Tuberculosis and the acute abdomen: an evaluation of the National Inpatient Sample

Author(s):
Joseph Forrester; Lakshika Tennakoon; Kristan Staudenmayer

Background:

Tuberculosis, an infection caused by Mycobacterium tuberculosis, can cause acute abdominal pathology requiring surgery. While most cases of tuberculosis resolve with appropriate anti-mycobacterial therapy, surgery may still be required.

Hypothesis:

To describe the modern epidemiology of acute abdominal complications associated with tuberculosis in the United States.

Methods:

We retrospectively analyzed the 2010-2014 National Inpatient Sample for all admissions associated with International Classification of Disease-Ninth Revision-Clinical Modifier diagnosis codes for tuberculosis and acute abdominal pain. A case of acute abdominal tuberculosis was defined as any inpatient admission with a diagnosis of tuberculosis and a diagnosis of acute abdominal pain. Outcomes of interest included need for an abdominal operation and mortality after surgery. Adjusted analyses accounting for survey methodology were performed.

Results:

There were 66,034 inpatient admissions associated with tuberculosis infection of which 3,638 (6%) had acute abdominal pain. Among cases, 1,578 (43%) were 45-64 years of age and 2,344 (64%) were male. Most cases were Hispanic (n=1,090, 30%) or Black (n=924, 25%) and were in the lowest quartile of income by zip code (n=1,367, 38%). Most cases had a primary diagnosis of pulmonary (n=1,928, 53%), miliary (n=522, 14%) or abdominal (n=482, 13%) tuberculosis. Of the 347 (0.5% of total) cases who underwent surgery, 111 (32%) underwent an abdominal exploration. Other procedures included repair or resection of a hollow viscus (n=122, 35%), or biopsy (n=136, 39%). In adjusted analysis, an association between a diagnosis of tuberculosis and receiving surgery was found to depend upon the type of tuberculosis infection (odds ratio [OR]=1.17 for intestinal, peritoneal, or genitourinary tuberculosis vs. other types, 95% confidence interval [CI]=[1.12-1.22]) and whether the patient was of white or Asian race vs. black and Hispanic (OR=1.11, 95%CI [1.02-1.21]).  Thirty-nine (11%) of the 347 cases who underwent surgery died during hospitalization. After controlling for known confounders, increased mortality after surgery was associated with hypertension (OR=12.11, 95% CI [1.33-110.00]) and coagulopathy (OR=22.56, 95%CI [2.46-207.08]).

Conclusions:

Surgery may still be required for patients with tuberculosis presenting with acute abdominal pain. Black and Hispanic patients are less likely to receive surgical intervention than White or Asian races. The in-hospital mortality from acute abdominal pain requiring surgery among patients with tuberculosis is high.