E570 abdominal tuberculosis

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E570 abdominal tuberculosis

  1. 1. ABDOMINAL TUBERCULOSIS
  2. 2. Introduction TB can involve any part of GIT from mouth toanus, 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% TBconfined 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 theGIT: 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 withoutGIT 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 onChronic.
  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 tuberculousLN 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 complicationPathogenesis Hyperplastic caecal TB Strictures of the small intestine--- commonly multiple Adhesions Adjacent LN involvement → traction, narrowing and fixation ofbowel loops.
  16. 16. Perforation 2ndcommonest 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 theileocaecal 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 minorOverall, 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 mucosaltrauma 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 bymycobacterial 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 adhesionsCaseating 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 ATTaloneHowever most will need surgery
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