Sricturoplasty in Tuberculous small bowel Strictures

Muhammad Akbar

Department of Surgery, Ayub Medical College, Abbottabad.

Background: This study was conducted at DHQ Hospital Hangu, Babul Madina Medical Centre & Shifa Medical Centre Hangu from March 1995 to February 2001 to evaluate the presentation of tuberculous small bowel strictures and assess the usefulness and applicability of stricturoplasty to these lesions. Methods: Ten patients were included in the study in whom the diagnosis of tuberculous small bowel strictures was made on laparotomy and histopathological examination of the tissues taken from the strictures. Heinki/Mikulikz's type stricturoplasty was done in all the cases. The patients were kept on antitubercular drugs and were followed for assessment of outcome. Results: Seventy percent of the patients’ presented/ operated upon in emergency. Age ranged from twenty to forty years with mean age 31.5 years. Male to female ratio was 6:4. Weight loss and malnutrition were the most common associated features. Terminal ileum alone was involved in 50% of the cases. The strictures were solitary in six and multiple in four cases. The lesions were acute in four and chronic in six patients. Stricturoplasty worked well both in acute and chronic cases. Conclusion: Stricturoplasty is safe, simple, and easy procedure particularly suitable at poorly equipped and under staffed district hospitals.

Keywords: Intestinal tuberculosis, Strictures, stricturoplasty.

INTRODUCTION

Intestinal Tuberculosis is a common and major health hazard in Pakistan just like other countries where ignorance, poverty, overcrowding and malnutrition are prevalent. The disease starts either as transverse ulcers in the intestine or hypertrophic mass lesions usually affecting ileocaecal region^1,2. Later on strictures develop which are usually situated in terminal ileum³. These strictures then cause intestinal obstruction, which is usually acute but may be subacute and chronic giving rise to mallabsorption syndrome⁴.

Laparotomy is required for diagnosis and is life saving in cases presenting with obstruction or perforation. A number of surgical procedures are available to deal with small bowl strictures, but stricturoplasty is simple, easier and safe operation⁵. It is especially useful for patient with poor general condition. The operation also enables one to deal with multiple lesions without sacrifice of the long segments of the intestine⁶.

This study was conducted to determine the presentation of the patient's with small bowl strictures and ascertain the applicability and usefulness of the stricturoplasty at DHQ level hospital.

PATIENTS AND METHODS

This study was conducted at DHQ hospital Hangu, Babul Madina Medical Centre & Shifa Medical Centre Hangu. These hospitals provide health care facilities to the Orakzai and Kurram Agencies in addition to Hangu district. This place is near Afghanistan border and bordering Afghan population also uses these facilities. The duration of study was six years from March 1995 to February 2001. Ten patients included in this study fulfilled the following criteria of paustian².

1-     Laparotomy revealed bowel stricture(s) with or without mesenteric lymphadenopathy/peritoneal tubercles.

2-     Histopathology of the stricture/Mesenteric lymph nodes or peritoneal tubercles revealed caseating granulomata.

The age, sex and the nationality of the patients were recorded. Their detailed history was taken with special reference to their abdominal pain and altered bowel habits and concomitant pulmonary tuberculosis. Proper physical examination was performed. Their nutritional status was assessed clinically by measuring body mass index (BMI) & mid arm muscles circumference (MAMC).

Peripheral lymphadenopathy was looked for. Radiographs of the abdomen and chest were taken. ESR was measured in al the patients in addition to routine baseline investigations. The ultrasound scan of the abdomen was obtained only in two cases. The patients were resuscitated when necessary before operation.

The operative findings were recorded regarding the site and number of strictures and associated findings, i.e., tubercles on peritoneal surfaces, mesenteric lymphadenopathy and thickening of mesentery. Stricturoplasty was performed in all cases. Bowel was opened longitudinally along the anti-mesenteric border between two loosely applied stay sutures at the centre. The incision extended 1–2 Cm in healthy non-strictured bowel on either side. The stay sutures were then pulled apart converting the linear incision into a diamond shaped defect. Biopsy from the margins of the incision including the strictured part was taken and sent for histopathology. Mesenteric lymph nodes and peritoneal tubercles when present were also sent for histopathology. Closure was then started from one stay suture and continued transversely to the other one. The repair was done in two layers, inner full thickness with 2/0 catgut and outer seromuscular with 2/0 silk. In patients with multiple strictures, similar procedure was done at more than one site.

Patients were kept on nasogastric suction and intravenous fluids for six to seven days. Antibiotics were used in all cases and the regimen was Metronidazol, Ampicillin and Streptomycin.

The patients were monitored for post operative complications. On sixth to seventh day the patients were allowed to take orally and full anti- tubercular regimen was started. This was Isoniazid (INH), Rifampicine, Ethambutol and Pyrazinamide. After two months Pyrazinamide was excluded from the regimen and the other three drugs were continued for a further four months. Regular monthly follow-up was possible in nine cases. On every visit the patients were clinically examined. Their proper drug intake was ensured and any drug complications searched for. One patient left for Afghanistan but his relatives conveyed his well-being and regular intake of drugs. He was only re-examined after 11 months when he came for advice regarding discontinuation of drugs.

RESULTS

Seven patients presented with acute intestinal obstruction and operated upon in emergency after resuscitation. In 2 patients diagnostic/exploratory laparotomy was performed for recurrent abdominal pain and altered bowel habits. One patient presented with pain in right lower quadrant of abdomen and operated upon on the presumptive diagnosis of acute appendicitis. Table-1 summarizes the preoperative presentation of these cases.

All the patients were between 20 to 40 years of age with mean age of 31.5 years. Male to female ratio was 6:4. Five patients were Afghan refugees. Diagnosis of intestinal tuberculosis was established only after operation.

Table-1: Presentation of tuberculous bowel strictures in 10 cases

Concomitant cervical lymphadenopathy was noted in two patients. X-ray chest was suggestive of pulmonary tuberculosis in one patient. High ESR and malnutrition were observed in five cases each. Table-2 illustrates these concomitant features.

Table-2: Concomitant clinical features in 10 patients of intestinal tuberculosis.

                Strictures in small bowel were solitary in six cases, All the solitary strictures caused acute intestinal obstruction.  Multiple small bowel strictures were found in remaining four cases. The number and sites of strictures are shown in Table-3.

Table-3: Location of strictures in 10 cases of intestinal tuberculosis

In one patient caecum was scarred and ileocaecal angle was deformed. In another patient there was mass formation in ileocaecal region with tubercles on peritoneal surfaces. Multiple peritoneal tubercles were also seen in two other cases. Mesentery of the small bowel particularly of the terminal ileum was thickened in seven cases. Mesenteric lymph nodes were enlarged in three cases. Strictures in four cases were oedematous, reddish, and broad while in remaining six cases they were thin white and well demarcated. Table-4 shows these morphological features.

Table-4: Morphology of intestinal tuberculosis in 10 patients.

Six patients underwent single stricturoplasty while in four patients the procedure was done in more than one site.  Mean hospital stay was nine days ranging from seven to sixteen days. Significant wound infection occurred in four patients.  Three patients had postoperative chest complications. No patient died in the study.

DISCUSSION

Tuberculosis is the common cause of small bowel strictures in our part of the world^4,5,6. Other causes of bowel strictures include Crohn’s disease^7,8, irradiation⁹, drugs¹⁰ and mesenteric vasculopathy¹¹ but are rare in this subcontinent¹². The operation of ‘stricturoplasty’ for tuberculous strictures of GIT was first reported in 1977 by Katarya¹³ from Chandigarh (India). The operation is similar to the Hienki 1886 and Mikulikz1888 pyloroplasty for pyloric stenosis described more then a century ago¹⁴. Surgeons knew the bowel strictures even before this, but the method of Heinki/Mikulikz was not applied to these lesions distal to pylorus, or at least not reported. Strictures were sometimes bypassed and sometime resected. Katarya's article revolutionized the treatment of small bowel strictures. His good results attracted the surgeons all over the world. Pujari⁶, Khan C⁵, Mohayuddin QK¹⁵ and Dandapat MC¹² had reported their series from Indo-Pak-Subcontinent. The surgeons from the western world adopted this operation for the Crohn's disease prevalent there and found the results even more encouraging. They have made further modification in the method. Boufo-AJ, et al¹⁶ has reported stapled stricturoplasty in 1995 Endoscopic balloon dilatation has also been reported by Ball-WS et al¹⁷, Fregonese D et al¹⁸ and William & Palmer¹⁹.

Intestinal tuberculosis like tuberculosis elsewhere in the body affects young peoples at the peak of their reproductive life. This fact has serious impact on national economy and production as sick and ill individuals replace a working and productive class of community. All the patients in our study were between 20 to 40 years of age. This is in accordance with the results of Anand & Pathak²⁰, Ohri and Agrawal²¹, Das & Shukla²², Khan C⁵,Kirsten D²³ and Bilbao-Garey J²⁴.

Males were more commonly affected than females in our study. This is in contrast to the observation of Anand SS²⁵, Ohri & Agrawal²¹, who reported the male to female ratio of 1:3.16 and 1:4 in their series. Bilbao Garey J in 1992 has reported the equal distribution of this disease in both sexes²⁴. The male prevalence in our study is probably due to male dominant tribal society where females are restricted to their homes and not brought to the hospitals for treatment at the early stage of their disease.

Eight out of 10 patients in present study presented in emergency as acute abdomen. This is again in contrast to the observation of Bhansali³ and Palmer et al²⁶ where acute presentation of intestinal tuberculosis   was reported in 46% and 40% of their cases respectively. This is because of the poverty, ignorance and quackery in this tribal belt. Patients ignore their initial symptoms and treat them by traditional remedies till some catastrophe forces them to consult a doctor.

Weight loss and malnutrition was the most common associated feature in our study and was observed 5 out of 10 cases. Bhansali³ has reported weight loss and diarrhoea  in 52 out of her 300 cases. Anand²⁵, Ohri&Agrawal²¹, Lewis and Kolawole²⁷, Lewis and Aboyo²⁸, Parkash²⁹, Mukarjee & Singal³⁰ have reported the incidence of weight loss in 76%, 45%, 100%, 90%, 89% and 80% respectively in their cases of intestinal tuberculosis. This frequent weight loss in intestinal tuberculosis is because of stasis in the bowel due to strictures. Stasis causes bacterial overgrowth in the small bowel lumen, which reduces the conjugated bile acid concentration below critical micellar concentration so that fats are not absorbed properly. Inappropriate bacteria in the small bowel also ferment the carbohydrates to derive energy. The bacteria also compete with the host for available protein substrates metabolizing them to ammonia and fatty acids, which are unable to contribute towards protein anabolism. Thus bacterial growth in the small bowel causes malabsorption of fats, proteins and carbohydrates, which is then manifested clinically with weight loss and diarrhoea³¹.

Suggestive chest X-rays and peripheral lymphadenopathy was seen in one and two patients respectively. Similar findings have also been observed by many other authors.³². 

Terminal ileum was the most commonly involved bowl segment in our study. This is similar to the observation of Das&Shukla²², Anand SS²⁵ and Abrams and Holden¹. This frequent involvement of terminal ileum is due to relative physiological stasis, rapid absorption rate and abundance of lymphoid tissue in this area^1,22.

CONCLUSION

Tuberculous strictures of small bowel are common cause of intestinal obstruction in our community. Patients usually present late in the course of their disease and most often some acute catastrophe brings them to the surgeon. Clinical features are usually non-specific, vague, and diverse and accurate diagnosis is almost always established at operation. Stricturoplasty is a safe, simple and easy operation, particularly useful at small peripheral hospitals with limited staff and resources.

Acknowledgement

The author acknowledges Surgeon Hema Ratna from Andhra Pardesh India for providing material. The author also wishes to thank to Dr. Khalid Nazeer Bhatti, who personally went to India to collect some of the old and precious works on the subject from the library of all India Institute of Medical Sciences New Delhi.

REFERENCES

1.        Abrams JS, Holden WD. Tuberculosis of the Gastrointestinal tract. Arch Surg 1964;89:282-93.

2.        Bhansali SK. The challenge of abdominal tuberculosis in 310 cases. Ind J Surg 1978;40:65-77.

3.        Bhansali SK. Abdominal tuberculosis: Experience with 300 cases. Am.J Gastroenterol 1977;67:324-37

4.        Pimparker BD. Abdominal tuberculosis. J Assoc Phys India 1977;25:801-11.

5.        Khan C. Abdominal tuberculosis and it's surgical managment. Pakistan J Gastroenterol 1989;3(1):22-5

6.        Pujari BD. Modified surgical procedures in intestinal tuberculosis. Br J Surg 1989;66:180-4.

7.        Kum CK, Sim EK, Nooi SS, Goh P, Sinniah R. The surgical treatment of multiple small bowel strictures in Crohn’s disease by combined resection and stricturoplasty. Med J Malaysia 1992;47(4):323-7.

8.        Hurst RD, Michlssi F. Stricturoplasty for Crohn’s disease: Techniques and long term results. World J Surg 1998;22:359-63.

9.        Thomson-JS. Reoperation in patients with short bowel syndrome. Am J Surg 1992;164(5):453-6.  

10.     Matsuhashi N, Yamada A, Hiraishi M, Konishi J, Minota S, Saito T, et al. Multiple strictures of the small intestine after long term non steroidal anti inflammatory drug therapy. Am J Gastroentrol 1992;87(9):1183-6

11.     Kuwajerwla NK, Bapat RD, Joshi AS. Mesenteric vasculopathy in Intestinal tuberculosis Indian. J Gastroenterol 1997;16(4):134-6

12.     Dandapat MC, Mahapatra SK, Nanda N. Conservative surgical management of intestinal tuberculosis J Indian Med Assoc 1990;88:156-8.

13.     Katariya RN, Sood S, Rao PG. Strituroplasty for Tubercular strictures of the gastrointestinal tract.  Br J Surg 1977;64:494-6.

14.     Cuschieri A, Steele RJC, Moosa AR. Disorders of Stomach & Duodenum. In Essential Surgical Practice fourth edition. ARNOLD-2000, Module 8 Page 294.

15.     Mohayuddin QK. Intestinal tuberculosis. Proceedings of 12^th Pakistan tuberculosis seminar 29th Nov–1st Dec 1974: NWFP Tuberculosis Association. 52.

16.     Bufo AJ, Feldman S, Daniels GA, Lieberman RC. Stapled stricturoplasty for Crohn's desease. A new technique  Dis Colon Rectum 1995;38:664-7.

17.     Ball WS, Kosloske AM, Jewell PF, Seigel RS, Bartow SA. Balloon catheter dialitation of focal intestinal strictures following nacrotizing enterocolitis. J Pediatr Surg 1985;20:637-9.

18.     Fragunese D, Di Falco G, Di Toma F. Balloon dilatation of inanastomotic intestinal stenosis, long term results. Endoscopy 1990;22:249-53. 

19.     Williams AJ, Palmer AR. Endoscopic balloon dilatation as a therapeutic option in the management of Intestinal strictures resulting from Crohn’s disease. Br J Surg 1991;78:453-4.   

20.     Anand SS, Pathak IC. Surgical treatement of abdominal tuberculosis with special reference to ileocecal tuberculosis. Ind J Med Assoc 1961;37(9):423-9.

21.     Ohri BB, Agrawal VK. Treatment of Intestinal tuberculosis J Ind Med Assoc 1964;43(3):120-4.

22.     Das P, Shukla HS. Clinical diagonoses of intestinal tuberculoses. Br J Surg 1976;63:941-6.

23.     Kristen D, Polke-K, Kroeger-C, Magnussen H. Memento intestinal tuberculosis. Med Klin 1992;87(11):580-3.

24.     Bilbao GJ, Deletona JM, Carreno MC, Perez MR. Abdominal tuberculosis today. A review of 46 cases. Rev-Clin-Esp 1992;191(1):19-24.

25.     Anand SS. Hypertrophic ileocaecal tuberclusis in India with a record of 50 hemicolectomies. Ann. R Coll Surg England 1956;19:205-21.

26.     Palmer KR, Patil DH, Basran GS, Riodan JF. Abdominal tuberculosis in urban Britian—a common disease. Gut 1985;26:1296-305. .

27.     Levis EA, Kolawole TM. Tuberculous ileocolitis in Ibadan. A clinicoradiological review. Gut 1972;13:646-53.

28.     Levis EA, Aboyo AA. Tuberculosis of abdomen in Ibadan. Aclinicopathalogical review. Tubercle 1975;56:149-55.

29.     Parkash TM. Intestinal tuberculosis—18 years review. Ind J Surg 1978;40:56-64.

30.     Mukarjee P, Singal AK. Intestinal tuberculosis 500 operated cases. Proc Assoc Surg East Africa 1979;2:70-5. 

31.     Bjorneklett A, Hoverstad T, Hoving T. Bacterial overgrowth. Scand J Gastroenterol 1985;109:123-32.

32.     Underwood MJ, Thompson MM, Sayers RD, Hall AW. Presentation of Abdominal tuberculosis to general Surgeons. Br J Surg 1992;79(10):1077-9.

Address for Correspondence:

Dr. Muhammad Akbar, Assistant Professor Surgery, Ayub Medical College, Abbottabad-22040, Pakistan.

Email: akbar@ayubmed.edu.pk