abdominal tuberculosis surgical aspects
DESCRIPTION
prepared by post graduates of coimbatore medical college and hospitals.TRANSCRIPT
HOD : Prof. Dr. Vasanthakumar MS., UNIT CHIEF : Prof. Dr.Ravindran MS., ASSISTANT PROFESSORS: Dr.Vishwanathan MS., Dr.Muthulakshmi
MS.,PRESENTED BY Dr.Pradeep – Pathogenesis & Investigations Dr.Dhanaraj – Gastrointestinal TB Dr.Sudish- Peritoneal & Solid Organ TB Dr.Adarsh- Surgery in TB
ABDOMINAL TUBERCULOSIS
TUBERCULOSIS
ETIOPATHOGENESIS AND INVESTIGATIONS
WHY SHOULD WE KNOW ABOUT
TB??
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
TB declared as notifiable disease by INDIAN GOVERNMENT on
may9th 2012
http://articles.timesofindia.indiatimes.com/2012-05-09/india/31640562_1_mdr-tb-tb-cases-tb-diagnosis
Risk Factors Case series involving 60 patients
38% Cirrhosis
33% Renal Failure with Peritoneal Dialysis
27% Diabetes Mellitus
18% Underlying Malignancy
10% Systemic Corticosteroids
2% AIDS
12% No Risk Factorshttp://www.med.unc.edu
24th march 1882
World TB DAY
PATHOGENESIS
STAGE 1 ESTABLISHMENT
ALVEOLAR MACROPHAGE INGESTS TB BACILLI
M. tuberculosis blocks phagolysosome formation by inhbiting Ca2+ signals and the recruitment and assembly of the proteins that mediate phagosome-lysosome fusion
Fratti RA, et al. J cell Biol 2001
Racial differences in macrophages
microbicidal enzymes. Africans have macrophages less capable of destroying tb bacilli.
Mutations in NRAMP-1 gene involved in pushing out Fe2+ ions from the phagolysosome.
Cellier MF, et al.
Microbes Infect 2007; 9:1662.
STAGE 2 SYMBIOSIS
Tubercle bacilli ingestedBy non activated newly recruitedMonocytes.
STAGE 2 SYMBIOSIS
Incapable alveolar macrophage bursts. New monocytes from blood are recruited to
the site mainly by c5a, Monocyte Chemoattractant protein-1(MCP-1)
TB bacilli multiplies in these non activated monocytes.
7-21 days (<3weeks) – primary TB. Comes to an end when Th1 cells enters the
site
T-CELL
Secrete IFN γ
Activates Macrophages
Kills the inactivated macrophages which were allowing the tb bacilli growth inside them…
WHAT IS THE INITIAL RESPONSE
OF THE HOST??
CMI or DTH???
Main difference is concentration of antigen required….
STAGE 3 EARLY STAGES OF CASEOUS NECROSIS
Non activated Macrophages which allowed the growth of TB bacilli are killed by DTH mediated by T-cellsForming solid caseous necrosis
If DTH is directed towards the TB bacilli then why so
much of tissue destruction occurs??
up-regulation of ICAM-1, ELAM-1, VCAM-1, and other adhesion molecules
Activated endothelial cells presents tuberculin like antigen to macrophage
Leading to endothelial injury and its consequences
J Leukoc Biol. 1996;60:692–703.
DTH AND CMI
•T-CELLS•DESTROYS INACTIVATED MACROPHAGES IN WHICH BACILLI MULTIPLIES•INITIALLY BENEFICIAL
DTH
•MACROPHAGES and T-CELLS•BACILLI MULTIPLYING INSIDE ACTIVATED MACROPHAGES ARE DESTROYED•BENEFICIAL TO THE HOST
CMI
STAGE 3 EARLY STAGES OF CASEOUS NECROSIS
TB bacilli remains live but cannot multiply in solid caseous material.
TB bacilli escaping from the edges of caseous necrosis are engulfed by macrophages and caseous centre enlarges.
STAGE 4 INTERPLAY OF CMI AND DTH
ACTIVATED MACROPHAGESWALLS OFF THE EXPANDINGCAVITY AND PREVENTS FURTHER INCREASE INSIZE IN HOST WITH GOODCMI.
POOR CMI
IN HOST WITH POOR CMIDTH CONTINUES DESTROYS THE BACILLI AND LUNG TISSUE TOO.
TB BACILL SPREADS THROUGHLYMPHATIC AND HEMATOGENOUS ROUTE TO OTHER ORGANS.
1.ARE HOSTS WITH POOR CMI ARE MORE INFECTIVE??2.ROLE OF STEROIDS IN
ABDOMINAL TB??
STAGE 5 LIQUEFACTION AND CAVITY FORMATION
the large quantities of bacilli and their antigens in the liquefied caseum overwhelm a formerly effective CMI, causing progression of the disease and the destruction of local tissues, including the wall of an adjacent bronchus.
when the caseum liquefies, the entering
macrophages do not function effectively. Possibly, the entering macrophages are killed
by toxic fatty acids originating from host cells, or the bacilli, or both.
CAUSE OF LIQUEFACTION???
REF: Hemsworth GR, Kochan I. Secretion of antimycobacterial fatty acids by normal and activated macrophages. Infect Immun. 1978;19:170–177.
GENERAL INVESTIGATIONS
. Types of specimens:1.Pulmonary specimens -Sputum -Gastric lavage -Transtracheal aspirations -Bronchoscopy -Laryngeal swabbing2.Urine specimens3.Tissue and body fluid specimens4.Blood specimens5.Wounds, skin lesions, and aspirates
Microscopy
Sputum smears stained by Z-N stain
What is Smear Positivity All patients who have
submitted two Specimens and found to be positive for identification of AFB
Detecting AFB by fluorochrome stain using fluorescence microscopy
Culturing for isolation of Mycobacterium spp continues to be a Gold standard Agar based egg based BACTEC – 14.8days MGIT- 13.3days
4-6weeks
NEWER METHODS
PCR SENSITIVITY-92% SPECIFICITY-99%
INTERFERON –γ release assays.
QuantiFERON-TB
TB SPOT
SENSITIVITY-81%SPECIFICITY-91.2%
SENSITIVITY-87.5%SPECIFICITY-86.3%
GASTROINTESTINAL TUBERCULOSIS
Epidemiology Pathogenesis Clinical features Diagnosis
Epidemiology
Upto 1% of hospital admissions More common in immuno-suppressed Isolated abdominal tuberculosis:
Unselected autopsy series- 0.02 - 5.1% Higher prevalence in females in India (3:1–4:1)
Mainly disease of young adults
~ 2/3 of pt. are 21-40 yr old
TB & HIV
Incidence severity of abdominal TB will increase with the HIV epidemic
HIV – 50 % develop abdominal TB
Pathogenesis
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
In India, organism from all intestinal lesions – M. tuberculosis and not M. bovis.
Types
Ulcerative Hyperplastic Ulcerohyperplastic Diffuse colitis Sclerotic
PATHOLOGY
Bacilli in depth of mucosal glands
Inflammatory reaction
Phagocytes carry bacilli to Peyers Patches
Formation of tubercle
Tubercles undergo necrosis
Most active inflammation in submucosa.
PATHOLOGY
Submucosal tubercles enlarge
Endarteritis & edema
Sloughing
Ulcer formation
Accumulation of collagenous tissue
Thickening & Stenosis
PATHOLOGY
Lymphatic obstructionof mesentery and bowel Thick fixed mass
Regional lymph nodes• Hyperplasia• Caseation necrosis• Calcification
Bacilli via lymphatics
Inflammatory process in submucosa penetrates to serosa
Tubercles on serosal surface
Bacilli reach lymphatics
Order of Frequency
Ileum > caecum > ascending colon > jejunum
>appendix > sigmoid > rectum > duodenum
> stomach > oesophagus
More than one site may be involved
Bhansali - ileum involved in 102 and caecum in 100 of 196
pt. Prakash - ileocaecal involvement in 162 of 300 pt. Most common site - ILEOCAECAL REGION
WHY?
Increased physiological stasis Increased rate of fluid and electrolyte absorption Minimal digestive activity Abundance of lymphoid tissue at this site.
Clinical features
Constitutional symptoms
Fever (40%-70%) Weight loss (40%-90%) Anorexia Malaise
Pain (80%-95%)
Colicky (luminal stenosis) Continous ( LN involvement)
Altered bowel habits
Ileocecal TB
Colicky abdominal pain
Ball rolling in abdomen
Borborygmi
Right iliac fossa lump - ileocaecal region, mesenteric fat and LN
Isolated Colonic TB
9.2% of all cases
Multifocal involvement in ~ 1/3 (28% to 44%)
Anorectal TB
Hematochezia - most common symp. Due to mucosal trauma by stool
Constitutional symptoms
Constipation
Rectal stricture
Anal fistula – usually multiple
Gastroduodenal TB
Stomach and duodenum each ~ 1% of total cases
Mimics PUD - shorter history, non response to t/t
Mimics gastric Ca.
Duodenal obstruction - extrinsic compression by tuberculous LN
Hematemesis / Perforation / Fistulae / Obstructive jaundice
Cx-Ray usually normal
Endoscopic picture - non specific
Esophageal TB
Rare ~ 0.2% of total cases
By extension from adjacent LN
Low grade fever / Dysphagia / Odynophagia / Midesophageal ulcer
Mimics esophageal Ca
OBSTRUCTION
PERFORATION
MALABSORPTION
Complications
Obstruction
Pathogenesis
Hyperplastic caecal TB
Strictures (napkin ring) of the small intestine
Adhesions
Adjacent LN involvement traction, narrowing and fixation of bowel loops.
In India ~ 3% to 20% of bowel obstruction (Bhansali and Sethna).
Malabsorption
2nd most common cause in India
Pathogenesis
bacterial overgrowth in stagnant loop
bile salt deconjugation
diminished absorptive surface due to ulceration
involvement of lymphatics and LN
75% pt with intestinal obstruction
40% of those without (Tandon et al)
Perforation
5%-9% of SI perforations in India
2nd commonest cause after typhoid
Usually single and proximal to a stricture
Clue - Chest x-ray,
Pneumoperitoneum in ~ 50% cases
Investigations
Intestinal TB cont.
CT scan shows thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows).
Endoscopy Nodules
Variable sizes (2 to 6mm) Non friable Most common in caecum especially near IC valve.
Tubercular ulcers Large (10 to 20mm) or small (3 to 5mm) Located between the nodules Single or multiple Transversely oriented / circumferential contrast to
Crohns Healing of these ‘girdle ulcers’ strictures
Deformed and edematous ileocaecal valve
Esophageal TB Nodules
TB mass in stomach T.B. ulceration with narrow lumen
Is endoscopy diagnostic?
8 –10 Bx from ulcer edge
low yield on histopath as mainly submucosal disease
Granulomas in 8%-48%
Caseation in ~ 1/3 (33%-38%) of + cases
AFB stains - variable
Culture positivity in 40%
Combination of histology & culture diagnosis in 80% ( S K Sharma)
Take home message
Ileocecal TB is the most common intestinal TB Combination of histology & culture is necessary for diagnosis. Surgery is the only answer
PERITONEAL TUBERCULOSIS
AN OVERLOOKED DIAGNOSIS
Non specific presentation
Insidious presentation
Mimicks malignancy
Unhelpful labaratory tests
DIAGNOSTIC CHALLENGES
EPIDEMOLOGY
PATHOGENESIS
CLINICAL FEATURES
DIAGNOSIS
TREATMENT
6th most common extra pulmonary site
Incidence- 0.1% to 0.7% worldwide
Rising incidence
sexes are equally affected
35 and 45 years of age.
EPIDEMOLOGY
Activation of quiscent foci of
infection(common)
Direct spread –mesentric Lymph nodes –Intraabdominal organs
•Hematogenous spread from–Primary pulmonary TB–Miliary TB
PATHOGENESIS
CLINICAL PICTURE
wet-ascitic(most common)
• ascites• ±peritonitis
fibrotic-fixed
• Mass formation• Matting of bowel loops
dry-plastic form(less common)
• adhesions• ‘doughy feel’• tender abdominal masses.
Encysted(loculated)
• localized abdominal swelling
CLINICAL PRESENTATION
Case series involving 145 patients
73% Abdominal swelling (ascites) – most common
64% Abdominal pain 54% Fever and night sweats 44% Weight loss 18% both pulmonary & abdominal TB Hepatomegaly and splenomegaly - uncommon
CLINICAL FEATURES
Haematological indices. Microbiological diagnosis. Ascitic fluid analysis. New diagnostic tools-Adenosine deaminase,
Gene amplification. Immunodiagnostic tests. Imaging studies CXR- concomitant TB in less than 25% cases Barium studies . ultrasound and computed tomography.
INVESTIGATIONS
•Gross Appearance: Straw coloured .
EXUDATIVE WBC cell count- 500 and 1500 cells/mm3 – lymphocytosis.
LDH raised-> 90 U/L
Protein > 3g /dl.
SAAG <1.1mg/dl
RBC 7%.
AFB stain +ve < 3 per cent of cases.
positive culture is obtained in less than 20 per cent of cases
Ascitic fluid analysis
New diagnostic tools
Adenosine deaminase.
rapid and non-invasive
Purine-degrading enzyme
Assists with maturation and differentiation of T-lymphoid cells.
Raised- stimulation of T cells by the mycobacterial antigens.
Adenosine deaminase
•Cut-off value of 30 U/L 94% Sensitive 92% Specific.
FALSE VALUES- •In coinfection with HIV - normal or low. Falsely high values in malignant ascites.
Gene amplification.- LCR & PCR in detecting AFB in tissues.
serological tests- - ELISA to detect IgG to a 43 kDa antigen of M. tuberculosis found it to be highly sensitive. - High IFN-γ levels - detecting latent TB.
Elevated CA-125 -Not sensitive
Also raised in peritoneal carcinomatosis, ovarian malignancy.
Can use to follow treatment response
in obtaining peritoneal biopsies
safer and inexpensive alternative to diagnostic laparoscopy.
high diagnostic yield approaching 95%
Imaging studies
Ultrasound-
superior to CT in revealing the multiple, fine, mobile septations within the ascitic fluid
1. fluid -free or loculated;(echogenic debris) 2. “Club sandwich” or “sliced bread” sign.3. Lymphadenopathy- caseation and calcification.4. Bowel wall thickening .5. Pseudokidney sign
COMPUTED TOMOGRAPHY-
ascitic fluid has high attenuation values .
•Peritoneum(white arrow) –Smooth and uniform thickening –If nodular, think Peritoneal
Carcinomatosis.
•Omentum(open arrow) –Smudged, omental cake or
nodular..
•Mesentery –Loss of normal mesenteric
configuration -Thickened mesentery (>15 mm)
with mesenteric lymph nodes- early sign
•Lymphadenopathy.(black arrow)
DIAGNOSTIC TOOL OF CHOICE?
DIAGNOSTIC LAPROSCOPY
specificity in excess of 96% on the laparoscopic appearance alone.
With histological findings-sensitivity- 93% specificity- 98%
Peritoneal biopsies should always be examined whenever possible for culture and sensitivity. - gold standard
DIAGNOSTIC YEILD
Thickened peritoneum with tubercles (66%)
thickened and peritoneum with adhesions (21%);
fibro-adhesive type – with tubercles and adhesions 13%.
LAP FINDINGS
PIT FALLS Peritoneal carcinomatosis, sarcoidosis,
starch peritonitis and Crohn's disease - MIMICK LAP FINDINGS.
More expensive. Requires expertise. poor isolation of organism complications -bleeding, infection and bowel
perforation
ROLE OF
LAPAROTOMY?
unnecessary
with fibro-adhesive type of TBP when there
is an indication for a peritoneal biopsy.
ideal diagnostic test
requires the demonstration of
mycobacteria
characteristic laparoscopic appearance
itself, even in the absence of bacteriological confirmation, would be sufficient grounds for the diagnosis of TBP.
HIGH SPECIFICITY OF MACROSCOPIC APPEARANCE
BUT…
TREATMENT
MEDICAL vs SURGICAL
solely pharmacological.
Four drug regimen:–Isoniazid–Rifampin–Ethambutol–Pyrazinamide.
CAT I ATT Response to therapy is manifested by resolution of
symptoms and disappearance of ascites
UNCOMPLICATED
Surgery is reserved for complications or
uncertainty in diagnosis.
MDR-TB not responsive to ATT.
ABDOMINAL COCOON SYNDROME-
rare entity causing intestinal obstruction.
Diagnosis done by imaging studies.
Extensive bowel resection is associated with high morbidity.
Symptomatic relief generally ensues following conservative surgery, although recurrence has been reported.
DREADED COMPLICATION
ROLE OF CORTICOSTEROIDS?
four trials of adjuvant corticosteroids use in TBP
and all of them cited modest benefit.
Alrajhi et al.85 reported considerably low morbidity and complications in those treated with corticosteroids.
pending need for prospective, well-controlled clinical trials with long-term follow-ups to identify the category of patients most likely to benefit from such therapy
requires a high index of suspicion because of
the subtle nature of the symptoms and signs.
culture growth of the Mycobacterium remains the ‘gold standard’ for diagnosis.
It is essential to recognize that a combination of different diagnostic tests is used in order to arrive at the diagnosis of TBP
Tuberculous peritonitis--do not
miss it
Laparoscopy, however, remains the
best means of diagnosing the
disease
SOLID ORGAN TUBERCULOSIS
the portal of entry :hematogenous
dissemination miliary tuberculosis :hepatic artery focal liver tuberculosis :portal vein.
HEPATIC TB
three forms diffuse hepatic involvement- most common granulomatous hepatitis focal/local tuberculoma or abscess- rare
INVESTIGATIONS
Percutaneous liver biopsy.
laparoscopy liver biopsy- cheesy white irregular nodules.
CT SCAN.
CT abdomen
miliary micronodular with miliary calcifications
Multiloculated cystic mass(cluster sign)
MILIARY TB
lesions are small 1 to 2 mm epitheloid granulomas.
TUBERCULOMA Masses larger than 2mm in diameter
• It can occur due to disseminated or miliary form of
the disease• Most commonly encountered in HIV pt(developed
countries)• Fever, weight loss, diarrhea, left upper abdominal
pain, splenomegaly • Investigations• Image-guided percutaneous needle biopsy is the
gold standard for diagnosis.
CECT-abdomen-multiple hypo echoic foci(<2cm)
SPLENIC TUBERCULOSIS
Gross pathology of resected spleen showing innumerable caseating granulomas consistent with splenic tuberculosis.
Mackowiak P A et al. Clin Infect Dis. 2011;52:418-420
The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected].
Computed tomograph scan of the abdomen showing a spleen diffusely infiltrated by small, hypodense lesions consistent with splenic granulomas.
Mackowiak P A et al. Clin Infect Dis. 2011;52:418-420
The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected].
It is rare Often associated with miliary TB &
immunocompromised pt Result from lymphohaematogenous
dissemimation after pulmonary exposure Anorexia,malaise fever,weight loss,mass Investication: FNAC & BIOPSY (CT guided)
PANCREATIC TB
CT enhanced conrast-
Microscopic pyuria without bacteruria and with
or without hematuria.
Progression of the disease urine culture may be +ve for tubercle bacilli.
Cavitation of renal parenchyma may be seen.
Standard anti TB therapy
RENAL TB
Ovarian TB
Fallopian tubes are affected in 94% of women with genital tuberculosis.
Salpingitis caused by hematogenous dissemination is almost always bilateral .
A tubo-ovarian abscess that extends through the peritoneum into the extraperitoneal compartment suggests tuberculosis
Ovarian TB Tuberculous tubo-
ovarian abscess
(a) Contrast-enhanced CT scan shows a multiloculated mass with peripheral enhancement around centers .(arrow).
(b) Coronal T2-weighted MR image (7,200/90) shows the abscess (arrows).
Surgeon’s Viewpoint
A 24 yr old female comes with pain RIF,
MANTRELS 7/10 diagnosed as acute appendicitis.
On opening an inflammed appendix is found but studded with tubercles, omentum and caecum show multiple tubercles
Do we do appendicectomy ?
Patient comes with features of perforation
peritonitis On opening TB peritonitis with ileac
perforation with a stricture of about 3 cm 2 feet distal to perforation
Primary closure?Stricturoplasty?
Resection?
A 60 yr old male, known case of pulmonary TB
presenting with acute intestinal obstruction On opening ileocecal mass with peritonium
and omentum showing features of TBRt hemicolectomy?Limited resection?
Bypass?
Patent known case of pulmonary TB ,
presenting with ascites and subacute obstruction.
On diagnostic Lap we find Milliary TB with multiple adhesions
Do we do adhesiolysis?
Removing the appendix is a safe procedure
even if microscopic evidence of tuberculosis is present
Delay in treatment can cause significant morbidity
Appendicectomy
•Singapore Med J 2011; 52(2) : 91•Abrams & Holden, 1964
Stricturoplasty/ Resection
Both procedures were equally effective and had equal morbidity in cases of intestinal tuberculous strictures.
Stricturoplasty is superior to resection anastomosis in cases of multiple strictures as it conserves gut length
Stricturoplasty can even be performed safely in cases with coexistent gut perforation.
J Coll Physicians Surg Pak 2003 May;13(5):277-9
Zafar A et al ,Rawalpindi General Hospital, Rawalpindi
Stricturoplasty
Stricturoplasty is a simple, quick, and safe operative technique to manage tuberculous small intestinal strictures, in combination with limited resection or as a sole procedure
Stricturoplasty is suggested in pyloroduodenal and ileocaecal lesions
Abrar Hussain Zaid et al
Katariya et al
Perforation primary closure?
The results of oversewing alone are poor Bhansali et al.,1968
Resection anastomosis is the best method in treating perforations
N.O. Aston and A.M. de Costa, Postgraduate Medical Journal (1985) 61, 251-252
In critically ill is oval excision of the perforated area with a transverse anastomosis reinforced by an omental patch
Pujari, 1979
Resection Anastomosis
Is it safe?
Annals of Surgery November 1964
Two-stage procedures Reversal of stoma in a well-prepared gut with
ATT cover
Muhammad Saaiq et al
Turkish Journal of Trauma & Emergency
Surgery vol 17 2011 Rankie et al Recio et al Piechaud et al Asian J Surg 2002:25(2):145-8
Resection is a safe and effective procedure in
treating abdominal TB complications.
Resection of a tuberculous lesion where
feasible is the procedure of choice
With effective ATT limited and conservative
resections give good results
How much to resect?
•Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 393-396•P Agarwal et al , BHJ 2000
Low output fistulas without distal obstruction
ATT wait and watch High output fistulas Fistulas with distal obstruction Fistulas not responding to conservative
management Surgery
Fistulas
Saudi J Gastroenterol. 2010 October; 16(4): 305.
Adhesiolysis / ATT
Adhesive intestinal lesions may be relieved with antitubercular drugs alone without surgery.
Anand et al Balasubramaniam et al
To summarise
Tuberculous peritonitis once diagnosed is usually not a surgical disease.
Resection of diseased segment is the best method
Stricturoplasty and Resection anastomosis are safe procedures
Limited resection is advised with ATT cover Chemotherapy has no substitute and is
essential after surgery.
Thank You