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199
Donald H. Hulnick, M.D.Alec J. Megibow, M.D.
David P. Naidich, M.D.
Susan Hilton, M.D.Kyunghee C. Cho, M.D.
Emil J. Balthazar, M.D.
Abdominal Tuberculosis: CT
The computed tomography (CT) scans of27 patients with abdominal tuberculosiswere reviewed retrospectively to deter-mine the range of abdominal involve-ment. Most patientshad been at increasedrisk because of intravenous drug abuse,alcoholism, acquired immunodeficiencysyndrome (AIDS), cirrhosis, or steroidtherapy. The etiologic agent was Myco-bacterium tuberculosis in 23 patients andM. avium-intiacellulare in four patientswith AIDS. In five patients, tuberculosiswas limited to the abdomen. CT findingsincluded adenopathy, splenomegaly, he-patomegaly, ascites, bowel involvement,pleural effusiori, intrasplenic masses, andintrahepatic masses. Characteristic fea-tures were a tendency for adenopathy toprominently involve peripancreatic andmesentenic compartments, low-densitycenters withiti enlarged node�, complexnature of the ascites, and adenopathy ad-jacent to sites of gastrointestinal tract in-volvement. Recognition of these manifes-tations and maintenance of an index ofsuspicion, especially in patients at risk,should help optimize the correct diagno-sis and management of intraabdominal
tuberculosis.
Index terms: Abdomen, diseases #{149}Abdomen,
computed tomography, 70.121 #{149}Acquiredimmunodeficiency syndrome (AIDS) #{149}Lymphatic
system, diseases, 99.8231 #{149}Mycobacteria, 70.203Tuberculosis, intestinal, 70.23
Radiology 1985; 157:199-204
1 From the Department of Radiology, New York
University Medical Center, New York (D.H.H., A.J.M.,D.P.N., S.H., E.J.B.), and the Department of Radiology,Albert E. Einstein College of Medicine, Bronx, New
York (K.C.C.). Presented at the 70th Scientific Assem-bly and Annual Meeting of the Radiological Society ofNorth AmeriCa, Washington, D.C., November 25-30,1984. Received January 10, 1985; revision requestedMarch 5; accepted May 13.
C RSNA, 1985
M ANIFESTATIONS of tuberculosis within the abdomen are pro-tean. The gastrointestinal tract, lymphatic system, peritone-
um, and solid viscera are subject to varying degrees of involvement:alone, in combination, or in association within extraabdominal dis-
ease. Hence, clinical presentations of abdominal tuberculosis areextremely varied, and diagnosis may be obscured by lack of radio-
logic evidence of pulmonary tuberculosis (1, 2). Abdominal in-volvement is not rare, however, and complicates pulmonary tuber-culosis in 6%-38% of patients (3). computed tomography (CT)offers the advantage of examining the range of abdominal involve-
ment in a single examination, but only two small series have beenrepofted previously (4, 5). CT findiz�gs in 27 patients are presented
here.
MATERIALS AND METHODS
The CT scans of 27 patients with proved intraabdominal tuberculosisexamined between July 181 and October 1984 at six New York City hospi-tals were reviewed retrospectively. No patients with disease limited to themUsculoskeletal system or genitourinary tract were included. Twenty-threepatients were male, and four were female. Their ages ranged from 21 to 68,with an average age of 37 years. Seventeen patients were white, eight were
black, and two were oriental. Most patients had one or more risk factors forthe development Of tuberculosis. Ten had a history of intravenous drugabuse, eight were alcoholics, and eight suffered immunosuppression as aresult of acquired immunodeficiency syndrome (AIDS) (six cases), steroid
therapy (one case), or cirrhosis (one case). Infection was limited to theabdomen in five patients but was present also in the lung or other extraab-dominal sites in the remainder. The causative agent was Mycobacteriumtuberculosis in 23 patients and M. avium-intracellulare in four patients withAIDS. The diagnoses had been proved by microbiological or pathologicanalysis of abdominal tissue (19 cases) or by improvement seen on abdomi-nal CT studies following antituberctilous chemotherapy prescribed because
of the documentation of tuberculosis in extraabdominal sites (seven cases).Scans were performed on commercially available equipment using 10-
mm collimation at 10-15-mm intervals. Oral and intravenous contrast me-dia were administered whenever possible. Clinical charts and other radio-logic studies were reviewed in each case.
RESULTS
Adenopathy was the most common finding on CT study and waspresent in 24patients. In 13 patients there was no associated gastro-
intestinal or penitoneal involvement, but generalized adenopathyor an abnormal chest radiograph evidenced the presence of ftiber-culosis elsewhere. In three patients, abdominal lymph nodes werethe only sites involved. Enlarged nodes were found in the periaor-tic/penicaval retropenitoneum, mesentery, omentum, peripancrea-
tic and porta hepatis regions, and groin (Fig. 1). Most patients hadinvolvement of more than one compartment. Adenopathy patterns
varied widely, including increased numbers of nodes of normal
size, scattered mildly enlarged nodes, localized clusters of severalenlarged nodes, and large conglomerate masses (Fig. ld). Peripan-
Figure 1
200 #{149}Radiology October 1985
Tuberculous lymphadenopathy.
a. Contrast material enhanced scan at the level of the portal vein (PV) shows low-density adenopathy with ring enhancement in theperipancreatic and netroperitoneal compartments (arrows).
b. Multiple enlarged discrete soft-tissue density mesentenic lymph nodes (N) are associated with dilated small-bowel loops with thickenedfolds (SB). Note relative lack of retroperitoneal involvement.
c. Contrast material enhanced scan at the kidney level demonstrates multilocular low-density retroperitoneal masses with ring enhance-ment (M) and soft-tissue density mesentenic adenopathy (*).
d. Heterogeneous soft-tissue density mass in left upper quadrant (M) proved to represent a mesentenic tuberculous abscess. Note lack of
retroperitoneal involvement.
creatic or porta hepatis adenopathywas demonstrable in 21 patients (Fig.la), mesentenic/omental adenopathyin 20 (Fig. ib), and netropenitoneal ad-
enopathy in 19 (Fig. lc). A striking
finding was the relative severity of
the adenopathy in the mesenteric,
omental, and penipancreatic locations
compared with the degree of retro-penitoneal involvement. The retro-
penitoneum was the dominant site of
adenopathy in only three patients,while mesentenic/omental adenop-athy was dominant in eight, and pen-
pancreatic adenopathy was dominant
in seven. The remaining six patientshad diffuse abdominal adenopathybut no particular site of dominant in-volvement.
The centers of enlarged lymph
nodes were of low density in ten pa-
tients (Fig. la and c). Administration
of intravenous contrast material ac-
centuated this finding by enhancing
the inflammatory rim surrounding
the caseous center. Discrete abscesses
containing low-density material were
drained surgically from the mesen-tery (two cases), porta hepatis (two
cases), and uterine adnexa (one case)
(Fig. 2a and b). Abscesses of soft-tis-sue density material were found in
the mesentery (one case) (Fig. id) and
penipancreatic region (two cases) (Fig.
4c and d). Despite the considerablebulk of adenopathy in several pa-
tients, lymph-node masses were not
responsible for obstruction of the un-
nary, biliary, or gastrointestinal tracts
in any patient.
Splenomegaly, defined as a span 13
cm or greater (6), was a prevalent
finding (18 cases). In only three pa-
tients were discrete intrasplenic
masses identified by CT (Fig. 2c). He-
patomegaly, defined as a span greater
than 20 cm (7), was a less common
finding (ten cases). No patient had
hepatomegaly without associated
splenomegaly. In only one patient
did a CT scan demonstrate mntrahepa-tic masses (Fig. 3). Liver biopsy resultswere positive for caseating granulo-matous disease in three patients
whose CT scans showed enlarged but
homogeneous livers and in one pa-
tient with a liver that appeared as nor-
IIK
Hepatic tuberculosis. Multiple low-density intrahepatic masses are
associated with adenopathy (N) in the porta hepatis. The spleen
was enlarged and showed similar masses.
. .‘.-
Volume 157 Number 1 Radiology #{149}201
�‘. A
C
Tuberculous peritonitis.a. Contrast material enhanced scan at level of kidneys
shows relatively high-density ascites (A) and markedaccentuation of mesentenic vessels with mesentenic ad-
enopathy (arrows). Retropenitoneum is relatively unin-
volved.b. In the same patient, scan through the pelvis (B blad-
der, C = colon) demonstrates bilateral tubo-ovanian ab-
scesses (A), showing partial low density on the right.
c. Scan at the renal level (K) without contrast material
shows enlarged spleen with low-density mass (5) with-
in it and voluminous ascites complicated by soft tissuestanding and small irregular densities.
mal in size and density on CT scans.
Ascites was present in seven pa-
tients, three of whom also had pleural
effusion. The fluid was voluminousand diffusely distributed throughout
the peritoneal cavity in five patients
and was loculated in small scatteredpockets in two. Tuberculous salpingi-
tis apparently preceded diffuse pen-
tonitis in two patients (Figs. 2a and b),
and one patient had preexisting cm-
rhosis and ascites (Fig. 2c). Fluid-den-sity measurements ranged from 20 to
45 Hounsfield units (HU) and aver-
aged 30 HU for the seven patients.Penitoneal enhancement following
administration of intravenous con-
trast material was seen in three pa-
tients. In all patients with ascites,
there was abnormal thickening of softtissue and nodulanity associated withthe penitoneal surfaces, mesentery,and omentum (Fig. 2c).
CT scans demonstrated ileo-cecaltuberculosis in one patient (Fig. 4a
and b), diffuse small-bowel involve-
ment in another patient (Fig. lb), and
a peripancreatic tuberculous abscessassociated with a duodenal fistula in
two patients (Fig. 4c and d). In eachcase, there was adenopathy adjacent
to the involved bowel segment. In
one patient with endoscopically
proved colonic tuberculosis, the CTscan demonstrated diffuse abdominal
adenopathy with a mesentenic pre-
dominance, but the sites of colonic in-
#{149}#{149}�: -�::--__ �:-:: T
Figure 4
202 #{149}Radiology October 1985
Gastrointestinal tuberculosis.
a. Scan through lower abdomen shows thickening of cecal wall (C) and an adjacent mass of conglomerate adenopathy
(arrows).
b. In the same patient, small-bowel series demonstrates ulcerohypentrophic ileo-cecal tuberculosis.
c. A large, irregular, soft-tissue penipancreatic mass (M) deviates the stomach (S) anteriorly. A focus of extraluminal air
(arrow) is seen medial to the widened duodenal sweep (D).
d. Hypotonic upper gastrointestinal study shows spiculation of the medial aspect of the second and third duodenal
segments (arrows) and outlines extravasation into the penipancreatic abscess (curved arrows).
volvement could not be identified
from the scan.
DISCUSSION
Tuberculosis within the abdomen
potentially can affect the gastrointes-
tinal tract, peritoneum, lymph nodes,
liver, on spleen. Possible mechanisms
in the development of abdominal dis-
ease include ingestion of infected ma-
tenial such as sputum or milk, or he-
matogenous dissemination to the
abdominal viscera and lymphatic sys-
tem from a distant focus, usually in
the lung. Prior to the advent of CT
scanning, radiologic evaluation was
confined largely to studies of the gas-
trointestinal tract with contrast me-
dia. Extramucosal disease in lymph
nodes, peritoneal involvement, on in-
volvement of the liver and spleen
could not be evaluated directly by
this method. Even before the era of
chemotherapy, however, it had been
shown that up to two-thirds of pa-
tients with abdominal tuberculosis
had lymphadenopathy or penitoneal
disease without gastrointestinal in-
volvement (8, 9). Contrast material
studies alone, therefore, have been of
limited utility in detecting and locat-
ing the full range of abdominal dis-
ease. Furthermore, the virtual disap-
pearance of bovine tuberculosis in the
United States and the general avail-
ability and effectiveness of antituber-
culous chemotherapy have resulted
in a decreased incidence of intestinal
tuberculosis caused by ingestion.
Concurrently, tuberculosis has be-
come less readily recognized, perhaps
because of its decreased incidence or a
changing pattern of clinical and ra-
diological presentation since the ad-
vent of chemotherapy (10-12). Today,
immunodeficiency associated with ci-
then alcoholism, intravenous drug
abuse, diabetes, cancer, steroid thera-
py, and acquired states (e.g., AIDS)are prominent risk factors (13), and
indeed, in our series only 20% of the
patients did not have at least one of
these risk factors.
Volume 157 Number 1 Radiology #{149}203
Abdominal lymphadenopathy was
the most common manifestation of tu-berculosis on CT scans in our series
and was present in nearly all (23 of26) patients. Of course, adenopathy
within the abdomen is found in amultitude of pathologic conditions,
benign and malignant; but in our pa-
tients, tuberculous adenopathy exhib-
ited several characteristic but not pa-
thognomonic features. There was a
striking tendency for the involve-
ment of mesentenic and penipancrea-
tic node groups to accompany and
usually overshadow the extent of ret-
ropenitoneal involvement (Fig. la, b,and d). While a previous study (4) did
describe omental involvement, thefinding of mesentenic, porta hepatic,and penipancneatic adenopathy wasnot emphasized. Lymphangiographicstudies in patients with abdominal tu-
berculosis have noted a gradient of
retroperitoneal involvement, most se-vere in the upper abdomen (14), and
mesentenic adenitis and penipancrea-
tic involvements are well-recognizedmanifestations of abdominal disease(9, 15, 16). Perhaps this distributionreflects the lymphatic drainage ofsites in the small bowel and liver that
had been seeded hematogenously butmay not have developed frank clini-cally apparent infection. Iliac, lum-bar, and lower abdominal nodegroups are less commonly involved
because they drain the lower extrem-ities, pelvic viscera, and distal co-lon-areas less likely to be affected byhematogenous tuberculous dissemi-
nation, except when infection is over-whelming.
In our series, lymph node masses,even when large, did not cause ob-
struction of the biliary ducts, uneters,
or bowel. It should be noted, howev-en, that obstructive jaundice second-any to adenopathy in the porta hepa-tis, hepatoduodenal ligament, and
penipancreatic area has been reportedas a rare complication of tuberculosisin North American patients (17, 18)
and is apparently less rare in the Fili-pino population (19).
Low-density centers within tuber-culous abdominal lymph nodes havebeen noted in previous reports (4, 5)and were identified in 40% (ten of 24)of our patients (Fig. la and c). Thisfinding is not diagnostic, however,and may be found occasionally in
metastatic malignancy, lymphoma(especially if treated), pyogenic infec-tion, and Whipple disease (20). In tu-berculosis, presumably the low-den-sity nature of the involved nodes issecondary to caseation necrosis. Inour series, however, there was nostrong correlation between the site orextent of adenopathy and the density
of the involved nodes. The largest
mesentenic abscess (10 cm) was of
soft-tissue density (Fig. id), while the
smallest (2 cm) was of low density.
Gastrointestinal tuberculosis can
result from ingestion, extension from
the lymphatic system, or hemato-
genous dissemination; each of these
pathophysiologic mechanisms is rep-
resented in our series. One patient
whose chest radiograph was within
normal limits had a history of recent
travel to an area endemic for bovine
tuberculosis. This patient had ulcero-
hypentrophic ileo-cecal disease, pne-
sumably caused by ingestion of in-
fected milk (Fig. 4a and b). In two
patients, massive penipancneatic tu-
berculous adenopathy eroded into
the duodenum, resulting in fistula
(Fig. 4c and d). In a patient with AIDS,
diffuse bowel involvement (Fig. ib)
was associated with hematogenous
dissemination to the lymph nodes,
bone marrow, central nervous system,
liver, and spleen. Though CT was of
diagnostic importance in demonstrat-
ing ancillary findings such as adenop-
athy, barium studies were essential
for further characterizing the nature
of the bowel pathology in each pa-
tient.
Tuberculous peritonitis, as seen in
seven of our patients, is a well-de-
scnibed manifestation of abdominal
disease (8, 9, 15, 21-23) but occurs in
less than 4% of patients with pulmo-
nary tuberculosis (1, 2). Peritonitis
and ascites may be associated with
widespread abdominal and extraab-
dominal disease, as in three of our pa-
tients. Tubenculous salpingitis pro-
gressing to diffuse peritonitis, a
known mechanism of spread (2), wasevident in two of our patients (Fig. 2a
and b). The association of cirrhosis
and tuberculous peritonitis has alsobeen described (20) and was present
in one patient (Fig. 2c). In the seventh
patient, tuberculous peritonitis ap-
peaned to develop primarily, as no
pulmonary or other abdominal site of
infection was evident.
In these seven patients, ascitic fluid
density ranged from 20 to 45 HU, (av-
enage, 30 HU). It has been suggestedthat high-density ascites may be char-
actenistic of tuberculosis (4, 5). Theo-
retically this can be explained by the
high protein and cellular contents in
a tuberculous effusion, particularlywhen cell-mediated immunity has de-veloped. We emphasize, however,
that tubenculous ascites may also be
near water in density, perhaps reflect-
ing an earlier transudative stage of
immune reaction. The problems in-
herent in using CT density measure-
ments as absolute standards of refer-
ence should be recognized (24), and
this is especially evident when “mea-
suning” small areas such as pockets of
ascites. Moreover, as in our cases, an-
cillany findings of tubo-ovanian ab-
scesses, adenopathy, penitoneal en-
hancement, or a “dirty” appearance to
the mesentery indicate a complex na-
tune to the ascites and should suggest
the diagnosis of tubenculous penitoni-
tis. Recognition of these features
proved more relevant than merely
measuring ascitic fluid density or at-
tempting to classify peritoneal in-
volvement into the classic wet, dry, or
fibrotic-fixed forms (1, 2, 21).
Tuberculosis of the liver or spleen
is reportedly uncommon, except in as-
sociation with miliary dissemination
(2, 9). Though hepatic involvement
by tuberculosis reportedly tends to be
diffuse (2), the macronodular or pseu-
dotumon forms, as found in one of our
patients (Fig. 3), is rarely seen as well
(25). The high incidence of spleno-
megaly (18 of 27 cases) and hepatome-
galy (ten of 27 cases) in our series is
higher than in previous series (8, 9,
14, 15), and four of our patients did
not appear to have miliary disease or
even disease outside the abdomen.Our findings may in part be related tothe high incidence of coexisting alco-
holism and intravenous drug abuse in
our patients. Interestingly, no patient
had hepatomegaly without spleno-
megaly, and in many cases the en-
largement was mild, perhaps indicat-
ing that enlargement of the liven or
spleen in some cases represented a
nonspecific response to infection.
Patients with AIDS presented spe-
cial problems. There have been sever-
al recent reports of disseminated in-
fection with M. avium-intracellulare
complex in these patients (26-29), aswas seen in four of our cases. Yet two
of our patients with AIDS were in-
fected with typical M. tuberculosis. Pri-or to the AIDS epidemic, disseminat-
ed infection with M. avium was
exceedingly rare (30-32). In our series
each patient with M. avium infection
had been chronically ill with AIDS-
related diseases and exhibited multi-
system involvement. However, dis-
tinguishing M. tuberculosis from M.
avium infection was not possible byCT criteria alone. In all AIDS patients,differential diagnosis must include
the Lymph Node Syndrome, Kaposi
sarcoma, lymphoma, and other op-
portunistic infections as well as typi-
cal and atypical tuberculosis (33); ag-gressive biopsy, smear, and culture
studies of relevant tissue are neces-
sary for an accurate diagnosis (26, 27,
34-37).In any patient, diagnosis of intraab-
dominal tuberculosis is difficult be-cause symptoms are vague, signs non-
204 #{149}Radiology October 1985
specific, and clinical tests often notconclusive. Though the presence or ahistory of pulmonary disease may besuggestive, nearly one-fifth of our pa-tients (five of 27) had no evidence of
extraabdominal disease. Recovery ofmycobactenia from the stool may notnecessarily indicate gastrointestinalinfection. Results of purified proteinderivative skin tests may be falselypositive or negative. Results of liverbiopsy testing are usually negative inthe absence of miliary disease (2). Theimportance of reaching the correct di-agnosis, however, is formidable, as
untreated abdominal tuberculosis car-nies a 50% mortality rate (8). Laparoto-my should be avoided if possible, andeven those patients requiring surgery
benefit from preoperative antituber-culous chemotherapy (9).
Unfortunately, there are no CTfindings, alone or in combination,that are pathognomonic of tuberculo-sis. Abdominal adenopathy, predomi-nantly in the mesenteric and peripan-creatic areas, is a suggestive finding.Low-density centers within the en-larged nodes are also a characteristicfeature. Ascites-perhaps relativelyhigh in density, loculated, or accom-panied by peritoneal enhancement oradenopathy, and associated with mes-entenic and omental soft-tissuechanges-is suggestive of tubercu-bus peritonitis. Bowel abnormalityassociated with adjacent adenopathymust also raise the possibility of gas-trointestinal tuberculosis. And mostimportant, to make the correct diag-nosis, an index of suspicion must bemaintained, especially in those pa-tients at increased risk.
Acknowledgments: We gratefully thank Drs.L. Berliner, J. Lang, R. Meisell, and K. Zirinskyfor contributing cases for this study, and JennieLopez for assistance in manuscript preparation.
Send correspondence and reprint requests to:Donald H. Hulnick, M.D. Department of Radi-ology, New York University Medical Center,
560 First Avenue, New York, NY 10016.
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