abdominal tuberculosis

ABDOMINAL TUBERCULOSI

S

Dr. Minhajuddin KhurramAL-AMEEN MEDICAL COLLEGE HOSPITAL,

bIJAPUR

A common disease in India and other developing countries

It the 6th most common type of extra-pulmonary tuberculosis

40% of Indians harbour tb bacilli In 2010, Global Incidence – 9.4million In india – 2.3millionPrevalence in India is 3.1 million3,20,000 deaths… -WHO

Introduction

Introduction

24th March 1882- World Tb day

TB declared as notifiable disease by INDIAN GOVERNMENT on may9th 2012

Introduction

1. Intestinal (Koenig’s syndrome)A. Iliocaecal region

Ulcerative -60% Hyperplastic-10% Mixed-30%

B. Ileal region Stricture type

2. Peritoneal tuberculosisA. AcuteB. Chronic

Ascitic Encysted Plastic Purulent

Types

3. Tuberculous mesenteric lymphadenitisA. Calcified lesionB. Acute Meseneteric lymphadenitisC. Pseudo-mesenteric cystD. Tabes mesentericaE. Chronic Lymphadenitis

4. Ano-recto-sigmoidal5. Involvement of solid organs as a part

of milary tuberculosis6. Involvement of omentum7. Rare types

A. Oesophageal (0.2% of abdominal)B. Gastroduodenal

Types

1. By ingestion◦ Ingestion of food contaminated with

tubercle bacilli causing Primary Intestinal Tuberculosis

◦ Ingestion of sputum containing tuberculous bacteria from primary pulmonary focus - Secondary Intestinal Tuberculosis

2. Hematogenous spread from lungs3. Through lymphatics (neck)4. Fallopian tubes (retrograde

spread)

Mode Of Spread

Etiology

Most common site of abdominal tuberculosis due to:◦ Stasis◦ Abundant payer’s patches◦ Alkaline media◦ Bacterial contact time is more◦ Minimal digestive activity◦ Maximum absorption in the area

Ileocaecal Tuberculosis

A. Ulcerative type (60%):◦ Secondary to pulmonary tuberculosis◦ Virulent organism◦ Poor body resistance◦ Multiple circumferential transverse ulcers

(Girdle ulcers) with skip leisons ◦ Commonly in ileum◦ Rarely in caecum


◦ Napkin ring strictures in longstanding ulcers (common in ileum)

◦ Intestinal nodes involvement with caseation and abscess

◦ May present with blood in stools, diarrhoea, loss of appetite and reduced weight

◦ Complications: Acute: Ulcer perforation Chronic: Stricture Subacute obstruction


B. Hyperplastic Type -10%◦ Primary GIT tuberculosis◦ Less virulent organism◦ Good body resistance◦ Chronic granulomatous lesions in ileoceacal

region◦ Fibroblastic activity in submucosa and

subserosa causes thickening of bowel wall with lymph node enlargement

Presenting as Mass in Right Iliac Fossa (Nodular fixed and firm mass)

◦ Caseation is very rare


B. Hyperplastic Type -10%◦ No primary leision in the chest◦ Complication: May cause sub-acute intestinal

obstruction due to mass


Others◦ Abdominal pain (90%)

Colicky type in intestinal tuberculosis Dull aching in mesenteric lymphadenitis

◦ Mass in right iliac fossa (35%) Hard, nodular, fixed, nontender mass mimicing ca

caecum◦ Subacute intestinal obstruction (20%)◦ Can be associated with adenocarcinoma of

caecum

Clinical Features

1. Ca Caecum2. Ameboma3. Appendicular mass4. Lymph node mass5. Psoas abscess6. Crohn’s disease

Differential Diagnosis

Chest Xray – for primary focus Blood investgations: Mantoux, ELISA, serum

IgG ESR- raised Plain Xray abdomen

◦ Intestinal obstruction◦ Calcified lymph nodes◦ Hollow viscus perforation◦ Calcified Granuloma in liver

Investigations

USG abdomen◦ Thickened bowel wall◦ Loculated ascitis◦ Interloop ascitis◦ Mesenteric thickening◦ Lymph node enlargement◦ Pulled up caecum (Pseudokidney sign)

Investigations

Barium study Xray (barium enema or barium follow through)◦ Pulled up caecum◦ Obtuse ileocaecal angle; straightening (Goose

neck)◦ Steirlin sign: Hurrying of barium due to rapid flow

and lack of barium in inflamed site◦ Fleischner sign (Inverted umbrella sign):

Narrow ileum with thickened ileocaecal valve◦ Napkin leisons◦ Chicken intestine: Hypersegmentation ◦ Mega Ileum: Dilatation of proximal ileum

Investigations

Barium Study showing Mega Ileum

Colonoscopy◦ To rule out ca◦ Shows mucosal nodules, ulcers, strictures,

deformed ileocaecal valve, mucosal oedema and diffuse colitis

◦ Biopsy can be taken to eslablish the diagnosis

Investigations

CT Abdomen◦ CT scan shows thickening

of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows).

Investigations

Diagnostic laproscopy◦ Direct visualization◦ Collect acsitic fluid◦ Take biopsy from mass, omentum or peritoneum

Investigations

PCR of tissue Acsitic tap fluid analysis

◦ Exudate fluid (protein >2.5gm%)◦ Lymphocyte predominant cells >250 cu mm

(upto 4000 cu mm)◦ Glucose <30mg%◦ Specefic gravity >1.016◦ ADA (Adenosine deaminase activity) 95%

specificity and 98% sensitivity◦ LDH > 90 units/litre

Investigations

1. Obstruction 20%2. Malabsoprption, blind loop syndrome3. Dissemination of tuberculosis4. Cold abscess formation5. Hemorrhage6. Perforation7. Fecal fistula

Complications

Mediacal management:◦ First line drugs:

INH Rifampicin Pyrazinamide Ethambutol

◦ Second line drugs: Amikacin, kanamycin, PAS, Ciprofloxacin, Clarithrymycin, Azythromycin, Rifabutin Drug: RNTCP 2H3R3Z3 E3 + 4H3R3

◦ Treatment to be continued for 6-9 months◦ Supportive nutrition

Treatment

Surgical Management:◦ Indications:

Intestinal obstruction Severe hemorrhage Acute abdomen (perforation) Intra-abdominal abscesses/ fistula formation Uncertain diagnosis

Treatment

Surgical Management:

1. Ileocaecal resection with 5 cm margin

2. Stricturoplasty- single stricture

3. Single strictutre with friable bowel : Resection

4. Multiple Strictures: Resection and anastomosis

5. Multiple strictures with long segment gaps:

Multiple stricturiplasty

Treatment

Surgical Management:6. Early perforation: resection and anastomosis

(due to friable bowels)7. Perforation with severe contamination: resection

with colostomy8. Adhesiolysis by laproscopy (Very difficult

procedure)9. Drainage of abscesses and treatment for fistula

in ano

Treatment

It is usually stricture type May be multiple Presents with intestinal obstruction Bowel adhesions, localization, fibrosis,

secondary infection are common Perforation (5%) Plain Xray – Multiple air fluid levels Resection and anastomosis with Anti-

tubercular drugs

Ileal Tuberculosis

It is post primary Becoming more common Activation of long standing latent foci Blood spread Can develop from diseased mesenteric

lymph nodes, intestines or fallpian tubes

Peritoneal Tuberculosis

Basic pathology◦ Enormous thickening of the parietal peritoneum◦ Multiple tiny yellowish tubercles◦ Dense adhesions in peritoneum and omentum

with small intestines◦ May precipitate obstruction◦ Thickening of bowel wall


Abdominal Cocoon Syndrome◦ Dense adhesions in peritoneum and omentum

with contents inside as small bowel causing intestinal obstruction


A. Acute –mimics acute abdomen◦ Rare◦ On-table diagnosis◦ Features of peritonitis◦ Due to perforation or rupture of mesenteric lyph

nodes◦ Exploratory laprotomy reveals straw coloured fluid

with tubercles in the peritoneum, greater omentum and bowel wall

◦ Fluid evacuated and sent for culture and AFB study◦ Biopsy taken from omentum◦ To be closed without drains


A. Chronic◦ Presents as

Abdominal pain Fever Ascites Loss of appetite and weight Abdominal mass Doughy abdomen (10%)

◦ Typesa) Ascitic formb) Encysted formc) Plastic formd) Purulent form


a) Acsitic peritoneal tuberculosis:◦ Intense exudate caused ascitis◦ Common in children and young adults◦ Enormous abdominal distension◦ May cause congenital hydrdocele, umbilical

hernia, shifting dullness, fluid thrill and mass per abdomen

◦ Rolled up omentum and nodular due to extensive fibrosis


a) Acsitic peritoneal tuberculosis:◦ Doughy abdomen◦ Shifting dullness◦ Asitic tap reveals straw coloured fluid from

which AFB can be isolated (<3%)◦ Anti-tubercular drugs for one year◦ Repeated tapping may be required


b) Encysted (Loculated) peritoneal tuberculosis

◦ Exudation with minimal fibroblastic reaction

◦ Ascites gets loculated due to fibrinous deposition

◦ Non shifting Dullness is the typical feature

◦ May present as intra-abdominal mass mimicing

ovorain cyst, mesenteric cyst

◦ USG guided aspiration and antitubercular drugs

to be given


c) Plastic Peritoneal Tuberculosis◦ Extensive fibroblastic reaction◦ Widespread adhesions◦ Between coils of intestine (matted intestines),

abdominal wall, omentum◦ Obstruction Distension of abdomen◦ Colicky abdominal pain (recurrent)◦ Diarrhoea, loss of weight, mass per abdomen◦ Doughy abdomen


c) Plastic Peritoneal Tuberculosis◦ Open or laproscopic biopsy (to rule out

peritoneal carcinomatosis)◦ Anti-tubercular drugs◦ Surgery to relieve obstruction by adhesolysis


d) Purulent peritoneal tuberculosis◦ Direct spread from tuberculous salpingitis◦ Mass per abdomen containing pus, omentum,

fallopian tubes, small and large bowel◦ Cold abscess may get adherant to umbilicus◦ May cause umbilical discharge◦ Genitourinary tuberculosis usually present◦ Aanti-tubercular drugs with exporation of

umbilical fistula


1. Calcified lesion:

◦ Along the line of the mesentery a single or

multiple calcified lesions

◦ Payer’s patches involved

◦ No active infection

◦ May be on right or left side (R>L)

◦ Antitubercular drugs

Tuberculous Mesenteric Lymphadenitis

2. Acute mesenteric lymphadenits◦ Common in children◦ Mimics acute appendicitis◦ Tender mass of lymph node palpapble in Right

iliac fossa which are matted and non-mobile◦ Intestines adherant to caseating lymph nodes

obstruction◦ Surgery for appendicitis or obstruction with

lymph node biopsy◦ Antitubercular drugs


3. Pseudo-mesenteric cyst◦ Caseating material collected between the layers of

mesentery◦ Forms cold abscess◦ Mimicking a mesenteric cyst

4. Tabes mesenterica◦ Massive enlargement of mesenteric lymph nodes due

to tuberculosis

5. Chronic Lyphadenitis◦ Children◦ Failure to thrive◦ Protuberant abdomen and emaciation◦ Lymph node on deep palpation in right iliac fossa


Mimics ca rectum Occurs within 10 cmof anal verge Presents with tenesmus, diarrhoea and multiple

discahrging fistula in ano Fistula is painless, not indurated with undermined

edges Shallow bluish ulcers with undermined edges Investigation:

◦ Sigmoidoscopy◦ USG◦ Discharge study◦ fistulectomy and biopsy

Treatment: Drugs, fistulectomy or sigmoid resection

Ano-Recto-Sigmoidal Tuberculosis

As a part of other abdominal tuberculosis Rolled up omentum Cold abscess in omentum Anti-tubercular drugs Syrgery for cold ascess

Omental Tuberculosis

Age: 25 to 50 yrs Equal in both sexes Constitutional symptoms:o Fever (50-70%)oAnorexia (80%)oCachexiaoDiarrhoea (10-20%)oAnemia

Clinical Features

Clinical Features

THANK YOU

abdominal tuberculosis

Health & Medicine