abdominal tuberculosis 2

8/3/2019 Abdominal Tuberculosis 2

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ABDOMINALABDOMINAL

TUBERCULOSISTUBERCULOSISDr. M.D. RaviDr. M.D. Ravi

Professor/PediatricsProfessor/PediatricsJSS Medical College, MysoreJSS Medical College, Mysore


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CASE STUDYCASE STUDY

1.1. 6 year old female child presents with low6 year old female child presents with low

grade fever of 1 month, loss of weightgrade fever of 1 month, loss of weight

2.2. She is malnourished ( PEM Gr 3 IAP)She is malnourished ( PEM Gr 3 IAP)3.3. She has a distended abdomenShe has a distended abdomen freefree

fluid with hepatosplenomegalyfluid with hepatosplenomegaly


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OBJECTIVESOBJECTIVES

1.1. What is the cause of her ascites?What is the cause of her ascites?

2.2. What could be the cause of fever andWhat could be the cause of fever and

malnutrition?malnutrition?3.3. How should one investigate this case?How should one investigate this case?

4.4. What is the treatment?What is the treatment?


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DISCUSSIONDISCUSSION

1.1. As this child initially had fever, probablyAs this child initially had fever, probablyinfective cause of ascitesinfective cause of ascites

2.2. Long standing low grade fevr andLong standing low grade fevr andmalnutrition suggests TBmalnutrition suggests TB

3.3. Ascites in a malnourished child shouldAscites in a malnourished child shouldbe taken as abdominal TB unless provedbe taken as abdominal TB unless proved

otherwiseotherwise4.4. So diagnosis is probably ascitic form ofSo diagnosis is probably ascitic form of

abdominal TBabdominal TB


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CASE 2CASE 2

1.1. 8 year old male presents with low grade8 year old male presents with low gradefever of 3 weeks, followed by abdominalfever of 3 weeks, followed by abdominalpain, vomitingpain, vomiting bilious since 2 daysbilious since 2 days

2.2. He is malnourished and dehydratedHe is malnourished and dehydrated

3.3. Xray abdomen shows features ofXray abdomen shows features ofsubacute obstructionsubacute obstruction

4.4. He undergoes surgeryHe undergoes surgery peroperative, aperoperative, astricture in the ileum with fewstricture in the ileum with fewcircumferential ulcerscircumferential ulcers


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BACTERIOLOGYBACTERIOLOGY

1.1. M. tuberculosisM. tuberculosis -- nonmotile, nonnonmotile, nonsporesporeforming, pleomorphic, weakly gramforming, pleomorphic, weakly gram--positivepositiverods, 1 to 5 m long, typically slender, androds, 1 to 5 m long, typically slender, andslightly bent.slightly bent.

2.2. AcidAcid--fastness is the capacity to perform stablefastness is the capacity to perform stablemycolate complexes with certain aryl methanemycolate complexes with certain aryl methanedyesdyes

3.3. Isolation of M. tuberculosis on solid mediaIsolation of M. tuberculosis on solid media

often takes 3 to 6 weeks, time for isolation andoften takes 3 to 6 weeks, time for isolation anddrug susceptibility testing of mycobacteria candrug susceptibility testing of mycobacteria canbe reduced to 1 to 3 weeks if the radiometricbe reduced to 1 to 3 weeks if the radiometricsystem is used (BACTEC)system is used (BACTEC)


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EPIDEMIOLOGYEPIDEMIOLOGY

1.1. More than 35% of the worlds population is infectedMore than 35% of the worlds population is infectedwith M. tuberculosis.with M. tuberculosis.

2.2. The WHO estimates that during the 1990s there wereThe WHO estimates that during the 1990s there were90 million new cases of tuberculosis worldwide, with90 million new cases of tuberculosis worldwide, with

30 million deaths caused by the disease30 million deaths caused by the disease

3.3. The period between 5 and 14 years has often beenThe period between 5 and 14 years has often beencalled the favored age, because children in this agecalled the favored age, because children in this agerange may develop infection, but it is much less likelyrange may develop infection, but it is much less likelyto progress immediately to disease.to progress immediately to disease.

4.4. IndiaIndia --Annual rate of infection is 2.1% per year < 5 yrsAnnual rate of infection is 2.1% per year < 5 yrsage (40 million children exposed to risk and 3age (40 million children exposed to risk and 3--4 million4 millioninfected)infected)


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PATHOGENESISPATHOGENESIS

1.1. Abdominal tuberculosis may occur afterAbdominal tuberculosis may occur after

ingestion of tubercle bacilli or as part ofingestion of tubercle bacilli or as part of

generalized lymphohematogenous spreadgeneralized lymphohematogenous spread

2.2. Though primary intestinal TB is known, theThough primary intestinal TB is known, thevast majority are secondaryvast majority are secondary

3.3. Tubercle bacilli penetrate the gut wall via theTubercle bacilli penetrate the gut wall via the

Peyers patches or the appendix, giving rise toPeyers patches or the appendix, giving rise tolocal ulcers followed by mesentericlocal ulcers followed by mesenteric

lymphadenitis and sometimes peritonitislymphadenitis and sometimes peritonitis


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PATHOLOGYPATHOLOGY

1.1. Abdominal TB actually means all intraAbdominal TB actually means all intra--

abdominal structures, but conventionallyabdominal structures, but conventionally

refers to gastroinytestinal tract andrefers to gastroinytestinal tract and

peritoneumperitoneum

2.2. May be isolated or with extraintestinalMay be isolated or with extraintestinal

lesionlesion


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CLINICAL FEATURESCLINICAL FEATURES

1.1. Commonest GIT involvementCommonest GIT involvement 2/3 cases2/3 cases

ileum, colon, ileocecal, jejunum and duodenumileum, colon, ileocecal, jejunum and duodenum

ulcerative, hypertrophic, ulcerohypertrophiculcerative, hypertrophic, ulcerohypertrophic

or part of miliaryor part of miliary2.2. PeritonealPeritoneal 1/31/3 exudative ( generalised orexudative ( generalised or

loculated), adhesive (plastic), miliaryloculated), adhesive (plastic), miliary

3.3. Lymph nodesLymph nodes 4%4% -- mesenteric, other localmesenteric, other local

nodes, retroperitonealnodes, retroperitoneal


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1.1. CommonCommon abdominal pain, chronicabdominal pain, chronicdiarrhea, anorexia and weight lossdiarrhea, anorexia and weight loss

2.2. Distension of abdomen may occur ifDistension of abdomen may occur ifascites, hepatosplenomegalyascites, hepatosplenomegaly

3.3. May present with acute or subacuteMay present with acute or subacuteintestinal obstructionintestinal obstruction

4.4. Significantly malnourished child withSignificantly malnourished child withascitesascites always think of abdominal TBalways think of abdominal TBas probable diagnosisas probable diagnosis


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1.1. May have features of extraintestinalMay have features of extraintestinalinvolvementinvolvement

2.2. Occasionally, the periadenitis can causeOccasionally, the periadenitis can causethe omentum to get rolled upthe omentum to get rolled up vaguevaguemass feltmass felt

3.3. Peritonitis clasically has a doughy feel toPeritonitis clasically has a doughy feel to

the abdomenthe abdomen4.4. Hepatosplenomegaly, peripheral lymphHepatosplenomegaly, peripheral lymph

node enlargementnode enlargement


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LABSLABS

1.1. Definitive diagnosis requiresDefinitive diagnosis requiresbacteriological or histological proofbacteriological or histological proof difficultdifficult

2.2. FNACFNAC from mass, nodesfrom mass, nodes

3.3. Endoscopy with biopsyEndoscopy with biopsy

4.4. Ascitic tapAscitic tap exudative, resembles CSFexudative, resembles CSF

findingsfindings5.5. Liver biopsyLiver biopsy may show tuberclesmay show tubercles

6.6. Peritoneal biopsyPeritoneal biopsy


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XRAYXRAY

1.1. Chest for coexisting lung involvement (Chest for coexisting lung involvement (

66--90%)90%)

2.2. Palin film abdomenPalin film abdomen fluid levels,fluid levels,calcification of nodes, omental masscalcification of nodes, omental mass

3.3. Ba mealBa meal ulceration, stricture,ulceration, stricture,

hypertrophic segment, matting of coils ofhypertrophic segment, matting of coils of

intestine, mass effect of nodesintestine, mass effect of nodes

improved yield by double contrastimproved yield by double contrast


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OTHER TESTSOTHER TESTS

1.1. CTCT ascites, enlarged nodes withascites, enlarged nodes with

radiolucent (caseating) centresradiolucent (caseating) centres

2.2. UltrasoundUltrasound ascites, loculationascites, loculation3.3. ADA activity in ascitic fluidADA activity in ascitic fluid markedlymarkedly

increased ( Sensitivity 95increased ( Sensitivity 95--100%,100%,

specificity 96specificity 96--98%)98%)


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CASE 1CASE 1

1.1. The child had a positive Mantoux test,The child had a positive Mantoux test,

and her ascitic fluid analysis showedand her ascitic fluid analysis showed

exudative fluid with high ADAexudative fluid with high ADA

2.2. Chest Xray was normalChest Xray was normal

3.3. Abdominal U/S showed loculationAbdominal U/S showed loculation


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COMPLICATIONSCOMPLICATIONS

1.1. Intestinal obstructionIntestinal obstruction

2.2. FistulaFistula

3.3. Confined perforation with abscessConfined perforation with abscess4.4. HemorrhageHemorrhage

5.5. StrictureStricture

6.6. MalnutritionMalnutrition


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TREATMENTTREATMENT

1.1. Category I of WHOCategory I of WHO 2 HRZ + 8 months INH +2 HRZ + 8 months INH +

thiacetazone or 4 months SM+INH+Rthiacetazone or 4 months SM+INH+R

2.2. IAPIAP group 4group 4 2HRZ/4HR2HRZ/4HR

3.3. Monitor hepatotoxicity periodically at least forMonitor hepatotoxicity periodically at least for

66--8 wks8 wks-- if occurs, stop HR and giveif occurs, stop HR and give

Ethambutol 15 mg/kg till complete recovery ofEthambutol 15 mg/kg till complete recovery of

hepatic injury, then restarthepatic injury, then restart

4.4. Surgery for perforation,fistula, obstructionSurgery for perforation,fistula, obstruction


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FOLLOW UPFOLLOW UP

1.1. If ethambutol used, ophthal evaluationIf ethambutol used, ophthal evaluation

monthlymonthly

2.2. Hepatic parameters for RHHepatic parameters for RH3.3. Follow up for adhesions of intestine,Follow up for adhesions of intestine,

nutritional statusnutritional status


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SUMMARYSUMMARY1.1. The commonest cause of ascites in aThe commonest cause of ascites in a

malnourished child is abdominal TBmalnourished child is abdominal TB

2.2. Commonest presentation is withCommonest presentation is withmalnutrition and chronic diarrhea andmalnutrition and chronic diarrhea and

ascitesascites3.3. Can present as an acute abdomen dueCan present as an acute abdomen due

to obstructionto obstruction

4.4. Many investigations are helpful, butMany investigations are helpful, butdefinitive diagnosis requires histologicaldefinitive diagnosis requires histologicalor bacteriological proofor bacteriological proof

abdominal tuberculosis 2

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