DR MASOOD TAREENRESIDENT GASTROLNH KHI

ABDOMINAL TUBERCULOSIS

INTRODUCTION

Tuberculosis, MTB, in the past also called phthisis, phthisis pulmonalis or consumption  caused by various strains of mycobacteria usually Mycobacterium  tuberculosis.  

Until mid 1800s, many believed TB was hereditary . 1865 Jean Antoine-Villemin proved TB was contagious 

Robert Koch discovered M. tuberculosis, the bacterium that causes TB in 1882.

INTRODUCTION

TB can involve any part of GIT from mouth to anus, peritoneum & pancreatobiliary system

TB of GIT- 6th most frequent extrapulmonary site

Mycobacterium tuberculosis is the pathogen in most cases.

Mycobacterium bovis in some parts of the world

Mycobacterium avium intracellulare has become a major pathogen in HIV patients.

ETIOPATHOGENESIS

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

CLASSIFICATION OF ABDOMINAL TB Gastrointestinal Tuberculosis Tuberculosis Of The Solid Viscera Peritoneal Tuberculosis Tuberculosis Of The Mesentery And Its

Contents

GASTROINTESTINAL TUBERCULOSISUlcerativeHypertrophicSclerotic or fibrousDiffuse colitis

Peritoneal tuberculosis

-Acute -Chronic o Ascitic formo Encysted formo Fibrous form

Tuberculosis of the solid visceraLiver ,BILLIARY TRACTPancreasSpleen

Tuberculosis of the mesentery and its contents

o Mesentric adenitiso Mesentric abscesso Bowel adhesions

MISCELLANOUS

Retroperitoneal lymph node tuberculosis

G I TUBERCULOSIS

Constitutes 70 to80% of abdominal tuberculosis.

Ileoceacal area most commonly affected. It can be of ulcerative, hypertrophic, diffuse colitis, ulcerohypertrophic, and sclerotic

forms. Luminal narrowing is often caused by adjacent lymphadenitis which results in traction

diverticula formation, narrowing and sinus tract formation.

G I Tuberculosis

Ulcerative form Usually occurs in adult patients whoare malnourished Ulcers lie transverse “girdle ulcers” Areas of the normal appearing

mucosamay be found Healing and fibrosis results in stricture

Hypertrophic form Commonly occurs in young patients who are relatively well nourished.

Characterized 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

Most common symptom is; abdominal pain others include abdominal distention, witless anorexia,

fever, diarrhea or constipation bleeding per rectum.

Signs include Anemia, malnutrition, abdominal tenderness, as

cites, mass in the right iliac fossa And features of intestinal obstruction.

Peritoneal Tuberculosis

sis

Acute tuberculous peritonitis Chronic tuberculous peritonitisA. Ascitic formo Insidious in onset, abdominal pain usually absent, rolled

up omentum infiltrated with tubercle may felt as a transverse solid mass

B. Encysted (loculated) formC. Fibrous formo Wide spread adhesions may cause coils of intestine

matted together and distended, they may act as blind loop

HEPATOBILARY TB In a patient with PUO, marked elevation of serum alkaline

phosphatase(3 to 6 times) with mild elevation of s.transaminases, normal PT, s.albumin and a slight increase in bilirubin, hepatic tuberculosis should be suspected

CLINICAL SYNDROMES OF HEPATOBILIARY TUBERCULOSIS

Congenital tuberculosis Primary hepatic tuberculosis Disseminated/miliary tuberculosis Tuberculoma Tuberculosis of biliary tract Hepatic failure Granulomatous hepatitis

INVESTIGATIONS

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%specificityat cut

off value 32 IU/L), PCR Monteux test (positive in 50 to 100%)

INVESTIGATIONS

CUlture medium Lowenstein-Jensen Liquid medium QuantiFERON-TB test(QFT) BACTEC radiometric system Mycobacterial Growth indicator tubes Animal pathogenicity PCR assay Ligase chain reaction

Illeoceacal TB (80-90%)

PLAIN XRAY 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 .

BARIUM ENEMA

Irregular thickened nodular folds in the terminal illeum

‘Stierlin sign’: on ba enema -rapid emptying of narrowed terminal illeum into the cecum which is shortened and rigid Thickened illeoceacal valve

Enema Shows Wide Gaping Of Ileocecal Valve With Thickkening Of Valve

Barium Meal Follow Through

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 cecum with an abnormal ileocaecal valve and/or terminal ileum

c. Stricture of the ascending colon with shortening of and involvement of

ileocaecal region

ULTRASOUND

‘Fleischner sign’: Inverted umbrella defect:- wide gaping patulous IC valve associated with narrowing of the immediately adjacent terminal illeum

Deep fissures and large shallow linear/stellate ulcers with elevated margins Sinus tracts and fistulas

Symmetric annular ‘napkin ring ‘ stenosis

ABDOMINAL CT CT 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

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 cases.

Fine needle aspiration cytologyPeritoneal biopsy

COLONOSCOPY

COLONOSCOPYY - mucosal nodules & ulcers 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

COLONOSCOPIC DIAGNOSIS

 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 60%

LAPROSCOPY

Most Effective Method. 80 to 95% diagnostic accuracy. Characteristic finding include multiple, yellowish-white miliary nodules over peritoneum, erythematous, thickened and hyperemic peritoneum

TREATMENT

Medical Treatment standard 12 month regimen Corticosteroids-role not well established A six month short-course ATT is as effective Surgical Treatment To 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

DRUG INDUCED HEPATITIS Once the diagnosis of DIH is established; first stop all potentially hepatotoxic drugs . In the interim period, at least three non-

hepatotoxic drugs such as ethambutol, streptomycin and quinolones such as levofloxacin or ofloxacin or ciprofloxacin can be used

. After complete resolution of transaminitis, most antituberculosis drugs can be safely restarted in a phased manner.

The BTS suggested that the first-line drugs can be reintroduced sequentially in the order isoniazid, rifampicin and pyrazinamide.

Abdominal tuberculosis, a frequently recognized form extrapulmonary tuberculosis is increasing with increasing frequency of HIV infection.

A high index clinical suspicion, appropriate and timely

I Investigations, early diagnosis and treatment can considerably reduce the morbidity and mortality from this curable but potentially lethal disease.

THANK YOU