A prospective audit of the use of diagnostic laparoscopy to establish the diagnosis of abdominal tuberculosis.

Abstract

HIV epidemic is one of the major challenges to the South Africa’s socio-economic development. The incidence of tuberculosis is rising in sub-Saharan Africa, and in 2009 South Africa had the second highest incidence of tuberculosis in the world. Approximately 80% of incident tuberculosis cases in South Africa are HIV positive. In HIV positive individual, abdominal tuberculosis has been reported as the most common form of extra-pulmonary tuberculosis. HIV/AIDS has resulted in a resurgence of abdominal tuberculosis in South Africa. Making the diagnosis of abdominal tuberculosis is still difficult, though the condition is common. The role of laparoscopy in making the diagnosis is undefined. Method: All patients with clinically and radiologically suspected but histologically or microbiologically unconfirmed abdominal tuberculosis were referred to the investigating team and laparoscopy was performed to diagnose abdominal tuberculosis. Histology was performed on tissue biopsy specimens and TB culture on ascitic fluid and peripheral blood specimens. Results: From January 2008 to June 2010 a total of 190 patients were referred to us. No surgical intervention was taken in 60 patients; all of them were HIV positive. Twenty six of them died (43%) in the hospital during the evaluation period before the diagnostic laparoscopy, and the rest (57%) were unfit for anaesthesia. Forty nine patients required emergency laparotomy either for bowel obstruction or peritonitis and 39% of them died. Eighty one patients underwent diagnostic laparoscopy and 77% of them were HIV positive, in 16% the HIV status was unknown. Two percent had clinical ascites. Laparoscopic findings included intra-abdominal lymphadenopathy in 56, minimal ascitic fluid in 46, intra-abdominal mass in 17, and deposits on bowel wall, peritoneum or omentum in 20 patients. Fifty five patients (68%) had positive histology for tuberculosis. In 15 patients (19%) histology revealed non-specific inflammation, no pathology was found in one patient and no specimen was taken from one patient. Eighty percent of peritoneal deposits and 77% of lymph nodes were positive for tuberculosis, whereas 35% ascitic fluid culture was positive. In nine patients (11%) an alternative diagnosis was found (appendicitis, adenocarcinoma, lymphoma). Conclusion: Laparoscopy was feasible and showed a high yield to establish the diagnosis of abdominal tuberculosis and to provide an alternate diagnosis. Laparoscopy was useful to establish the gross features of abdominal tuberculosis and to provide the adequate specimens for examinations. Very poor follow negated the evaluation of the clinical response to anti tuberculosis therapy.