abdominal tuberculosis
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abdominal tuberculosis abdominal tuberculosis Presentation Transcript

  • ABDOMINAL TUBERCULOSIS
  • 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.
  • 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 +. View slide
  • Incidence & severity ofabdominal TB will increase withthe HIV epidemic View slide
  • 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
  •  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.
  • Distribution of tuberculous lesionsIleum > caecum > ascending colon > jejunum>appendix > sigmoid > rectum > duodenum> stomach > oesophagus More than one site may be involved
  •  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.
  • 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.
  • 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.
  •  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
  • Tuberculosis of esophagus Rare ~ 0.2% of total cases By extension from adjacent LN Low grade fever / Dysphagia / Odynophagia / Midesophageal ulcer Mimics esophageal Ca
  • 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
  • Ileocaecal tuberculosis Colicky abdominal pain ‘Ball of wind’ rolling in abdomen Borborygmi Right iliac fossa lump - ileocaecal region, mesenteric fat and LN
  • 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.
  • 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
  • Malabsorption  Pathogenesis  bacterial overgrowth in stagnant loop  bile salt deconjugation  diminished absorptive surface due to ulceration  involvement of lymphatics and LN
  • 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
  • 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
  • Rectal and Anal Tuberculosis Hematochezia - most common symp. Due to mucosal trauma by stool Constitutional symptoms Constipation Rectal stricture Anal fistula – usually multiple
  • Diagnosis and Investigations Non specific findings---  Raised ESR  Positive Mantoux test  Anemia  Hypoalbuminaemia
  • Immunological Tests ELISAResponse to mycobacteria variable & reproducibility poorValue of immunological tests remain undefined
  • 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
  • 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
  • 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
  • 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%
  • 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
  • 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