Introduction: Abdominal Tuberculosis (TB) is a significant form of extra-pulmonary tuberculosis (EPTB), impacting the gastrointestinal tract, peritoneum, lymph nodes, and occasionally solid organs. While TB primarily affects the lungs, approximately 15% of cases are extra-pulmonary, with abdominal TB being one of the most frequent forms. Diagnosing abdominal TB is challenging due to its non-specific symptoms and low bacterial load, often leading to inconclusive microbiological tests and misdiagnosis with conditions like Crohn’s disease or abdominal malignancies.

Epidemiology: The incidence of abdominal TB ranges from 2.7% to 21% of all EPTB cases, with a notable burden in India, where TB accounts for significant morbidity and mortality. Abdominal TB’s association with other comorbidities, such as chronic liver disease, further complicates diagnosis and management, particularly in younger, female, and immunocompromised patients.

Clinical Presentation: Symptoms of abdominal TB are varied and often non-specific, including abdominal pain, fever, weight loss, and ascites. Diagnostic delays are common due to the subtlety of these symptoms, making early clinical suspicion critical. Imaging modalities like ultrasound and CT scans, along with microbiological and histopathological evaluations, are essential for accurate diagnosis.

Case Series

Case 1: A 47-year-old female with a history of pulmonary TB presented with abdominal distension. Imaging and FNAC revealed ascites and thickened ileo-cecal junction, consistent with TB. GenXpert confirmed the presence of Mycobacterium tuberculosis without rifampicin resistance. Due to suboptimal drug levels indicated by therapeutic drug monitoring (TDM), her regimen was adjusted, leading to successful treatment completion.

Case 2: A 24-year-old female presented with abdominal pain and vomiting, and imaging revealed lymphadenopathy with granulomas at the ileo-cecal junction. GenXpert confirmed TB without rifampicin resistance. The patient developed drug-induced hepatotoxicity, necessitating a temporary switch to hepato-safe drugs. Once stabilized, she resumed standard ATT and completed a 7-month course with clinical improvement.

Diagnostic Challenges and Management: Diagnosing abdominal TB requires a multidisciplinary approach, utilizing imaging, microbiological tests, and histopathological evaluations. Therapeutic drug monitoring (TDM) and close monitoring of drug-induced side effects, particularly hepatotoxicity, are crucial in managing complex cases. Individualized treatment regimens, including adjustments based on TDM and patient response, are essential for optimal outcomes.