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116 Tuberculosis

frozen section examination may help in such cases. A mesenteric lymph care provider or a nurse. DOT should be used with all children suffer-
node should preferably be removed in such cases, as caseation and ing from tuberculosis. The lack of availability of the paediatric dosage
granulomas are much more likely to be present in lymph nodes than in forms of most antituberculosis medications necessitates using crushed
the intestinal lesions. An omental nodule may also be taken for biopsy. pills and suspensions. Even when drugs are given under DOT, tolerance
The correction of a stenotic bowel lesion may be done if found. of the medications must be monitored closely. Intermittent regimens
It is important to remember that: should be monitored by DOT for the duration of therapy because poor
compliance may result in inadequate drug delivery.
• Laparotomy is better performed under empirical cover of antituber-
cular drugs for about 2 weeks, wherever feasible. Surgery for Pulmonary Tuberculosis
It must be emphasized that medical therapy remains the mainstay of
• The aim of surgery in tubercular abdominal patients is to do mini- treatment in pulmonary tuberculosis, and surgical treatment is primarily
mal intervention and avoid any major operative procedure. Perhaps
used to handle complications and hasten recovery.
only a bypass surgery is enough just to relieve the symptoms.
Tubercular pathology cannot be eradicated by surgery alone. In children, the primary complex is usually directly or indirectly the
main etiologic factor responsible for the need for surgical intervention.
• External diversion (ileostomy or double-barrel stoma), internal Indications for surgical intervention are limited in children, and the
diversion with side-to-side bowel anastomosis, closure of the perfo- challenge lies in determining the timing and nature of intervention.
ration, and stricturoplasty are the commonly performed procedures. Indications for surgery in paediatric pulmonary tuberculosis include:
Surgical resection is less commonly performed. • airway obstruction, extrinsic lymph node compression or intralumi-
• Laparoscopy is not indicated due to the high possibility of adhe- nal obstruction;
sions inside the peritoneal cavity. The risk of perforation of the • progressive primary infection-cavity formation;
bowel is also high while being handled with instrumentation. Tract
contamination may result in chronic tubercular fistula. • posttuberculous bronchiectasis;
Medical Treatment • bronchial stenosis/stricture;
Antimicrobial treatment is the same for pulmonary and abdominal • drainage of lung abscess;
tuberculosis. Medical treatment with a standard full course of ATT is • bronchopleural fistula, broncho-oesophageal fistula;
indicated in all patients. In peritoneal tuberculosis, only medical treat-
ment is required. Intestinal tuberculosis is a systemic disease. In GI • massive hemoptysis;
tuberculosis, surgery may be required and preferably is done 6–8 weeks • chest wall sinus;
after starting the antitubercular therapy. Although the use of short
course regimens for 6–9 months have been found to be equally effec- • posttubular constrictive pericarditis;
tive by few studies, many physicians still extend the treatment duration • fibrothorax/trapped lung;
to 12 to 18 months, according to the conventional regimens in cases of
abdominal tuberculosis. This is justified in view of the unpredictable • suspicion of malignancy;
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absorption due to the diseased gut and associated symptoms such as • pulmonary resection for MDR-TB;
vomiting and malabsorption.
The main antitubercular drugs are isoniazid (INH), rifampicin, • tubercular rib osteomyelitis; and
ethambutol, pyrazinamide (PZA), and streptomycin (SM). Thiacetazone • tubercular empyema.
and p-aminosalicylic acid (PAS) are not recommended for use for
abdominal tuberculosis. In a study of 350 patients with extrapulmonary Indications for pulmonary resection in cases of tuberculosis include:
tuberculosis (including 47 children), a 9-month regimen using only • persistently positive sputum cultures with cavitation after 6 months
34
INH and rifampicin was successful in 95% of the cases, with only 0.7% of continuous optimal chemotherapy with two or more drugs;
of the cases relapsing during a follow-up of 9 years. • symptomatic bronchiectasis not controlled with conservative measures;
Patients with peritoneal, nodal, or ulcerative intestinal disease are
usually treated with drugs (e.g., ATT). Corticosteroids have also been • advanced disease with extensive caseation necrosis;
used to reduce subsequent complications of adhesions in patients • massive life-threatening haemoptysis or recurrent severe haemoptysis;
with peritoneal disease. No controlled studies have been performed to • trapped lung;
show the additional benefit of using steroids. Patients with intestinal
obstruction due to strictures and hypertrophic lesions require surgical • localised disease with resistant organisms (localised disease defined
treatment. Successful treatment of obstructing intestinal lesions with as that encompassing one or two segments of the lung); and
ATT alone has also been seen. Patients usually report improvement in • a mass lesion of the lung in an area of tubercular involvement.
systemic symptoms in a few weeks, but relief of intestinal symptoms
may require a much longer duration. Surgery for Abdominal Tuberculosis
Monitoring with liver function tests (LFTs) is necessary, especially if In GI tuberculosis, if symptoms recur after starting drugs, then elective
the patient has suspected icterus or malaise, anorexia, or abdominal pain. surgery is planned. Emergency surgery may be required in 25–30%
INH, rifampicin, and pyrazinamide should be discontinued temporarily of abdominal tuberculosis cases, particularly those who present with
in the presence of icterus or a threefold rise in transaminases. As the perforation, acute intestinal obstruction not responding to conserva-
antitubercular therapy causes healing with fibrosis, this may result in tive measures, acute peritonitis, and, rarely, significant hematochezia
further narrowing and intestinal stricture. Therapy can also alter the (Figure 18.2). Historically, bypassing the stenosed segment was prac-
histopathological picture and may even increase the perforation rate. ticed when effective antitubercular drugs were not available, as any
Directly Observed Therapy surgery involved with side-to-side anastomosis or the resection of the
Since noncompliance to these regimens is a common cause of treat- bowel segment was considered hazardous in the presence of active dis-
ment failure, directly observed therapy (DOT) is recommended. This ease. This practice, however, produced blind loop syndrome, fistulas,
involves administration of medication under supervision by a health and recurrent obstruction in the remaining segments. With the advent