregular firm or hard liver, prominent ascites, and a large spleen, a previous attack of hepatitis, alcoholism. A bruit is often present (32.26).

Suggesting Crohn's disease (rare)[md]loss of weight and diarrhoea are the main symptoms. The differential diagnosis may be impossible until tissues are examined histologically.

NON-OPERATIVE TREATMENT [s7]FOR ABDOMINAL TUBERCULOSIS INDICATIONS. (1) You are reasonably certain of the diagnosis. He is either not obstructed, or his obstruction is subacute. (2) There are no signs of strangulation.

REGIME. Give him chemotherapy (29.1). If he is an adult, his abdominal symptoms and masses are unlikely to respond for about 2 months, although a child may respond sooner. Don't expect chemotherapy to work miracles, if he has acute disease and ascites. If he fails to respond to tuberculosis treatment, consider the possibility of: (1) AIDS in addition to tuberculosis. (2) Carcinoma, or an abdominal lymphoma.

If he is subacutely obstructed, pass a nasogastric tube, give him intravenous fluids, and resuscitate him as in Section 10.5. If he improves and his obstruction passes off, good. If it does not, you may have to operate to divide adhesions, but there is no guarantee that they will not form again.

A DIAGNOSTIC LAPAROTOMY [s7]FOR PLASTIC ABDOMINAL TUBERCULOSIS A minilap for ascitic tuberculosis is described above. A standard laparotomy through an ordinary incision is a more extensive procedure, which may involve you in further surgery. Do one if he has a persistent vague abdominal pain, perhaps some intestinal symptoms, weight loss, and a raised ESR. Open his peritoneal cavity through a right paramedian incision, mostly below his umbilicus, and look for the findings listed above.

If you cannot find peritoneal tubercles or rubbery lymph nodes easily, take a biopsy from his parietal peritoneum. Incise his peritoneum and biopsy a lymph node. If the site of the biopsy bleeds, control it with packs or with a 3/0 figure of eight suture which underlies the bleeding point on both sides.

If you find a firm mass at his ileocaecal junction, perhaps with adhesions to adjacent structures and a normal peritoneum, the diagnosis is more difficult. Cut across an enlarged node. If you see caseous areas, you have confirmed the diagnosis. Even so, take a specimen for histology. Avoid taking a biopsy from the wall of his gut[md]this may lead to a fistula.

If the nature of an ileocaecal mass is uncertain, and it might be neoplastic, biopsy an enlarged node nearby and proceed as immediately below. Start chemotherapy postoperatively, and await the histological report.

If his ileocaecal mass is probably tuberculous, leave it if it is not is causing obstruction. If it is causing obstruction, do an ileotransversostomy, or if you are experienced, do a right hemicolectomy. If he is debilitated, an ileotransversostomy would be wiser, however skilled you are. Some surgeons would do one or the other of these operations whether or not the mass is causing obstruction.

If he is bleeding rectally, or has a tuberculous ulcer, treat him non-operatively if you can. Only do a hemicolectomy if bleeding is severe and continuous.

If you find a thick fibrotic segment of small gut and his ileocaecal region is normal, you can resect it and anastomose the ends if it is not too long, and there is not too much scarring or too many thick adhesions. If it is very short, do a stricturoplasty as in A, Fig. 29-8.

If a tuberculous ulcer has perforated his terminal ileum, oversew and patch it, as you would with a typhoid perforation (31.8). Or, treat it by resection and end to end anastomosis (9-9).

If loops of his gut are stuck down by plastic peritonitis, don't do too much dissection[md]the risks are too high. Instead, if he really is obstructed, do a simple side to side entero-enterostomy. Use the same technique as an ileotransversostomy. This will bypass the diseased segment, and avoid much stressful surgery.

ILEOTRANSVERSOSTOMY [s7]FOR OBSTRUCTION DUE TO PLASTIC TUBERCULOSIS See also Section 9.3. Do it side to side, as in Fig. 9-12, but without dividing the gut and closing the ends, because there is no gut to be resected.

PREPARATION. If he is obstructed, make sure you correct his electrolytes first, as in Section 10.5. If you have time, prepare his gut. Give him a fluid diet, cleansing enemas for two days before, and a suitable course of a bowel-sterilizing agent, such as neomycin with sulphaphthalazole.

INCISION. Make a right paramedian muscle-splitting incision. Choose a point on his ileum which is at least 3 cm proximal to any stenosed or diseased gut, and apply a Babcock clamp to the antemesenteric border, lifting the gut out of the wound as you do so. Apply a second Babcock clamp about 3 cm proximal to the first one.

Reach up and draw his transverse colon into the wound. If necessary, extend the incision upwards.

Lift up the omentum which hangs below his transverse colon. It is attached to the anterior surface of his colon by a relatively bloodless fold. Divide this fold with scissors. Displace the freed omentum upwards, and so expose 6 cm of the anterior surface of his transverse colon. Place two Babcock clamps on the taenia of his colon 4 cm apart. Bring the clamps on his ileum up towards those on his colon, so the two parts of his gut lie side by side.

To minimize spillage and contamination, milk the central segment of his transverse colon empty. Then apply non[nd]crushing clamps to each end of the denuded area. Squeeze away the contents of his ileum, and apply light occluding clamps to it in the same way.

Make a two-layer side to side anastomosis with a 3 cm stoma as in Fig. 9-12, but without resecting gut and closing the ends. Make it 2 mm from the edge of the taenia to give extra strength. Use interrupted or continuous Lembert sutures. Open his colon over a distance of about 3 cm.

Draw his omentum down and tack it lightly to the site of the anastomosis with a few interrupted sutures through the serosa only. Replace his gut in his abdomen.

Fig. 29-8 OBSTRUCTIVE ABDOMINAL TUBERCULOSIS. A, to C, the Heinecke[nd]Miculicz procedure for a stricture of the small gut. A, incise the gut longitudinally. B, insert stay sutures beside the middle of the incision, pull them out, and sew up the gut transversely. C, the completed procedure. D, to G, side to side anastomosis to bypass a stricture. D, the stricture with the loops of gut either side of it about to be apposed. E, place a layer of continuous seromuscular sutures between the loops, before you open them. F, the next step is a layer of continuous over and over sutures between the two loops. G, the completed anastomosis. See Fig. 9-12 for further details. Kindly contributed by Samiran Nundy.