ABDOMINAL TUBERCULOSIS
Introduction   TB can involve any part of GIT from mouth to    anus, peritoneum & pancreatobiliary system.   Very varied...
HIV & TB    Before era of HIV infection > 80% TB     confined to lung    Extrapulmonary TB increases with HIV    40 –60...
Incidence & severity ofabdominal TB will increase withthe HIV epidemic
Pathogenesis   Mechanisms by which M. tuberculosis                 reach the    GIT:       Hematogenous spread from prim...
   Most common site - ileocaecal region       Increased physiological stasis       Increased rate of fluid and electrol...
Distribution of tuberculous lesionsIleum > caecum > ascending colon > jejunum>appendix > sigmoid > rectum > duodenum> stom...
   Peritoneal involvement occurs from :       Spread from LN       Intestinal lesions or       Tubercular salpingitis...
Peritoneal tuberculosis occurs in 3 forms.  •   Wet type - ascitis.  •   Encysted (loculated) type - localized swelling.  ...
Clinical Features   Mainly disease of young adults   ~ 2/3 of pt. are 21-40 yr old   Sex incidence equal.   Clinical p...
   Constitutional symptoms       Fever (40%-70%)       Weight loss (40%-90%)       Anorexia       Malaise   Pain (80...
Tuberculosis of esophagus   Rare     ~ 0.2% of total cases   By extension from adjacent LN   Low grade fever / Dysphagi...
Gastroduodenal TB   Stomach and duodenum each ~ 1% of total cases   Mimics PUD - shorter history, non response to t/t  ...
Ileocaecal tuberculosis   Colicky abdominal pain   ‘Ball of wind’ rolling in abdomen   Borborygmi   Right iliac fossa ...
Obstruction   Most common complication                    Pathogenesis       Hyperplastic caecal TB       Strictures of...
Perforation     2nd commonest cause after typhoid     Usually single and proximal to a stricture     Clue - TB Chest x-...
Malabsorption    Pathogenesis        bacterial overgrowth in stagnant loop        bile salt deconjugation        dimin...
Segmental / Isolated colonic tuberculosis   Involvement of the colon without involvement of the    ileocaecal region   9...
Colonic tuberculosis   Pain --- predominant symptom ( 78%-90% )   Hematochezia in < 1/3 - usually minor    Overall, TB a...
Rectal and Anal Tuberculosis   Hematochezia - most common symp. Due to mucosal    trauma by stool   Constitutional sympt...
Diagnosis and Investigations   Non specific findings---       Raised ESR       Positive Mantoux test       Anemia    ...
Immunological Tests   ELISAResponse to mycobacteria variable & reproducibility poorValue of immunological tests remain un...
Ascitic fluid examination    Straw coloured    Protein >3g/dL    TLC of 150-4000/µl, Lymphocytes >70%    SAAG < 1.1 g/...
Adenosine Deaminase (ADA) Aminohydrolase that converts adenosine  inosine    ADA increased due to stimulation of T-cells...
ColonoscopyColonoscopy - mucosal nodules & ulcers Nodules       Variable sizes (2 to 6mm)       Non friable       Most...
Colonoscopic Diagnosis   8 –10 Bx from ulcer edge   Low yield on histopath as mainly submucosal disease   Granulomas in...
Laparoscopic Findings    Thickened peritoneum with tubercles -        Multiple, yellowish white, uniform (~ 4-5mm) tuber...
Management   ATT for at least 6 months including     2 months of Rif, INH,    Pzide and Etham   However in practice t/t ...
abdominal tuberculosis
abdominal tuberculosis
abdominal tuberculosis
abdominal tuberculosis
abdominal tuberculosis
abdominal tuberculosis
abdominal tuberculosis
Upcoming SlideShare
Loading in …5
×

abdominal tuberculosis

4,126 views

Published on

0 Comments
2 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
4,126
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
236
Comments
0
Likes
2
Embeds 0
No embeds

No notes for slide

abdominal tuberculosis

  1. 1. ABDOMINAL TUBERCULOSIS
  2. 2. Introduction TB can involve any part of GIT from mouth to anus, peritoneum & pancreatobiliary system. Very varied presentation possible ⇒ TB of GIT- 6th most frequent extrapulmonary site.
  3. 3. HIV & TB  Before era of HIV infection > 80% TB confined to lung  Extrapulmonary TB increases with HIV  40 –60% TB in HIV+ pt - extrapulmonary  Globally, propotion of coinfected pt > 8 %  ~ 0.4 million people in India coinfected.  16.6% abdominal TB pt in Bombay HIV +.
  4. 4. Incidence & severity ofabdominal TB will increase withthe HIV epidemic
  5. 5. 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
  6. 6.  Most common site - ileocaecal region  Increased physiological stasis  Increased rate of fluid and electrolyte absorption  Minimal digestive activity  Abundance of lymphoid tissue at this site.
  7. 7. Distribution of tuberculous lesionsIleum > caecum > ascending colon > jejunum>appendix > sigmoid > rectum > duodenum> stomach > oesophagus More than one site may be involved
  8. 8.  Peritoneal involvement occurs from :  Spread from LN  Intestinal lesions or  Tubercular salpingitis Abdominal LN and peritoneal TB may occur without GIT involvement in ~ 1/3 cases.
  9. 9. Peritoneal tuberculosis occurs in 3 forms. • Wet type - ascitis. • Encysted (loculated) type - localized swelling. • Fibrotic type - masses composed of mesenteric & omental thickening, with matted bowel loops.
  10. 10. Clinical Features Mainly disease of young adults ~ 2/3 of pt. are 21-40 yr old Sex incidence equal. Clinical presentation → Acute / Chronic / Acute on Chronic.
  11. 11.  Constitutional symptoms  Fever (40%-70%)  Weight loss (40%-90%)  Anorexia  Malaise Pain (80%-95%)  Colicky (luminal stenosis)  Continous ( LN involvement) Diarrhoea (11%-20%) Constipation Alternating constipation and diarrhoea
  12. 12. Tuberculosis of esophagus Rare ~ 0.2% of total cases By extension from adjacent LN Low grade fever / Dysphagia / Odynophagia / Midesophageal ulcer Mimics esophageal Ca
  13. 13. 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
  14. 14. Ileocaecal tuberculosis Colicky abdominal pain ‘Ball of wind’ rolling in abdomen Borborygmi Right iliac fossa lump - ileocaecal region, mesenteric fat and LN
  15. 15. Obstruction Most common complication Pathogenesis  Hyperplastic caecal TB  Strictures of the small intestine--- commonly multiple  Adhesions  Adjacent LN involvement → traction, narrowing and fixation of bowel loops.
  16. 16. Perforation  2nd commonest cause after typhoid  Usually single and proximal to a stricture  Clue - TB Chest x-ray, h/o SAIO  Pneumoperitoneum in ~ 50% cases
  17. 17. Malabsorption  Pathogenesis  bacterial overgrowth in stagnant loop  bile salt deconjugation  diminished absorptive surface due to ulceration  involvement of lymphatics and LN
  18. 18. Segmental / Isolated colonic tuberculosis Involvement of the colon without involvement of the ileocaecal region 9.2% of all cases Multifocal involvement in ~ 1/3 (28% to 44%) Median symptom duration <1 year
  19. 19. Colonic tuberculosis Pain --- predominant symptom ( 78%-90% ) Hematochezia in < 1/3 - usually minor Overall, TB accounts for ~ 4% of LGI bleeding Other features--- fever / anorexia / weight loss / change in bowel habits
  20. 20. Rectal and Anal Tuberculosis Hematochezia - most common symp. Due to mucosal trauma by stool Constitutional symptoms Constipation Rectal stricture Anal fistula – usually multiple
  21. 21. Diagnosis and Investigations Non specific findings---  Raised ESR  Positive Mantoux test  Anemia  Hypoalbuminaemia
  22. 22. Immunological Tests ELISAResponse to mycobacteria variable & reproducibility poorValue of immunological tests remain undefined
  23. 23. Ascitic fluid examination  Straw coloured  Protein >3g/dL  TLC of 150-4000/µl, Lymphocytes >70%  SAAG < 1.1 g/dL  ZN stain + in < 3% cases  + culture in < 20% cases
  24. 24. Adenosine Deaminase (ADA) Aminohydrolase that converts adenosine  inosine  ADA increased due to stimulation of T-cells by mycobacterial Ag  Serum ADA > 54 U/L  Ascitic fluid ADA > 36 U/L  Ascitic fluid to serum ADA ratio > 0.985  Coinfection with HIV → normal or low ADA
  25. 25. ColonoscopyColonoscopy - 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
  26. 26. 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%
  27. 27. Laparoscopic Findings  Thickened peritoneum with tubercles -  Multiple, yellowish white, uniform (~ 4-5mm) tubercles  Peritoneum is thickened & hyperemic  Omentum, liver, spleen also studded with tubercles.  Thickened peritoneum without tubercles  Fibro adhesive peritonitis  Markedly thickened peritoneum and multiple thick adhesions Caseating granulomas + in 85%-90% of Bx
  28. 28. Management ATT for at least 6 months including 2 months of Rif, INH, Pzide and Etham However in practice t/t often given for 12 to 18 months 2 recent reports → obstructing lesions may relieve with ATT alone However most will need surgery

×