ABDOMINAL TUBERCULOSIS DR. KAMAL JR 2 ND YEAR PULMONARY
MEDICINE
Slide 2
GASTROINTESTINAL TUBERCULOSIS Tuberculosis enteritis as a
complication of pulmonary T.B. was appreciated by HIPPOCRATESs in
the 5 th century B.C. Diarrhea attacking a person with phthisis is
a mortal symptom (Walsh, 1909)
Slide 3
Abdominal TB can involve any part of GIT from mouth to anus,
the peritoneum and pancreato- billiary system. Total EP TB accounts
for about 10-12% of total no. of TB cases, out of which 11-16% are
abdominal koch. Sixth most frequent EP TB after lymphatics,
genitourinary, bone & joint, milliary & meningeal TB.
Caused by M. tuberculosis, M. bovis & NTM. Age group 20-40 most
commonly affected & slight female preponderance has been
described.
Slide 4
HIV & TB Before era of HIV infection > 80% TB was
confined to lung Extrapulmonary TB increases with HIV 40 60% TB in
HIV+ pt are extrapulmonary Globally, proportion of co-infected pt
> 8 % ~ 0.4 million people in India are co-infected. In one
study, 16.6% abdominal TB pt in Bombay was HIV +.
Slide 5
Mechanisms by which M. tuberculosis reach the GIT: Hematogenous
spread from primary lung focus Ingestion of bacilli in sputum from
active pulmonary focus. Direct spread from adjacent organs. Via
lymph channels from infected LN Rare Mechanism : Contiguous spread
of infection from a fallopian tube TB peritonitis as complication
of peritoneal dialysis PATHOGENESIS
Slide 6
DISTRIBUTION OF TUBERCULOUS LESIONS Ileum > caecum >
ascending colon > jejunum >appendix > sigmoid > rectum
> duodenum > stomach > oesophagus More than one site may
be involved
Slide 7
Most common site - ileocaecal region Increased physiological
stasis Increased rate of fluid and electrolyte absorption Minimal
digestive activity permitting greater contact time between the
organism & mucosal surface. Abundance of lymphoid tissue at
this site(peyers patches) & microfold cell ( M cell )
Slide 8
Most active site of inflammation is submucosa Bacilli in glands
Inflamatory reaction Phagocytes carry Bacilli in Peyers patch
formation of tubercles Necrosis of tubercles Enlarges Endarteritis,
edema & sloughing Ulcer formation& Accumulation of
collagenous tissue Thickening & stenosis
Slide 9
It can be acute or chronic ACUTE TUBERCULOSIS PERITONITIS
Present as acute abdomen & are often subjected to emergency
surgery On opening abdomen, straw colored fluid may be present
& tubercles may be found to be scattered on the peritoneum
& greater omentum. OMENTUM SCATTERED WITH TUBERCLES
Slide 10
ASCITIC FORM : Insidious in onset, abdominal pain usually
absent, rolled up greater omentum infiltrated with tubercles may be
felt as transverse mass. ENCYSTED(LOCULATED ) FORM: There is
localized swelling & diagnosis is usually retrospective.
FIBROUS FORM: Widespread adhesion may cause coils of intestine to
be matted together & distended which act as blind loop leading
to steatorrohoea, malabsorpation syndrome & abdominal
pain.
Slide 11
It is of following types: ULCERATIVE: Usually occur in adults
who are malnourished Ulcers may b solitary or multiple &
usually lies transverse to the long axis of the gut girdle. Healing
& fibrosis of the ulcers lead to formation of napkin ring
stricture & obstructive symptoms Formation of fistula is there
TRANSVERSE ULCER
Slide 12
Usually occur in young adult who are relatively well nourished
with low volume infection by less virulent organism. Caecum is most
commonly affected site There is extensive fibrosis &
inflammation that often result in adherance of bowel, mesentry,
lymph node into the mass. ULCEROHYPROTROPHIC FORM: Display features
both of ulcerative & hypertrophic form
Slide 13
Less common form of intestinal TB Very similar to ULCERATIVE
COLITIS SCLEROTIC FORM It is associated with stricture formation
Resected portion of illeocaecalTB
Slide 14
Abdominal pain is the most common symptom & is most
commonly located in right lower quadrant of abdoman. Patient with
intestinal obstructio has cramp like character. Diarrhoea : 11-20%
of patient. Liquid to semisolid stool passed 6-8 times a day. Mucus
is usually present. Diarrhoea alternating with constipation is
present also present in some patient. Constitutional symptoms:
fever, malaise, weight loss, anorexia. Other symptoms: moving lump
in abdomen, nausea, vomiting, malaena & constipation, menstural
abnormalities.
Slide 15
Most patient are ill & malnourished. Tenderness may be
present mostly in right iliac fossa. Palpable abdominal mass may be
present which may be due to hyperplastic caecal TB, Lymph node
enlargement & rolled up omentum. Classic doughy abdomen has
been described in only 6-11% patients. Signs of peritonitis may be
present when there is intestinal perforation.
Slide 16
Tuberculosis of esophagus Rare ~ 0.2% of total cases By
extension from adjacent LN Low grade fever / Dysphagia /
Odynophagia / Midesophageal ulcer Mimics esophageal Ca Upper part
is more commonly involved than lower part Endoscopic biopsy is must
for confirmation of diagnosis
Slide 17
Rare due to presence of gastric acid and paucity of lymphoid
organ. Ulcerative form is commonest & ulcers are found along
lesser curvature. Usually retrospective diagnosis & not
suspected until time of surgery DUODENAL TUBERCULOSIS Rare form
Usually present with obstructive symptom which is more often due to
extrinsic obstruction caused by lymph node or adhesion. Rare is
obstructive jaundice.
Slide 18
Common with ileocaecal TB but isolated is rare Abdominal
perforation may b presenting symptom Diagnosed mostly on abdominal
exploration ANAL TB Lesion are ulcerative,lupuoid & verrucus.
Perianal ulcers are shallow with blue undermined edges May be
associated with inguinal LAD. Fistula in ano & perianal abscess
may be present.
Slide 19
Often associated with miliary TB & more often occur in
immuno-compromised host May present as acute or chronic
pancreatitis or may mimic malignancy. FNAC & biopsy are
helpful
Slide 20
Occur in disseminated or miliary form of TB Most common in
HIV+ve patients Common features are left upper quadrant abdominal
pain, weight loss & diarrhea May Present as hypersplenism or
splenic abscess
Slide 21
One or more of the following four criteria must be fulfilled to
diagnose abdominal TB. Histopathological evidence of tubercles with
caseation necrosis & AFB. Presence of M tuberculosis in sputum,
tissue, or ascitic fluid. Clinical, radiological or operative
evidence of proven TB elsewhere with good therapeutic response.
Good therapeutic response to ATT.
Slide 22
HAEMATOLOGY & SERUM BIOCHEMISTRY Anaemia, leucopenia with
relative lymphocytosis ESR is raised in 50-100% patients LAB
INVESTIGATION ARE NON SPECIFIC TUBERCULIN SKIN TEST: Positive in
55-100% cases. In area where TB is endemic it neither confirms the
diagnosis nor exclude the diagnosis. CHEST X RAY: associated
pulmonary TB has been described in 24-28% cases. Evidence of TB in
chest x ray support the diagnosis but normal chest x ray does not
rule it out.
Slide 23
PLAIN X RAY ABDOMEN: May show calcified lymph nodes and
granulomas dilated loops with fluid level, dilatation of terminal
ileum Ascitis Pneumoperitoneum in intestinal perforation X ray
abdoman showing calcified LN
Slide 24
Straw coloured Protein >3g/dL TLC of 150-4000/l, Lymphocytes
>70% SAAG < 1.1 g/Dl Ascitis to blood glucose ratio
ADA: Adenosine deaminase ADA is increased due to stimulation of
T-cells by mycobacterial Ag Serum ADA > 54 U/L Ascitic fluid ADA
> 36 U/L Ascitic fluid to serum ADA ratio > 0.985 Coinfection
with HIV normal or low ADA False high values seen in malignant
ascitis & chronic kidney disease.
Slide 26
Barium studies Enteroclysis followed by barium enema is the
best protocol Increased transit time with hypersegmentation
(chicken intestine) and flocculation is the earliest sign Localised
areas of irregular thickened folds, mucosal ulceration, dilated
segments and strictures Thickened iliocaecal valve with a broad
triangular appearance with the base towards the caecum (inverted
umbrella sign or (Fleischners sign) Rapid transit and lack of
barium retention (Sterlins sign) Narrow beam of barium due to
stenosis(strings sign)
Slide 27
Conical caecum:- shrunken in size & pulled out of iliac
fossa Goose neck deformity- loss of normal ileocaecal angle &
terminal dilated ileum appearing from retracted pulled up caecum
Both Stierlin & String sign is present in crohns disease Barium
oesophagogram-ulcerative oesophagitis, stricture, pseudo tumour
masses, fistula, sinus, traction diverticulae Duodenal
tuberculosis-segmental narrowing, widening of the C loop due to
lymphadenopathy
Slide 28
Group1: Highly s/o intestinal TB if one or more of the
following features are present a. Deformed ileocaecal valve with
dilatation of terminal ileum b. Contracted caecum with an abnormal
ileocaecal valve and/or terminal ileum c. Stricture of the
ascending colon with shortening of and involvement of ileocaecal
region
Slide 29
GroupII: Suggestive of intestinal tuberculosis if one of the
following feature present a.Contracted caecum b.Ulceration or
narrowing of the terminal ileum c.Stricture of the ascending colon
d.Multiple areas of dilatation, narrowing and matting of small
bowel loops GroupIII: Non-specific changes Features of matting,
dilatation and mucosal thickening of small bowel loops GroupIV:
Normalstudy
Slide 30
Multiple tuberculous strictures small intestine Ba. Meal
follow-through Yehia Aly, Cairo University Chicken intestine:
hypersegmentation of small intestine NARROWING OF INTESTINE:
STRINGs SIGN
Slide 31
Often reveals a mass made up of matted loops of small bowel
with thickened walls, diseased omentum, mesentery and loculated
asites Fine septae may be seen in the ascitic fluid Inter loop
ascites gives rise to charecteristic club sandwitch appearance
Mesenteric thickening is better detected in the presence of ascites
and is often seen as the stellate sign of bowel loops radiating
from its root In intestinal tuberculosis bowel wall thickening is
usually uniform and concentric as opposed to the eccentric
thickening at the mesenteric border seen in Crohnsdisease and the
variegated appearance seen in malignancy
Slide 32
Granulomas or absess in the liver,pancreas or spleen Pseudo
kidney sign illeocaecal region pulled upto sub hepatic position Usg
abdoman showing lymphadenopathy & omental thickening USG
ABDOMAN SHOWING FREE FLUID & LAD
Slide 33
CT is better than USG in detecting high dense ascites of high
attenuation 25-45 HU Abdominal lymphadenopathy is the commonest
manifestation of tuberculosis on CT Retroperitoneal,
peripancreatic, portahepatis, and mesenteric/omental lymph node
enlargement may be evident Caseous necrotising lymph node appears
as low attenuating necrotic centers and thick enhancing
inflammatory rim Omental thickening is well seen as omental cake
appearance. A fibrous wall can cover the omentum due to long
standing inflammation & is called omental line. An omental line
is less common in malignancy
Slide 34
Preferential thickening of the medial caecal wall with an
exophytic mass engulfing the terminal ileum associated with massive
lymphadenopathy is characteristic of tuberculosis Short segments of
mural thickening with normal intervening bowel associated with
ileocaecal involvement strongly suggest tuberculosis
Slide 35
CT SCAN OF PELVIS SHOWING ASCITIS & OMENTAL MASS CT SCAN OF
ABDOMAN SHOWING LOCULATED ASCITIS & MESENTRIC LN & STRANDS
CIRCUMFERE NTIAL THICKENING OF CAECUM & NARROWING OF TERMINAL
ILEUM
Slide 36
MRI:-has no added advantage Endoscopy Colonoscopy: - it is
excellent tool for diagnosis. Ulceration is the most common
finding. Ileocaecal valve may edematous or deformed. Nodules,
ulcers, pseudopolyps may be seen. Mucosal nodules of variable sizes
& ulcers in a discreate segment of colon, 4-8 cm in length are
pathognomic. A combination of histology and culture can establish
diagnosis in 80% of cases Fine needle aspiration cytology : it can
be done from lymph nodes, abscesses,& focal lesion of viscera.
Peritoneal biopsy- it can be blind or open parietal peritoneal
biopsy under LA. Laparoscopy :-most effective method. 80 to 95%
diagnostic accuracy. Characteristic finding include multiple,
yellowish-white miliary nodules over peritoneum, erythematous,
thickened and hyperemic peritoneum, turbid ascitis & adhesions.
chances of perforation are higher when patients with fibroadhesive
disease are subjected to laproscopy.
Slide 37
Slide 38
Bhargava et al used ELISA with monoclonal Ab against 38 kDa
protein Found a senstivity of 81% and specificity of 88% &
diagnostic accuracy of 84%. However, ELISA remain positive even
after therapy, the response to mycobacteria is variable & its
reproducibility is poor. PCR: Amplification of 340 bp nucleotide
seq located within the 38 kDa protein gene of M. tuberculosis
Diagnostic accuracy as a single test is questionable
Slide 39
Medical treatment Earlier 8-12 month of ATT given now it has
been observed that A six month short-course ATT is as effective as
standard 12 month regimen Corticosteroids-role not well established
Surgical treatment To manage complication such as Obstruction,
perforation and massive hemorrhage Strictures by stricturoplasty or
resection Perforation by resection and anastomosis Bypass surgery
not indicated Surgery followed by full course of ATT 39
Slide 40
Malabsorption Coeliac disease Lymphoma Immunoproliferative
small intestinal diseae Crohns disease MASS Appendicular mass
Actinomycosis Caecal carcinoma Lymphoma Ascites Cardiac disease
Renal disease Hepatic disease malignacy
Slide 41
1. OBSTRUCTION : Most common complication Pathogenesis
Hyperplastic caecal TB Strictures of the small intestine---
commonly multiple Adhesions Adjacent LN involvement traction,
narrowing and fixation of bowel loops.
Slide 42
2. PERFORATION: 2 nd commonest cause after typhoid Usually
single and proximal to a stricture Clue - TB Chest x-ray, h/o SAIO
Pneumoperitoneum in ~ 50% cases 3. MALABSORPTION: Pathogenesis
bacterial overgrowth in stagnant loop bile salt deconjugation
diminished absorptive surface due to ulceration involvement of
lymphatics and LN
Slide 43
43 Medical treatment . Earlier 8-12 month of ATT given now it
has been observed that A six month short-course ATT is as effective
as standard 12 month regimen Corticosteroids-role not well
established Surgical treatment To manage complication such as
Obstruction,perforation and massive hemorrhage Strictures by
stricturoplasty or resection Perforation by resection and
anastomosis Bypass surgery not indicated Surgery followed by full
course of ATT
Slide 44
TUBERCULOSIS CXRAY show previous or active TB. Involvement of
fewer than 4 segments, patulous ileocaecal valve,transverse ulcers,
scars & pseudopolyp. Granulomas : Multiple(mean no. 5.35 per
site), large(>0.05 mm^2), confluent & in submucosal region
Preferential thickening of ileocaecal valve & medial wall of
caecum CROHNs DISEASE Feautres like arthralgia, arthritis, eythema
nodosum are more common Anorectal fissures, longitudnal ulcers,
apthous ulcers, cobblestone Infrequent(mean no : 0.75), small(95m)
& mucosal granuloma Thickening is more uniform & lesser
thickening of the bowel
Slide 45
Abdominal koch is most difficult type of TB to diagnose &
its reoccurence is even more difficult to diagnose as BMFT changes
like pulled up caecum, fibrosis, remain even after initial
treatment There are no specific sign & symptom & mimicks
many other disease Often patient do not have previous record to
differentiate between new & old finding No role of Montoux in
reoccurence & ELISA also remain positive even after
treatment.
Slide 46
HOW TO DIAGNOSE REOCCURENCE Usually on basis of clinical signs
& symptoms High clinical suspicion Proved from biopsy / HPE or
culture positive As one of the diagnostic criteria is RELIEF OF
SYMPTOMS WITH THERAPEUTIC TRIAL OF ATT so sometime diagnosis is
retrospective