05/12/2007

Most common form of extrapulmonary tuberculosis (3 to 4%)

Defined as tuberculosis infection of the abdomen including gastrointestinal tract, peritoneum, omentum, mesentery and its nodes, liver, spleen and pancreas

Mycobacterium tuberculosis is the most frequently isolated organism

Ingestion of milk or infected food

Swallowing of sputum in active PTB

Hematogenous spread from active pulmonary lesion, miliary tuberculosis

Contiguous spread from infected foci like fallopian tubes, mesenteric lymph node

Very rarely as a consequence of peritoneal dialysis

Gastrointestinal tuberculosis-Ulcerative

-Hypertrophic

-Sclerotic or fibrous

-Diffuse colitis

Peritoneal tuberculosis-Acute

-Chronic

1. Ascitic form

2. Encysted form

3. Fibrous form

Tuberculosis of the mesentery and its contents

Tuberculosis of the solid viscera

Liver

Pancreas

Spleen

MiscellaneousRetroperitoneal lymph node tuberculosis

Constitutes 70 to80% of abdominal tuberculosis

Any region of the gastro intestinal tract from mouth to anus can be involved

Ileoceacal area most commonly affected

It can be of ulcerative, hypertrophic, diffuse colitis, ulcerohypertrophic, and sclerotic forms

Entero-enteric, entero-vesical and entero-cutaneous fistula can occur

Luminal narrowing is often caused by adjacent lymphadenitis which results in traction diverticula formation, narrowing and sinus tract formation

Ulcerative form Usually occurs in adult patients who

are malnourished Ulcers lie transverse “girdle ulcers” Areas of the normal appearing mucosa

may be found Healing and fibrosis results in stricture Hypertrophic form Commonly occurs in young patients who are

relatively well nourished Characterised by extensive inflammation and

fibrosis which often results in adherence of bowel, mesentery and lymph nodes

Clinical features

20 to 40 yrs age group most often affected

A slight female preponderance

Most common symptom is abdominl pain others include abdominal distention, wt.loss anorexia, fever, diarrhoea or constipation borborygmi, bleeding per rectum

Signs include anemia, malnutrition, abdominal tenderness, ascites, mass in the right iliac fossa features of intestinal obstruction

Classic doughy abdomen described only in 6 to 11% in Indian studies

Oesophageal tuberculosis Very rare, upper part is involved more often than

lower part, commonly present with dysphagia and odynophagia

Gastric tuberculosis Rare due to the presence of gastric acid

Ulcerative form is the commonest

Duodenal tuberculosis (MAC infection)

Tuberculosis of Appendix

Anal tuberculosis Mostly ulcerative, may be lupoid, verrucus,

miliary lesion

Multiple fistulae with inguinal lymphadenopathy

Acute tuberculous peritonitis

Chronic tuberculous peritonitis

Ascitic formInsidious in onset, abdominal pain usualyabsent, rolled up omentum infiltrated with tubercle may felt as a transverse solid mass

Encysted (loculated) form

Fibrous formWide spread adhesions may cause coils of intestine matted together and distended, they may act as blind loop

In a patient with PUO, marked elevation of serum alkaline phosphatase(3 to 6 times) with mild elevation of s.transaminases, normal PT, s.albuminand a slight increase in bilirubin hepatic tuberculosis should be suspected

Clinical syndromes of Hepatobiliary tuberculosisCongenital tuberculosisPrimary hepatic tuberculosisDisseminated/miliary tuberculosisTuberculomaTuberculosis of biliary tractHepatic failureGranulomatous hepatitisTuberculous pylephlebitis

MalabsorptionCoeliac disease

Lymphoma

Immunoproliferative small intestinal diseae

Mass Appendicular mass

Actinomycosis

Crohn’s disease

Caecal carcinoma

Lymphoma

AscitesCardiac disease

Renal disease

Hepatic diseae

malignacy

Hematology &serum biochemistry

Anemia, raised ESR, hypoalbumenemia, leucopenia with relative lymphocytosis, normal serum transminase level, raised serum ALP

Ascitic fluid examination

Exudative, fluid protein>3gm%, SAAG<1.1 Ascitic/blood glucose ratio<0.96, WBC count usually 140 to 4000cells/mm³ consist of lymphocytes predominantly, AFB(+<3%), culture(+<20%), IFN-γ increased ADA((98%sensitivity&95%specificity

at cut off value 32 IU/L), PCR

Mantoux test (positive in 50 to 100%)

Culture medium

Lowenstein-Jensen

Middlebrook 7H11

Liquid medium

QuantiFERON-TB test(QFT)

BACTEC radiometric system

Mycobacterial Growth indicator tubes

Animal pathogenicity

PCR assay

Ligase chain reaction

Imaging studies Chest skiagram (associated PTB in 24 to 28%)

Plain X-ray abdomen

May show calcified lymph nodes or granulomas in the liver, spleen, pancreas. Other features include dilated loops with fluid levels, dilatation of terminal ileum and ascites . Pneumoperitoneum may be evident in patients with intestinal perforation

Barium studiesEnteroclysis 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 (Fleischner’s sign)

Rapid transit and lack of barium retension(Sterlin’s sign)

Narrow beam of barium due to stenosis(string’s sign)

Barium oesophagogram- ulcerative oesophagitis, stricture, pseudo tumour masses, fistula, sinus, traction diverticulae

Duodenal tuberculosis- segmental narrowing, widening of the “C” loop due to lymphadenopathy

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

GroupII: Suggestive of intestinal tuberculosis ifone of the following features is present

a.Contracted caecum

b.Ulceration or narrowing of theterminal ileum

c. Stricture of the ascending colon

d.Multiple areas of dilatation, narrowingand matting of small bowel loops

GroupIII: Non-specific changes

Features of matting, dilatation andmucosal thickening of small bowel loops

GroupIV: Normal study

Abdominal sonographyOften 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

Interloop ascites gives rise to charecteristic “club sandwitch ” appearance

Mesenteric thickening is better detected in the presence of ascites and is often seen as the “stellatesign” 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 Crohn’s disease and the variegated appearance seen in malignancy

Granulomas or absess in the liver ,pancreas or spleen

Abdominal computerised tomographyCT is better than USG in detecting high dense

ascites

Abdominal lymphadenopathy is the commonest manifestation of tuberculosis on CT

Retroperitoneal, peripancreatic, porta hepatis, and mesenteric/omental lymph node enlargement may be evident

Caseous necrosing lymph node appears as low attenuating, necrotic centers and thick, enhancing inflammatory rim

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

MRI:- has no added advantage Endoscopy

Colonoscopy:- Ulceration is the most common finding. Ileocaecal valve may edematous or deformed. Nodules, ulcers, pseudopolyps may be seen. A combination of histology and culture can establish diagnosis in 80% of casesFine needle aspiration cytologyPeritoneal biopsyLaparoscopy:- most effective method. 80 to

95% diagnostic accuracy. Characteristic finding include multiple, yellowish-white miliary nodules over peritoneum, erythematous, thickened and hyperemic peritoneum

High index of suspicion

USG of abdomen

Suggestive

Treat

Suspicious

Contrast barium studies

Classical

Treat

Suspicious

Endoscopic biopsy

Normal

CECT abdomen

Classical

Treat

Doubtful

Perform FNAC/biopsy

Medical treatmentA six month short-course ATT is as effective as

standard 12 month regimen

Corticosteroids-role not well established

Surgical treatmentTo 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

The treatment TB should precede the treatment of HIV, ie. HAART

Patient already on HAART, should continue the same treatment with appropriate modifications in HAART and ATT

Patients who are not receiving HAART, the need and time of initiation of HAART have to be decided on individual basis after assessing the CD4 count and type of TB

Adverse reactions to both ATT and ART are common so careful monitoring is needed

Abdominal tuberculosis, a frequently recognized form extrapulmonary tuberculosis is increasing with increasing frequency of HIV infection. A high index clinical suspicion, appropriate and timely investigations, early diagnosis and treatment can considerably reduce the morbidity and mortality from this curable but potentially lethal disease.

API update 2007

Tuberculosis by Sharma & Mohan

Harrison’s principles of internal medicine 16th ed.

American journal of gastro enterology