2. Most common form of extrapulmonary
tuberculosis (3 to 4%)
Defined as tuberculosis infection of the
abdomen including gastrointestinal tract,
peritoneum, omentum, mesentery and its
nodes, liver, spleen and pancreas
Mycobacterium tuberculosis is the most
frequently isolated organism
3. 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
4. Gastrointestinal Tuberculosis of the
tuberculosis mesentery and its
-Ulcerative contents
-Hypertrophic Tuberculosis of the
-Sclerotic or fibrous solid viscera
-Diffuse colitis Liver
Peritoneal tuberculosis Pancreas
-Acute Spleen
-Chronic Miscellaneous
1. Ascitic form Retroperitoneal lymph
2. Encysted form node tuberculosis
3. Fibrous form
5. Constitutes 70 to80% of abdominal tuberculosis
Any region of the gastro intestinal tract from
mouth to anus can be involved
Ileoceacal area most commonly affected
It can be of ulcerative, hypertrophic, diffuse
colitis, ulcerohypertrophic, and sclerotic forms
Entero-enteric, entero-vesical and entero-
cutaneous fistula can occur
Luminal narrowing is often caused by adjacent
lymphadenitis which results in traction
diverticula formation, narrowing and sinus tract
formation
6. Ulcerative form
Usually occurs in adult patients who
are malnourished
Ulcers lie transverse “girdle ulcers”
Areas of the normal appearing mucosa
may be found
Healing and fibrosis results in stricture
Hypertrophic form
Commonly occurs in young patients who are
relatively well nourished
Characterised by extensive inflammation and
fibrosis which often results in adherence of bowel,
mesentery and lymph nodes
7. Clinical features
20 to 40 yrs age group most often affected
A slight female preponderance
Most common symptom is abdominl pain
others include abdominal distention, wt.loss
anorexia, fever, diarrhoea or constipation
borborygmi, bleeding per rectum
Signs include anemia, malnutrition, abdominal
tenderness, ascites, mass in the right iliac fossa
features of intestinal obstruction
Classic doughy abdomen described only in 6 to
11% in Indian studies
8. Oesophageal tuberculosis
Very rare, upper part is involved more often than
lower part, commonly present with dysphagia and
odynophagia
Gastric tuberculosis
Rare due to the presence of gastric acid
Ulcerative form is the commonest
Duodenal tuberculosis (MAC infection)
Tuberculosis of Appendix
Anal tuberculosis
Mostly ulcerative, may be lupoid, verrucus,
miliary lesion
Multiple fistulae with inguinal lymphadenopathy
9. Acute tuberculous peritonitis
Chronic tuberculous peritonitis
Ascitic form
Insidious in onset, abdominal pain usualy
absent, rolled up omentum infiltrated with
tubercle may felt as a transverse solid mass
Encysted (loculated) form
Fibrous form
Wide spread adhesions may cause coils of
intestine matted together and distended, they
may act as blind loop
10.
11. 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
Tuberculous pylephlebitis
12. Malabsorption
Coeliac disease
Lymphoma
Immunoproliferative small intestinal diseae
Mass
Appendicular mass
Actinomycosis
Crohn’s disease
Caecal carcinoma
Lymphoma
Ascites
Cardiac disease
Renal disease
Hepatic diseae
malignacy
13. 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%specificity
at cut off value 32 IU/L), PCR
Mantoux test (positive in 50 to 100%)
15. Imaging studies
Chest skiagram (associated PTB in 24 to 28%)
Plain X-ray abdomen
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 . Pneumoperitoneum may
be evident in patients with
intestinal perforation
16. Barium studies
Enteroclysis followed by barium enema is the best
protocol
Increased transit time with hypersegmentation
(chicken intestine) and flocculation is the earliest sign
Localised areas of irregular thickened folds, mucosal
ulceration, dilated segments and strictures
Thickened iliocaecal valve with a broad triangular
appearance with the base towards the caecum
(inverted umbrella sign or (Fleischner’s sign)
Rapid transit and lack of barium retension
(Sterlin’s sign)
Narrow beam of barium due to stenosis(string’s sign)
Barium oesophagogram- ulcerative oesophagitis,
stricture, pseudo tumour masses, fistula, sinus,
traction diverticulae
Duodenal tuberculosis- segmental narrowing,
widening of the “C” loop due to lymphadenopathy
17. Group1: 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 caecum with an abnormal
ileocaecal valve and/or terminal ileum
c. Stricture of the ascending colon with
shortening of and involvement of
ileocaecal region
18. GroupII: Suggestive of intestinal tuberculosis if
one of the following features is present
a.Contracted caecum
b.Ulceration or narrowing of the
terminal ileum
c. Stricture of the ascending colon
d.Multiple areas of dilatation, narrowing
and matting of small bowel loops
GroupIII: Non-specific changes
Features of matting, dilatation and
mucosal thickening of small bowel loops
GroupIV: Normal study
19. Abdominal sonography
Often reveals a mass made up of matted loops of
small bowel with thickened walls, diseased
omentum, mesentery and loculated asites
Fine septae may be seen in the ascitic fluid
Interloop ascites gives rise to charecteristic “club
sandwitch ” appearance
Mesenteric thickening is better detected in the
presence of ascites and is often seen as the “stellate
sign” of bowel loops radiating from its root
In intestinal tuberculosis bowel wall thickening is
usually uniform and concentric as opposed to the
eccentric thickening at the mesenteric border seen in
Crohn’s disease and the variegated appearance seen
in malignancy
Granulomas or absess in the liver ,pancreas or
spleen
20. Abdominal computerised tomography
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
Short segments of mural thickening with normal
intervening bowel associated with ileocaecal
involvement strongly suggest tuberculosis
21. MRI:- has no added advantage
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 cytology
Peritoneal biopsy
Laparoscopy:- most effective method. 80 to
95% diagnostic accuracy. Characteristic
finding include multiple, yellowish-white
miliary nodules over peritoneum,
erythematous, thickened and hyperemic
peritoneum
22. High index of suspicion
USG of abdomen
Suggestive Suspicious Normal
Contrast CECT
Treat barium abdomen
studies
Classical Suspicious Classical Doubtful
Endoscopic Perform
Treat Treat
biopsy FNAC/biopsy
23. Medical treatment
A six month short-course ATT is as effective as
standard 12 month regimen
Corticosteroids-role not well established
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
24. The treatment TB should precede the treatment
of HIV, ie. HAART
Patient already on HAART, should continue
the same treatment with appropriate
modifications in HAART and ATT
Patients who are not receiving HAART, the
need and time of initiation of HAART have to
be decided on individual basis after assessing
the CD4 count and type of TB
Adverse reactions to both ATT and ART are
common so careful monitoring is needed
25. Abdominal tuberculosis, a frequently recognized
form extrapulmonary tuberculosis is increasing
with increasing frequency of HIV infection. A high
index clinical suspicion, appropriate and timely
investigations, early diagnosis and treatment can
considerably reduce the morbidity and mortality
from this curable but potentially lethal disease.
26. API update 2007
Tuberculosis by Sharma & Mohan
Harrison’s principles of internal medicine 16th ed.
American journal of gastro enterology