Tuberculosis (TB), caused by Mycobacterium tuberculosis (M. tuberculosis) complex bacteria, is one of the oldest diseases known to affect humans and is the leading infectious cause of mortality worldwide. Population genomic studies suggest that M. tuberculosis may have originated in Africa approximately 70,000 years ago, spreading alongside anatomically modern humans and expanding globally during the Neolithic Age as human population density increased. Up to one-third of TB cases can involve organs other than the lungs.

Tuberculosis is a chronic granulomatous disease caused by Mycobacterium tuberculosis, a thin, aerobic, acid-fast, rod-shaped, non-spore-forming bacterium measuring 0.5\(\mu\)m by 3\(\mu\)m [1, 2]. In developing nations where factors like ignorance, poverty, overcrowding, inadequate sanitation, and malnutrition prevail, tuberculosis is a significant health concern [3]. The World Health Organization (WHO) has declared it a global emergency and the most significant communicable disease worldwide. WHO estimated 10.4 million new TB cases worldwide in 2016, with 95% of these cases occurring in developing nations [4]. High-risk groups for TB exposure include household contacts, prisoners, destitute individuals, intravenous drug abusers, and immigrants from high-prevalence regions.

Abdominal tuberculosis is a serious public health concern in developing countries like India, associated with high morbidity and mortality rates [5, 6]. Approximately 15-25% of newly diagnosed gastrointestinal TB cases also have coexisting pulmonary tuberculosis. Abdominal tuberculosis constitutes around 5% of all global TB cases. It remains a significant public health challenge worldwide, particularly in resource-limited settings, posing diagnostic and therapeutic complexities [7]. Reactivation of latent TB can lead to abdominal tuberculosis, with lesions often present in the peritoneal cavity. Gastrointestinal tract contamination via milk from Mycobacterium bovis (found in cattle) can transmit tuberculosis. TB can affect any part of the digestive tract, including the oral cavity, anus, pancreatobiliary system, and peritoneum. The peritoneum and ileocecal region are most commonly affected, followed by the jejunum and colon [8].

In cases of intestinal tuberculosis, abdominal pain, constipation, and regurgitation suggestive of intestinal obstruction are common, and recurrent bouts of subacute intestinal obstruction can occur. Symptoms may include localized or widespread ascites, diarrhea, fever, weight loss, night chills, melena, and anemia. Abdominal TB can manifest as acute, chronic, or acute-on-chronic forms and is often incidentally discovered.

Clinical manifestations of abdominal TB resemble those of other diseases, leading to delayed diagnosis. The most prevalent site is the ileocecal region, characterized by decreased digestive activity, increased physiological stasis, enhanced fluid and electrolyte absorption, and abundant lymphoid tissue. Bacilli dissemination from mesenteric lymph nodes can lead to peritoneal involvement. Intestinal obstruction due to stricture or adhesions is a common complication. Perforation, a severe complication, is a surgical emergency with significant challenges for young physicians. In most cases, medical consultation trials should precede surgical intervention.

This study aimed to offer a fresh perspective on abdominal tuberculosis, enhancing understanding of its clinical manifestations, diagnostic methods, early management, and complications. Therefore, the study aimed to assess clinical and laboratory profiles of patients with abdominal tuberculosis.

The study was conducted at the VSS Institute of Medical Sciences and Research (VIMSAR), Burla, situated at 21.5027\(^o\) N and 83.8865\(^o\) E in western Odisha, India. Approval was obtained from the Institutional Ethics Committee prior to commencement. The research spanned from November 2019 to October 2021 (24 months) and focused on patients from the Outdoor (OPD) and indoor (IPD) divisions of the General Medicine Department at VIMSAR, Burla. This cross-sectional study enrolled a total of 73 patients. Inclusion criteria comprised patients admitted to the General Medicine Department with suspected abdominal tuberculosis, clinical diagnosis of TB abdomen, age > 14 years, and willingness to provide informed consent. Pregnant women, individuals with prior antitubercular therapy, and those unwilling to participate were excluded.

The Kuppuswamy scale, developed in 1976 [9], was utilized in this study. This composite score incorporates family head education, occupation, and monthly income to yield a score between 3 and 29, categorizing the family’s residence as rural or urban. Clinical variables, including fever, abdominal pain, abdominal distension, weight loss, ascites, constipation, diarrhea, night sweats, and intestinal obstruction, were assessed.

Diagnostic criteria for abdominal TB included strong clinical suspicion coupled with cytological, histopathological, radiological, and biochemical evidence. Procedures like ascitic fluid aspiration, fine-needle aspiration cytology (FNAC), and lymph node biopsy were conducted. Hematological parameters such as complete blood count, peripheral blood smear analysis, and Erythrocyte Sedimentation Rate (ESR) were documented.

Data collected underwent scrutiny, codification, and entry into IBM SPSS Statistics 24.0 software (www.spss.co.in) for analysis. Significance testing employed a ’p’ value threshold of <0.05.

Among the 73 cases studied, 45 (61.6%) were male and 28 (38.4%) were female, indicating a male preponderance with a male-to-female ratio of 1.6:1. The majority of males (44.4%) and females (39.3%) fell within the 48-64 years age group. In terms of socio-economic status, 44 (60.3%) belonged to the upper lower class IV, while only 10 cases (13.7%) were categorized as upper middle class II. The remaining 26% were classified as lower middle-class III, according to the modified Kuppuswamy scale [9]. Of the patient population (n=73), 54 (74%) resided in rural areas, with the remaining 19 (26%) living in urban regions. The distribution of socio-economic status is presented in Table 1.

Table 1. Distribution of socio-economic status in the study population (n=73)

Modified Kuppuswamy Scale \cite{15}	No.	Percentage
II (Upper middle)	10	13.7
III (Lower middle)	19	26
IV (Upper lower)	44	60.3
Total	73	100

In our study, the highest proportion (47.9%) of patients presented with abdominal pain, followed by 42.5% with fever. The next significant complaint was weight loss (38.4%), while the lowest number of cases reported diarrhea (8.2%). As depicted in Table 1, the majority of cases (76.7%) exhibited ascites, with the lowest occurrence (24.7%) being intestinal obstruction. Gastrointestinal tuberculosis was the most prevalent form, accounting for 32.9% of cases (Table 1), while peritoneal tuberculosis constituted the least common type (8.2%). Other forms of abdominal TB included tuberculosis of the solid viscera (30.1%) and tuberculosis of the abdominal lymph nodes (28.8%). Within the study cohort, 56.2% had total leukocyte counts within the normal range, while leukocytosis and leukopenia were observed in 34.2% and 9.6% of cases, respectively. Anemia was observed in the majority of study subjects (87.7%), while the remaining 12.3% fell within the normal range. Table 2 reveals that 58.9% of the study population exhibited normal platelet counts, with thrombocytopenia and thrombocytosis recorded in 32.9% and 8.2% of cases, respectively.

Table 2. Distribution of symptomatology in the study population (n=73)

Symptoms	Frequency	Percentage
Fever	31	42.5
Abdominal pain	35	47.9
Weight loss	28	38.4
Constipation	13	17.8
Diarrhea	06	8.2
Night sweat	09	12.3

Anemia was observed in 74.2% of cases, while pancytopenia was noted in 10.6%. A smaller subset of cases (4.5%) fell within the normal range. Among the study population, 87.7% exhibited elevated Erythrocyte Sedimentation Rate (ESR), while 12.3% had normal ESR levels. The distribution of cases based on clinical signs is presented in Table 3, and the types of abdominal tuberculosis identified in the study are illustrated in Figure 1.

Table 3. Distribution of cases as per clinical signs (n=73)

Clinical sign	Frequency	Percentage
Pallor	54	74
Icterus	23	31.5
Ascites	56	76.7
Intestinal obstruction	18	24.7
Lymphadenopathy	21	28.8
Oedema	34	46.6

The study was conducted at VIMSAR, Burla, and included 73 patients suspected of having abdominal tuberculosis between November 2019 and October 2021. The data were analyzed to interpret demographic characteristics, clinical and laboratory parameters, as well as hematological, biochemical, cytological, radiological, and histopathological findings of patients admitted to the Department of General Medicine with a high index of suspicion for abdominal tuberculosis.

The age distribution revealed that the highest proportion of cases fell within the 48-64 years age group (42.5%), followed by the 31-47 years age group (35.6%). This distribution indicated a greater susceptibility to abdominal tuberculosis in middle-aged individuals. In the present study, the prevalence of abdominal tuberculosis was relatively low in both younger and older age groups. Of the cases, 61.6% were male and 38.4% were female, yielding a male preponderance with a male-to-female ratio of 1.6:1. This observation aligns with similar findings by Agrahari et al., where 60% of patients were male and 40% were female [1]. Mavila et al. reported that 56% were males and 44% were females, with ages ranging from 16 to 80 years. In a study by Kunwar et al., which investigated 108 cases of abdominal tuberculosis, the average age of presentation ranged between 21 and 40 years, with a male predominance (1.1:1) [5]. In contrast, Anand (1956) reported a male-to-female ratio of 1:3.16 in a series of 50 cases, with 30% of cases occurring in the age group of 15-20 years [10].

Socioeconomic status, as measured by the modified Kuppuswamy scale [9], indicated that the upper lower-class IV population constituted the largest segment (60.3%), followed by the lower middle class (26%), and the upper middle class II (13.7%) category. The modified Kuppuswamy scale, developed by Kuppuswamy in 1976, employs a composite score that incorporates the education and occupation of the family head, along with the family’s monthly income, resulting in a score range of 3-29. It is widely utilized to assess socioeconomic status in both urban and rural areas. In India, the prevalence of tuberculosis is associated with factors such as overcrowding, malnutrition, and poor hygiene, as highlighted by Ananda in 1956 [10].

Residential patterns demonstrated that 74% of patients belonged to rural areas, whereas only 26% resided in urban locales. This indicates that rural regions accounted for three-quarters of the study’s observations.

The distribution of symptomatology in the study population indicated that the highest number of patients (47.9%) presented with abdominal pain, followed by fever in 42.5% of cases. Other significant complaints included weight loss (38.4%), constipation (17.8%), night sweats (12.3%), and diarrhea (8.2%).

In their study, Das and Shukla in 1976 [11] reported fever incidence of 42.2%, weight loss of 35%, anorexia of 44%, vomiting of 70%, constipation of 46.7%, diarrhea of 1.1%, and menstrual disorders of 5.6%. Thus, constitutional symptoms such as fever and weight loss were consistent with other researchers’ findings [11]. Diarrhea was present in 8.2% of cases in the present series, which can be attributed to enteritis causing hypermotility and rapid food transit. Another study by [12] reported diarrhea in 15% of their case series. Kunwar et al. [13] observed abdominal pain in 92% of cases, weight loss in 70%, and fever in 40%, aligning with the findings of this study. Similarly, Agrahari et al. [1] noted abdominal pain in 93.3% of cases, fever in 30%, diarrhea in 10%, constipation in 30%, and weight loss in 83.3%, differing only in fever and diarrhea. Mavila et al. reported abdominal pain in 81.8% of cases, weight loss in 73.3%, fever in 67.3%, and constipation in 9% of cases in their case series [4]. Thus, the distribution of symptomatology in this study aligns with reports by other authors.

Regarding clinical signs, the distribution of cases was as follows: 56 (76.7%) patients had ascites, 54 (74%) had pallor, 34 (46.6%) had edema, 23 (31.5%) had icterus, 21 (28.0%) had lymphadenopathy, and 18 (24.7%) had intestinal obstruction. Ascites mainly results from inflammatory exudates on the peritoneal surface, leading to free fluid accumulation. In contrast, Mavila et al. found ascites in only 26.4% of cases. Tandon et al. found ascites in all 11 (100%) cases, highlighting the consideration of abdominal TB in ascites cases [13]. This aligns with our study findings. A study by [11] showed ascites in 38.4% of cases, partially differing from our case series [11]. Notably, Das and Shukla in 1976 [11] reported pallor in 56.5% of cases. A higher prevalence of pallor in our series might stem from the region’s lower socioeconomic status compared to the rest of the country. Agrahari et al. [1] found pallor in 56.7% and lymphadenopathy in 40%, showing similarities to our study. However, icterus was absent in their study, differing from ours. Intestinal obstruction resulting from stricture or adhesion kinking was noted in 30% of cases by Ohri et al. in 1984 [14]. Kunwar et al. [5] and Mavila et al. [4] reported intestinal obstruction in 13% and 9.43% of cases, respectively, reflecting similarities with our study population.

The types of abdominal tuberculosis observed in the study population included gastrointestinal tuberculosis (24 (32.9%)), which was the most common, followed by solid viscera tuberculosis (22 (30.1%)), tuberculosis of the abdominal lymph nodes (21 (28.8%)), and a minimum of six (8.2%) cases of peritoneal tuberculosis. In contrast, Mavila et al. [4] reported that intestinal tuberculosis accounted for 49.09%, peritoneal tuberculosis for 32.72%, mesenteric lymph node tuberculosis for 12.72%, and solid organ tuberculosis for 5.45% of cases [4]. Similarly, Agrahari et al. [1] reported ileocaecal TB in 36.7% of cases, peritoneal involvement in 16.66%, jejunum in 16.66%, colon and rectum in 10%, multiple intestinal sites in 10%, mesentery and lymph nodes in 10%, and upper gastrointestinal tuberculosis in 10% of cases, which slightly deviates from this case series. This discrepancy may arise due to the small sample size in the present study.

Regarding leukocyte count in the study population, 41 (56.2%) cases fell within the normal range (4000-11000 WBCs per microliter), followed by leukocytosis in 25 (34.2%) cases, and leukopenia in 7 (9.6%) cases. Leukocytosis, defined as an increase in white blood cell count, is often observed during infections, including tubercular infections, as evidenced by 34.2% of cases in this study. Leukopenia, characterized by an abnormally low white blood cell count, was detected in 9.6% of cases.

Hemoglobin levels estimation revealed that 64 (87.7%) patients were anemic, while 12.3% of patients exhibited normal hemoglobin levels. Routine hematological investigations were conducted, considering hemoglobin levels > 10 g% as normal [12]. Das and Shukla in 1976 [11] reported hemoglobin levels below 12 gm% in 82% of cases, while Vikil and Desai in 1985 [14] identified anemia in 94% of cases. Anemia may be attributed to anorexia, vomiting, and poor food intake leading to low absorption due to tuberculous enteritis. Mavila et al. [4] reported anemia in 77.36% of cases in 2016. Hemoglobin level estimation in this series concurs with findings from other studies.

Total platelet count analysis revealed that 24 (32.9%) patients had thrombocytopenia, six (8.2%) had thrombocytosis, and 43 (58.9%) exhibited normal platelet counts. In 1995, Sarode et al. observed significant platelet hyperaggregation in 88% of patients with intestinal tuberculosis (ITB) (P < 0.001). Hyperactive platelets usually induce a chronic inflammatory response in intestinal tuberculosis [14]. Normal platelet count ranges from 150,000 to 400,000 platelets/L of blood. Thrombocytopenia is characterized by a lower-than-normal platelet count, which can lead to easy bruising, excessive bleeding from wounds, or bleeding from mucous membranes, such as in the gastrointestinal tract and other tissues.

Anemia was the predominant finding in the peripheral smear examination (74.2%), while pancytopenia was observed in 10.6% of cases. A minimum of three (4.5%) patients exhibited a completely normal peripheral smear. Anemia in tuberculosis is commonly attributed to factors such as nutritional deficiencies, malabsorption syndromes, impaired iron utilization, and bone marrow suppression.

The erythrocyte sedimentation rate (ESR), determined using the Westergren method, was elevated in 87.7% of cases, while the remainder of the population fell within the normal range. Das and Shukla in 1976 [11] reported high ESR in 92.2% of cases. Similarly, Agrahari et al. [1] observed increased ESR in all patients. Another study [5] indicated elevated ESR in 95% of the study population. Shi et al. [6] noted elevated ESR in 72% of intestinal tuberculosis patients. This elevated ESR finding aligns with the outcomes of the present study, mirroring those of other researchers.

This study reiterates the prevalence of tuberculosis in our country, particularly in underdeveloped Western Odisha, due to poor hygiene and poverty. Changes in abdominal tuberculosis patterns have occurred over time due to widespread and inappropriate antibiotic and drug usage, leading to clinical complexities. The inconsistent intake of prescribed medications is another factor contributing to the emergence of drug-resistant organisms.

The authors declare no conflicts of interest.

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