INTRODUCTION
x   Tuberculosis (T.B.) has existed from the
    very dawn of civilization.
x   Records of TB in mummies were...
x   Extrapulmonary tuberculosis was
    also known since antiquity.
x   Pott’s disease was described in
    paints and sta...
GASTROINTESTINAL TUBERCULOSIS
     Tuberculous enteritis as a complication of
 pulmonary T.B. was appreciated by Hippocrat...
GASTROINTESTINAL TUBERCULOSIS

Ebn Sina
The Famous Arab Scientist (980-1037)
in his book “Al-Kanoun”
described tuberculosi...
GASTROINTESTINAL TUBERCULOSIS

                 PATHOGENESIS

x   Mycobacterium tuberculosis is the pathogen in
    most c...
PATHOLOGY
Most active inflammation in submucosa.
 Bacill in depth of mucosal glands


          Inflammatory reaction

   ...
PATHOLOGY
Submucosal tubercles enlarge

       Endarteritis & edema

                    Sloughing

                      ...
PATHOLOGY
Inflammatory process in submucosa penetrates to serosa

        Tubercles on serosal surface

                  ...
FORMS OF GI TB

Ulceroconstrictive               Hypertrophic
   60% of patients               10% of patients

   Highly ...
T.B. Bacilli, Z.N. stain
Maha Hasaballa, Cairo University
T.B. stenotic surgical segment with involvement of
                                     mesenteric fat
                   ...
Pathology of the previous ulcer
                                 Sub mucosal muscular and
                                ...
GASTROINTESTINAL TUBERCULOSIS POSES A
DIAGNOSTIC PROBLEM

x   The disease is not common.
x   Not familiar to clinicians.
x...
The approach to the subject
was directed to these main points.

x   Country and continent of origin.
x   Age
x   Gender
x ...
To achieve this aim
The following was carried on
x   Search on the Pubmed was done for all abstracts since
    1965.
x   O...
Demonstration photos were kindly
provided by colleagues; staff members of
Faculty of Medicine, Cairo University
700

        600

        500

        400
Count




        300

        200

        100

          0
              1960...
Distribution of gastrointestinal tuberculosis




                                                          r
            ...
India
           23.9%       Malaysia
                        6.5%
                            S. Africa
                 ...
S. America
                1.1%
     Australia
       5.0%                  Asia
Europe                      57.0%
 13.9%
...
Children
 2.0%




                          Adults
                          98.0%




  Distribution of gastrointestinal...
Male
                             41.8%



Female
 58.2%




 Distribution of gastrointestinal
   tuberculosis cases by sex
Present
                                  55.9%


   Absent
    44.1%




Distribution of gastrointestinal tuberculosis
  ...
120%

100%

80%

60%

40%

20%

 0%




                                                             ry
                  ...
Present
                                     56.5%

  Absent
   43.5%




Distribution gastrointestinal tuberculosis cases...
120%

100%

80%

60%

40%

20%

 0%
                                  n




                                              ...
0%   5%      10%   15%   20%   25%   30%   35%      40%



      Fever                                                 35....
0%          10%       20%   30%       40%   50%   60%

            Dysphagia                                              ...
Esophageal Tuberculous Nodules
                                       Abdel Magid Kasem
                                  ...
0%          10%           20%       30%    40%   50%           60%


 Ulcer dyspepsia                                     ...
Diffuse narrowing of the body of the stomach
Calcified Lymph node.
Ba. Meal
Yehia Aly
Cairo University
Tuberculous mass in the stomach
                Abdel Magid Kasem
                Cairo University




Mucosal T.B. granul...
0%      10%     20%      30%   40%   50%   60%   70%   80%   90%

Perforation                                             ...
Small intestinal T.B.
Ileoscopy
                                Multiple tuberculous strictures small intestine
Waheed Dos...
0%      5%   10%     15%      20%   25%   30%           35%


         pain                                               ...
Tuberculous ulcerated coecal
Ileocoecol T.B.    mass Colonoscopy
Ba. Enema          Hunter, Cairo University
Yehya Aly
Cai...
0%   5%   10%     15%    20%     25%   30%   35%   40%     45%


          pain                                           ...
Colonic T.B. polypoid mass.     Colonic T.B. polypoid mass.
Colonoscopy                     Colonoscopy
Mazen Naga, Cairo,...
0%          20%           40%   60%      80%     100%

         ascitis                                                  9...
Peritoneal T.B.
                               Laparoscopy
                               Hunter, Cairo University
T.B. pe...
T.B. Peritoneal adhesions
Peritoneal T.B with adhesions                    Ultrasonography
Laparoscopy                    ...
0%   20%   40%       60%           80%   100%




jaundice                                            94.4%




   pain   ...
T.B. adhesion around the gall bladder            T.B. Liver abscess
Laparoscopy,                                     C.T. ...
0%   10%   20%     30%   40%   50%   60%       70%




Abd.pain                                          60.9%




jaundic...
Tuberculous distal common bile duct stricture
(Tuberculous Pancreatic Mass)
Waheed Doss, Cairo University
SUMMARY
x   Most publications on GI tuberculosis were in
    the last decade.
x   The publications were mainly from Asia.
...
SUMMARY
x   Adults represent the majority of G.I. T.B. cases.
x   The disease is slightly more prevalent in
    females.
x...
SUMMARY
x   Patients present with nonspecific constitutional symptoms,
    pyrexia and weight loss are the most common.
x ...
Gastrointestinal T.B.
Differential Diagnosis
Gastrointestinal T.B. should be considered in the
  differential diagnosis of...
CONCLUSION
x   Since 1980s, a resurgence of tuberculosis has
    occurred.
x   The disease is still and will remain a seri...
Do not fear to repeat what has already been said.
Men need most things dinned into
their ears many times and from all side...
G.I. TUBERCULOSIS, A FINAL WORD



Be aware
     of Abdominal Tuberculosis

                    (Bouma et al., 1997)
Gi Tuberculosis   Shokry Hunter
Gi Tuberculosis   Shokry Hunter
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Gi Tuberculosis Shokry Hunter

  1. 1. INTRODUCTION x Tuberculosis (T.B.) has existed from the very dawn of civilization. x Records of TB in mummies were found in Egypt as far as 5000 years ago. (Cave, 1935)
  2. 2. x Extrapulmonary tuberculosis was also known since antiquity. x Pott’s disease was described in paints and statues of ancient Egyptians. (Ghalioungy, 1958)
  3. 3. GASTROINTESTINAL TUBERCULOSIS Tuberculous enteritis as a complication of pulmonary T.B. was appreciated by Hippocrates in the 5th century B.C. Diarrhea attacking a person with phthisis is a mortal symptom (Walsh, 1909)
  4. 4. GASTROINTESTINAL TUBERCULOSIS Ebn Sina The Famous Arab Scientist (980-1037) in his book “Al-Kanoun” described tuberculosis (Al-Sol) in details. He described q Abdominal distention q Diarrhea q Borborygmi In late stages of the disease. (Hunter, 1999)
  5. 5. GASTROINTESTINAL TUBERCULOSIS PATHOGENESIS x Mycobacterium tuberculosis is the pathogen in most cases. x Mycobacterium bovis in some parts of the world with no pasteurization of milk. x Mycobacterium avium intracellulare has become a major pathogen in HIV patients. (Nial et al., 1997)
  6. 6. PATHOLOGY Most active inflammation in submucosa. Bacill in depth of mucosal glands Inflammatory reaction Phagocytes carry bacilli to Peyers Patches Formation of tubercle Tubercles undergo necrosis Portis (1953)
  7. 7. PATHOLOGY Submucosal tubercles enlarge Endarteritis & edema Sloughing Ulcer formation Accumulation of collagenous tissue Thickening & Stenosis (Howell & Knapton, 1964)
  8. 8. PATHOLOGY Inflammatory process in submucosa penetrates to serosa Tubercles on serosal surface Bacilli reach lymphatics Bacilli via lymphatics Lymphatic obstruction Regional lymph nodes of mesentery and bowel • Hyperplasia → Thick fixed mass • Caseation necrosis • Calcification (Boyed, 1943)
  9. 9. FORMS OF GI TB Ulceroconstrictive Hypertrophic 60% of patients 10% of patients Highly virulent Chronic Mostly small Intestinal Mostly Ileocoecal Mixed 30% of patients (Howell & Knapton, 1964)
  10. 10. T.B. Bacilli, Z.N. stain Maha Hasaballa, Cairo University
  11. 11. T.B. stenotic surgical segment with involvement of mesenteric fat Makram Milad, Cairo University T.B. transverse girdle ulcer small intestine Makram Milad, Cairo University
  12. 12. Pathology of the previous ulcer Sub mucosal muscular and subserous granulomas Makram Milad, Cairo University T.B. Lymphadenitis Makram Milad, Cairo University
  13. 13. GASTROINTESTINAL TUBERCULOSIS POSES A DIAGNOSTIC PROBLEM x The disease is not common. x Not familiar to clinicians. x Involves inaccessible sites. x May be associated with other serious disorders, the manifestations of which obscure or modify those of T.B.: HIV, Chronic Renal Failure, Diabetes Mellitus, Liver Cirrhosis, Neoplastic disease. (Kramer et al., 1990)
  14. 14. The approach to the subject was directed to these main points. x Country and continent of origin. x Age x Gender x Associated HIV infection x Associated pulmonary disease x Constitutional signs and symptoms x Signs and symptoms related to the site of involvement in the G.I. tract
  15. 15. To achieve this aim The following was carried on x Search on the Pubmed was done for all abstracts since 1965. x Original articles tackling the subject and available in Egyptian libraries were collected x Abstracts and original articles that describe symptoms and signs related to gastrointestinal tuberculosis were selected. x Abstracts and articles were classified according to organ involvement in the gastrointestinal tract. x Retrieved data were pooled, tabulated and statistically analyzed.
  16. 16. Demonstration photos were kindly provided by colleagues; staff members of Faculty of Medicine, Cairo University
  17. 17. 700 600 500 400 Count 300 200 100 0 1960 - 1965 1965 - 1970 1970 - 1975 1975 - 1980 1980 - 1985 1985 - 1990 1990 - 1995 1995 - 2000 Year Gastro-intestinal tuberculosis cases as reported by publication year (n = 2204)
  18. 18. Distribution of gastrointestinal tuberculosis r d de b la y ll r ga lia o bi ic at re nc pa r y lia bi he pa to cases (n=2204) by site m 3 u ie on rit pe 39 l ta r ec lo co 21 Site n lo o co ile e tin 24 es nt li al sm 5 h ac om st s gu ha op es 4 0 50 40 30 20 10 Percent
  19. 19. India 23.9% Malaysia 6.5% S. Africa 11.6% USA 8.5% Saudi Arabia Others 11.7% 37.8% Distribution of gastrointestinal tuberculosis cases by country
  20. 20. S. America 1.1% Australia 5.0% Asia Europe 57.0% 13.9% Africa 23.0% Distribution of gastrointestinal tuberculosis cases by continent
  21. 21. Children 2.0% Adults 98.0% Distribution of gastrointestinal tuberculosis cases by age group
  22. 22. Male 41.8% Female 58.2% Distribution of gastrointestinal tuberculosis cases by sex
  23. 23. Present 55.9% Absent 44.1% Distribution of gastrointestinal tuberculosis cases reporting associated HIV
  24. 24. 120% 100% 80% 60% 40% 20% 0% ry n l h ry us ta lo ac ilia ilia ec g co om ha ob or ob o op Ile ol St at tic C Es p a He re nc Pa Distribution of gastrointestinal tuberculosis cases reporting associated HIV by site
  25. 25. Present 56.5% Absent 43.5% Distribution gastrointestinal tuberculosis cases reporting associated pulmonary tuberculosis
  26. 26. 120% 100% 80% 60% 40% 20% 0% n ry l h um ry us ta lo ac ilia ilia ec g co ni om ha ob or ob o o rit op Ile ol St at tic Pe C Es p a He re nc Pa Distribution of gastrointestinal tuberculosis cases reporting associated pulmonary tuberculosis by site
  27. 27. 0% 5% 10% 15% 20% 25% 30% 35% 40% Fever 35.6% Wt. loss 34.1% Anorexia 35.0% Night sweats 5.0% Distribution of gastrointestinal tuberculosis cases reporting for associated general manifestations
  28. 28. 0% 10% 20% 30% 40% 50% 60% Dysphagia 57.0% Fistula 32.6% Haematemesis 12.8% Esophageal diverticula 2.3% Epigastric pain 1.2% Free mediastinal air 1.2% Mediastinitis 1.2% Local manifestations of esophagus cases (n= 86)
  29. 29. Esophageal Tuberculous Nodules Abdel Magid Kasem Cairo University Caseating Granuloma of the esophagus Makram Milad Cairo University
  30. 30. 0% 10% 20% 30% 40% 50% 60% Ulcer dyspepsia 52.4% Outlet obstruction 26.2% Mass 19.0% Haematemesis 11.9% Fistula 2.4% Local manifestations of gastroduedenal cases (n= 42)
  31. 31. Diffuse narrowing of the body of the stomach Calcified Lymph node. Ba. Meal Yehia Aly Cairo University
  32. 32. Tuberculous mass in the stomach Abdel Magid Kasem Cairo University Mucosal T.B. granuloma of the stomach, Endoscopic biopsy Makram Milad Cairo University Duodenal T.B. ulceration with narrow lumen Mazen Naga Cairo, University
  33. 33. 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% Perforation 81.3% Ascitis 20.5% Obstruction 11.6% Abd.pain 6.3% Ulcer 4.5% Abd.mass 1.8% Hge 0.9% Fistula 0.9% Local manifestations of small intestinal cases (n= 112)
  34. 34. Small intestinal T.B. Ileoscopy Multiple tuberculous strictures small intestine Waheed Doss, Cairo University Ba. Meal follow-through Yehia Aly, Cairo University
  35. 35. 0% 5% 10% 15% 20% 25% 30% 35% pain 30.8% diarrhea 16.7% distention 9.2% mass 8.5% malabsorption 2.0% Local manifestations of ileocoecal cases (n= 520)
  36. 36. Tuberculous ulcerated coecal Ileocoecol T.B. mass Colonoscopy Ba. Enema Hunter, Cairo University Yehya Aly Cairo University
  37. 37. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% pain 39.1% rectal bleeding 21.8% mass 12.1% distention 9.0% Local manifestations of colorectal cases (n= 463)
  38. 38. Colonic T.B. polypoid mass. Colonic T.B. polypoid mass. Colonoscopy Colonoscopy Mazen Naga, Cairo, University Hunter, Cairo, University
  39. 39. 0% 20% 40% 60% 80% 100% ascitis 90.6% pain 59.9% mass 23.7% lymphadenopathy 3.4% jaundice 3.4% distention 2.0% diarrhoea 1.0% Local manifestations of peritonitis cases (n= 881)
  40. 40. Peritoneal T.B. Laparoscopy Hunter, Cairo University T.B. peritonitis granulomata with fibrosis in the omentum Makram Milad
  41. 41. T.B. Peritoneal adhesions Peritoneal T.B with adhesions Ultrasonography Laparoscopy Zakareya Salama Hunter, Cairo, University Cairo University Calcified T.B lymph nodes C.T. scan Yehia Ali, Cairo, University
  42. 42. 0% 20% 40% 60% 80% 100% jaundice 94.4% pain 64.8% Local manifestations of hepatobiliary cases (n= 71)
  43. 43. T.B. adhesion around the gall bladder T.B. Liver abscess Laparoscopy, C.T. scan Hunter, Cairo University Yehia Aly, Cairo University Hilar stricture due to porta hepatis lymphadenopathy Waheed Doss, Cairo University
  44. 44. 0% 10% 20% 30% 40% 50% 60% 70% Abd.pain 60.9% jaundice 17.4% Local manifestations of pancreaticobiliary cases (n= 86)
  45. 45. Tuberculous distal common bile duct stricture (Tuberculous Pancreatic Mass) Waheed Doss, Cairo University
  46. 46. SUMMARY x Most publications on GI tuberculosis were in the last decade. x The publications were mainly from Asia. x In the Western hemisphere, the disease is mainly in emigrants from endemic areas.
  47. 47. SUMMARY x Adults represent the majority of G.I. T.B. cases. x The disease is slightly more prevalent in females. x HIV infection is a main risk factor. x Pulmonary T.B. is a frequent but not an essential association.
  48. 48. SUMMARY x Patients present with nonspecific constitutional symptoms, pyrexia and weight loss are the most common. x Local manifestations depend on the site of G.I. tract affection: q The esophagus: Dysphagia, fistula and haematemesis. q The stomach and duedenum: ulcer-dyspepsia, outlet obstruction and abdominal mass. q The intestine: pain, diarrhea, perforation & abdominal mass q The colon: pain and rectal bleeding. q The peritoneum: ascites and abdominal distension. q Hepato-pancreaticobiliary: pain and jaundice.
  49. 49. Gastrointestinal T.B. Differential Diagnosis Gastrointestinal T.B. should be considered in the differential diagnosis of : x Chronic diarrhea x Malabsorption syndrome x Abdominal masses x Ascitis x Inflammatory bowel disease particularly Crohn’s disease. x Gastrointestinal lymphomas x Other GIT malignancies.
  50. 50. CONCLUSION x Since 1980s, a resurgence of tuberculosis has occurred. x The disease is still and will remain a serious public health threat worldwide x Still the great mimicker, gastro intestinal tuberculosis. (Jadvar, 1997)
  51. 51. Do not fear to repeat what has already been said. Men need most things dinned into their ears many times and from all sides mak THE FI es th R em p ST RUM rick up th OR eir e ars THE SECOND registers s D enter THIR THE (Rene Laennec, 1781-1826)
  52. 52. G.I. TUBERCULOSIS, A FINAL WORD Be aware of Abdominal Tuberculosis (Bouma et al., 1997)
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