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Abdominal tuberculosis

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abdominal tuberculosis for surgeons

abdominal tuberculosis for surgeons

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  • 1. Dr. Minhajuddin Khurram AL-AMEEN MEDICAL COLLEGE HOSPITAL, bIJAPUR
  • 2.  A common disease in India and other developing countries  It the 6th most common type of extra-pulmonary tuberculosis  40% of Indians harbour tb bacilli  In 2010, Global Incidence – 9.4million In india – 2.3million Prevalence in India is 3.1 million 3,20,000 deaths… -WHO
  • 3.  24th March 1882- World Tb day  TB declared as notifiable disease by INDIAN GOVERNMENT on may9th 2012
  • 4. 1. Intestinal (Koenig’s syndrome) A. Iliocaecal region  Ulcerative -60%  Hyperplastic-10%  Mixed-30% B. Ileal region  Stricture type 2. Peritoneal tuberculosis A. Acute B. Chronic  Ascitic  Encysted  Plastic  Purulent
  • 5. 3. Tuberculous mesenteric lymphadenitis A. Calcified lesion B. Acute Meseneteric lymphadenitis C. Pseudo-mesenteric cyst D. Tabes mesenterica E. Chronic Lymphadenitis 4. Ano-recto-sigmoidal 5. Involvement of solid organs as a part of milary tuberculosis 6. Involvement of omentum 7. Rare types A. Oesophageal (0.2% of abdominal) B. Gastroduodenal
  • 6. 1. By ingestion ◦ Ingestion of food contaminated with tubercle bacilli causing Primary Intestinal Tuberculosis ◦ Ingestion of sputum containing tuberculous bacteria from primary pulmonary focus - Secondary Intestinal Tuberculosis 2. Hematogenous spread from lungs 3. Through lymphatics (neck) 4. Fallopian tubes (retrograde spread)
  • 7.  Most common site of abdominal tuberculosis due to: ◦ Stasis ◦ Abundant payer’s patches ◦ Alkaline media ◦ Bacterial contact time is more ◦ Minimal digestive activity ◦ Maximum absorption in the area
  • 8. A. Ulcerative type (60%): ◦ Secondary to pulmonary tuberculosis ◦ Virulent organism ◦ Poor body resistance ◦ Multiple circumferential transverse ulcers (Girdle ulcers) with skip leisons ◦ Commonly in ileum ◦ Rarely in caecum
  • 9. ◦ Napkin ring strictures in longstanding ulcers (common in ileum) ◦ Intestinal nodes involvement with caseation and abscess ◦ May present with blood in stools, diarrhoea, loss of appetite and reduced weight ◦ Complications:  Acute: Ulcer perforation  Chronic: Stricture  Subacute obstruction
  • 10. B. Hyperplastic Type -10% ◦ Primary GIT tuberculosis ◦ Less virulent organism ◦ Good body resistance ◦ Chronic granulomatous lesions in ileoceacal region ◦ Fibroblastic activity in submucosa and subserosa causes thickening of bowel wall with lymph node enlargement  Presenting as Mass in Right Iliac Fossa (Nodular fixed and firm mass) ◦ Caseation is very rare
  • 11. B. Hyperplastic Type -10% ◦ No primary leision in the chest ◦ Complication: May cause sub-acute intestinal obstruction due to mass
  • 12.  Others ◦ Abdominal pain (90%)  Colicky type in intestinal tuberculosis  Dull aching in mesenteric lymphadenitis ◦ Mass in right iliac fossa (35%)  Hard, nodular, fixed, nontender mass mimicing ca caecum ◦ Subacute intestinal obstruction (20%) ◦ Can be associated with adenocarcinoma of caecum
  • 13. 1. Ca Caecum 2. Ameboma 3. Appendicular mass 4. Lymph node mass 5. Psoas abscess 6. Crohn’s disease
  • 14.  Chest Xray – for primary focus  Blood investgations: Mantoux, ELISA, serum IgG  ESR- raised  Plain Xray abdomen ◦ Intestinal obstruction ◦ Calcified lymph nodes ◦ Hollow viscus perforation ◦ Calcified Granuloma in liver
  • 15.  USG abdomen ◦ Thickened bowel wall ◦ Loculated ascitis ◦ Interloop ascitis ◦ Mesenteric thickening ◦ Lymph node enlargement ◦ Pulled up caecum (Pseudokidney sign)
  • 16.  Barium study Xray (barium enema or barium follow through) ◦ Pulled up caecum ◦ Obtuse ileocaecal angle; straightening (Goose neck) ◦ Steirlin sign: Hurrying of barium due to rapid flow and lack of barium in inflamed site ◦ Fleischner sign (Inverted umbrella sign): Narrow ileum with thickened ileocaecal valve ◦ Napkin leisons ◦ Chicken intestine: Hypersegmentation ◦ Mega Ileum: Dilatation of proximal ileum
  • 17.  Barium Study showing Mega Ileum
  • 18.  Colonoscopy ◦ To rule out ca ◦ Shows mucosal nodules, ulcers, strictures, deformed ileocaecal valve, mucosal oedema and diffuse colitis ◦ Biopsy can be taken to eslablish the diagnosis
  • 19.  CT Abdomen ◦ CT scan shows thickening of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows).
  • 20.  Diagnostic laproscopy ◦ Direct visualization ◦ Collect acsitic fluid ◦ Take biopsy from mass, omentum or peritoneum
  • 21.  PCR of tissue  Acsitic tap fluid analysis ◦ Exudate fluid (protein >2.5gm%) ◦ Lymphocyte predominant cells >250 cu mm (upto 4000 cu mm) ◦ Glucose <30mg% ◦ Specefic gravity >1.016 ◦ ADA (Adenosine deaminase activity) 95% specificity and 98% sensitivity ◦ LDH > 90 units/litre
  • 22. 1. Obstruction 20% 2. Malabsoprption, blind loop syndrome 3. Dissemination of tuberculosis 4. Cold abscess formation 5. Hemorrhage 6. Perforation 7. Fecal fistula
  • 23.  Mediacal management: ◦ First line drugs:  INH  Rifampicin  Pyrazinamide  Ethambutol ◦ Second line drugs:  Amikacin, kanamycin, PAS, Ciprofloxacin,  Clarithrymycin, Azythromycin, Rifabutin  Drug: RNTCP 2H3R3Z3 E3 + 4H3R3 ◦ Treatment to be continued for 6-9 months ◦ Supportive nutrition
  • 24.  Surgical Management: ◦ Indications:  Intestinal obstruction  Severe hemorrhage  Acute abdomen (perforation)  Intra-abdominal abscesses/ fistula formation  Uncertain diagnosis
  • 25.  Surgical Management: 1. Ileocaecal resection with 5 cm margin 2. Stricturoplasty- single stricture 3. Single strictutre with friable bowel : Resection 4. Multiple Strictures: Resection and anastomosis 5. Multiple strictures with long segment gaps: Multiple stricturiplasty
  • 26.  Surgical Management: 6. Early perforation: resection and anastomosis (due to friable bowels) 7. Perforation with severe contamination: resection with colostomy 8. Adhesiolysis by laproscopy (Very difficult procedure) 9. Drainage of abscesses and treatment for fistula in ano
  • 27.  It is usually stricture type  May be multiple  Presents with intestinal obstruction  Bowel adhesions, localization, fibrosis, secondary infection are common  Perforation (5%)  Plain Xray – Multiple air fluid levels  Resection and anastomosis with Anti- tubercular drugs
  • 28.  It is post primary  Becoming more common  Activation of long standing latent foci  Blood spread  Can develop from diseased mesenteric lymph nodes, intestines or fallpian tubes
  • 29.  Basic pathology ◦ Enormous thickening of the parietal peritoneum ◦ Multiple tiny yellowish tubercles ◦ Dense adhesions in peritoneum and omentum with small intestines ◦ May precipitate obstruction ◦ Thickening of bowel wall
  • 30.  Abdominal Cocoon Syndrome ◦ Dense adhesions in peritoneum and omentum with contents inside as small bowel causing intestinal obstruction
  • 31. A. Acute –mimics acute abdomen ◦ Rare ◦ On-table diagnosis ◦ Features of peritonitis ◦ Due to perforation or rupture of mesenteric lyph nodes ◦ Exploratory laprotomy reveals straw coloured fluid with tubercles in the peritoneum, greater omentum and bowel wall ◦ Fluid evacuated and sent for culture and AFB study ◦ Biopsy taken from omentum ◦ To be closed without drains
  • 32. A. Chronic ◦ Presents as  Abdominal pain  Fever  Ascites  Loss of appetite and weight  Abdominal mass  Doughy abdomen (10%) ◦ Types a) Ascitic form b) Encysted form c) Plastic form d) Purulent form
  • 33. a) Acsitic peritoneal tuberculosis: ◦ Intense exudate caused ascitis ◦ Common in children and young adults ◦ Enormous abdominal distension ◦ May cause congenital hydrdocele, umbilical hernia, shifting dullness, fluid thrill and mass per abdomen ◦ Rolled up omentum and nodular due to extensive fibrosis
  • 34. a) Acsitic peritoneal tuberculosis: ◦ Doughy abdomen ◦ Shifting dullness ◦ Asitic tap reveals straw coloured fluid from which AFB can be isolated (<3%) ◦ Anti-tubercular drugs for one year ◦ Repeated tapping may be required
  • 35. b) Encysted (Loculated) peritoneal tuberculosis ◦ Exudation with minimal fibroblastic reaction ◦ Ascites gets loculated due to fibrinous deposition ◦ Non shifting Dullness is the typical feature ◦ May present as intra-abdominal mass mimicing ovorain cyst, mesenteric cyst ◦ USG guided aspiration and antitubercular drugs to be given
  • 36. c) Plastic Peritoneal Tuberculosis ◦ Extensive fibroblastic reaction ◦ Widespread adhesions ◦ Between coils of intestine (matted intestines), abdominal wall, omentum ◦ Obstruction  Distension of abdomen ◦ Colicky abdominal pain (recurrent) ◦ Diarrhoea, loss of weight, mass per abdomen ◦ Doughy abdomen
  • 37. c) Plastic Peritoneal Tuberculosis ◦ Open or laproscopic biopsy (to rule out peritoneal carcinomatosis) ◦ Anti-tubercular drugs ◦ Surgery to relieve obstruction by adhesolysis
  • 38. d) Purulent peritoneal tuberculosis ◦ Direct spread from tuberculous salpingitis ◦ Mass per abdomen containing pus, omentum, fallopian tubes, small and large bowel ◦ Cold abscess may get adherant to umbilicus ◦ May cause umbilical discharge ◦ Genitourinary tuberculosis usually present ◦ Aanti-tubercular drugs with exporation of umbilical fistula
  • 39. 1. Calcified lesion: ◦ Along the line of the mesentery a single or multiple calcified lesions ◦ Payer’s patches involved ◦ No active infection ◦ May be on right or left side (R>L) ◦ Antitubercular drugs
  • 40. 2. Acute mesenteric lymphadenits ◦ Common in children ◦ Mimics acute appendicitis ◦ Tender mass of lymph node palpapble in Right iliac fossa which are matted and non-mobile ◦ Intestines adherant to caseating lymph nodes obstruction ◦ Surgery for appendicitis or obstruction with lymph node biopsy ◦ Antitubercular drugs
  • 41. 3. Pseudo-mesenteric cyst ◦ Caseating material collected between the layers of mesentery ◦ Forms cold abscess ◦ Mimicking a mesenteric cyst 4. Tabes mesenterica ◦ Massive enlargement of mesenteric lymph nodes due to tuberculosis 5. Chronic Lyphadenitis ◦ Children ◦ Failure to thrive ◦ Protuberant abdomen and emaciation ◦ Lymph node on deep palpation in right iliac fossa
  • 42.  Mimics ca rectum  Occurs within 10 cmof anal verge  Presents with tenesmus, diarrhoea and multiple discahrging fistula in ano  Fistula is painless, not indurated with undermined edges  Shallow bluish ulcers with undermined edges  Investigation: ◦ Sigmoidoscopy ◦ USG ◦ Discharge study ◦ fistulectomy and biopsy  Treatment: Drugs, fistulectomy or sigmoid resection
  • 43.  As a part of other abdominal tuberculosis  Rolled up omentum  Cold abscess in omentum  Anti-tubercular drugs  Syrgery for cold ascess
  • 44.  As a part of other abdominal tuberculosis  Rolled up omentum  Cold abscess in omentum  Anti-tubercular drugs  Syrgery for cold ascess
  • 45.  Age: 25 to 50 yrs  Equal in both sexes  Constitutional symptoms: o Fever (50-70%) o Anorexia (80%) o Cachexia o Diarrhoea (10-20%) o Anemia