TB ABDOMEN-INVESTIGATIONS,MEDICAL AND SURGICAL TREATMENT

1. Dr.Chaitanya Chittimuri
Department of Surgery
under guidance of
Dr.C.Jayaraj M.S,M.Ch
Dr.V.Raj Kamal M.S,D.N.B
Dr.K.Suresh Babu M.S
Dr.Ratna Kishore MS

2. DIAGNOSIS
• Paustian in 1964 stated that one or more of the following four criteria must be fulfilled to
diagnose abdominal tuberculosis :
(i) Histological evidence of tubercles with caseation necrosis;
(ii) a good typical gross description of operative findings with biopsy of mesenteric nodes
showing histologic evidence of tuberculosis;
(iii) animal inoculation or culture of suspected tissue resulting in growth of M.tuberculosis;
and
(iv) histological demonstration of acid fast bacilli in a lesion.

4. Plain X ray abdomen:
• Intestinal obstruction
• Calcified lymph nodes
• Hollow viscus perforation
• Calcified Granuloma in liver

5. Barium studies
Small bowel barium meal:
• Accelerated transit time & flocculation is the earliest sign
• Hypersegmentation of the barium column (chicken intestine)
• Localised areas of irregular thickened folds, mucosal ulceration,
dilated segments and strictures

6. Barium enema or Barium follow through
• Thickened iliocaecal valve with a broad triangular appearance with the
base towards the caecum (inverted umbrella sign or (Fleischner’s sign)
• “Conical caecum”, shrunken in size and pulled out of the iliac fossa due
to contraction and fibrosis of the mesocolon
• Obtuse ileocaecal angle; straightening (Goose neck)
• Steirlin sign: Hurrying of barium due to rapid flow and lack of barium
in inflamed site
• Napkin leisons
• Chicken intestine: Hypersegmentation
• Mega Ileum: Dilatation of proximal ileum

10. USG abdomen
• Mainly used for extraintestinal lesions(peritoneal & lymph nodes)
• Thickened bowel wall
• Loculated ascitis
• Interloop ascitis“club sandwich” or “sliced bread” sign
• Mesenteric thickening-≥15mm with increased echogenicity
• Pulled up caecum (Pseudokidney sign)

11. • Lymph node enlargement
 Discrete or conglomerated
 Echotexture is mixed
 heterogenous, anechoic
 areas represent caseation
 Caseation and calcification is highly s/o tubercular etiology
• USG can be used for guiding procedures like ascitic tap or FNAC or
biopsy from
enlarged lymph nodes/hypertrophic lesions

12. CT Abdomen
• Better than USG for
detecting
• High density ascites
• Lymphadenopathy with
caseation
• Bowel wall thickening
• Irregular soft tissue
densities in omental area
• Tuberculosis of liver &
spleen
 CT scan shows thickening
of the cecum with
pericecal inflammatory
changes. Mesenteric
lymph nodes are also
evident (arrows).

14. Loculated ascites Thickened omentum
Thickened ileocaecal bowel
Tubercles in spleen & liver

15. Colonoscopy
• Excellent tool for suspected colonic & terminal ileal involvement
• Mucosal nodules (2-6mm) & ulcers in a discrete segment of 4-8 cm, with normal
or
hyperemic intervening mucosa are pathognomic
• Other findings: strictures, deformed ileocaecal valve, mucosal oedema,
pseudopolyps and diffuse colitis
• Biopsy can be taken to eshtablish the diagnosis

16.  FNAC
• In patients with palpable masses
• High diagnostic accuracy
• L-J culture of FNAC material increases the yield further
• FNAC during colonoscopy adds to diagnostic yield in ileocaecal or
colonic TB
 Peritoneal Biopsy
• Blind percutaneous peritoneal needle biopsy & open parietal peritoneal
biopsy under LA
• Relatively safe, occasional bowel perforation with blind needle biopsy-
cope's abraham needle
• Diagnostic accuracy is 80%
peritoneum

17. Diagnostic laproscopy
• Direct visualization
• Collect acsitic fluid
• Take biopsy from mass,
omentum or peritoneum

18. • QUANTIFERON –TB GOLD ASSAY
• QuantiFERON-TB Gold: Indirect blood test for Mycobacterium
tuberculosis complex infection (both active & latent)
• Measures cell-mediated immune response to antigens simulating the
mycobacterial proteins
• Individuals infected with M. Tuberculosis complex have lymphocytes
in their blood that recognise
these specific antigens & in response secrete IFN-Υ

19. Ascitic tap fluid analysis
• Exudate fluid (protein >2.5gm%)
• TLC of 150-4000/µl, Lymphocytes >70%
• Glucose <30mg%
• Specific gravity >1.016
• ADA (Adenosine deaminase activity) 95% specificity and 98%
sensitivity
• LDH > 90 units/litre
• ZN stain + in < 3% cases
• + culture in < 20% cases

20. ADENOSINE DEAMINASE
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
• specificity and sensitivity of over 95 per cent
• Coinfection with HIV  normal or low ADA
• STOOL CULTURE FOR AFB-NOT USEFUL

22. • ELISA
• soluble antigen fluorescent antibody (SAFA)
• Sensitivity of 92% and specifity of 83%
• However, ELISA remains positive even after therapy, the response to
mycobacteria is variable and its reproducibility is poor

23.  PCR of tissue
 Serodiagnosis:
• Histological & microbiological methods often inadequate –
paucibacillary disease
• Many serological tests have been developed, but all have low
predictive value
• PCR assay for detection of M. tuberculosis in endoscopic biopsy
specimen has shown promising results

25. • Medical management:
• With no features of subacute obstruction–– Conservative antituberculous drugs
• Postoperatively: ATT for 6 months.
Category 1 (according to latest RNTCP guidelines):
2 HRZE + 4HR (6 months)
• First line drugs:
• INH 10-15mg/kg 300mg/day
• Rifampicin 15mg/kg 600mg/day
• Pyrazinamide 35mg/kg
• Ethambutol 20mg/kg
• Second line drugs:
• Amikacin, kanamycin, PAS, Ciprofloxacin,
• Clarithrymycin, Azythromycin, Rifabutin
• Treatment to be continued for 6-9 months
• Supportive nutrition

26. • Role of corticosteroids:
• Used to decrease fibrosis during healing so as to prevent
development of obstruction,but may delay healing and predispose to
perforation or further obstruction
• Current studies show that even obstructing intestinal lesions can be
successfully treated with ATT, so use of steroids is declining
these days

27. • HIV Coexistent Cases
• Treatment of TB should precede treatment of HIV infection
• Patients already on HAART, should continue same treatment with
appropriate adjustments in HAART and ATT
• Regimen is 2 (HRZE)3 + 7 (HR)3

29. FOLLOW UP
• WEIGHT GAIN
• IMPROVED APPETITE
• DECREASED DISTENSION AND PAIN
• NORMAL BOWEL HABITS
• ESR BECOMES NORMAL
• USG-IMPROVED SONOLOGICAL FEATURES

30. • NOT RESPONDING AFTER 6 WEEKS
• ASSESS FOR
DRUG RESISTANCE
CARCINOMAS AND LYMPHOMAS
CROHS DISEASE
EOSINOPHILIC ENTERITIS

31. Surgical Management
Indications:
• Intestinal obstruction
• Severe hemorrhage
• Acute abdomen (perforation)
• Intra-abdominal abscesses/ fistula formation
• Uncertain diagnosis

32. • SINGLE STRICTURE FRIABLE BOWEL RESECTION
>10cm from IC junction HEALTHY BOWEL STRICTUROPLASTY
• SINGLE STRICTURE
<10cm from IC junction RESECTION

33. • MULTIPLE STRICTURES LONG SEGEMENT GAPS IN BETWEEN
SHORT SEGMENT GAPS MULTIPLE
STRICTUROPLASTY
RESECTION

34. STRICTUROPLASTY
• 7cm stricture -Heineke-Mikulicz

35. • 7-15 cm strictures-Finney's strictureplasty

36. • >15 cm strictures-Michelassi Strictureplasty

37. PERFORATION OF ILEAL BOWEL
BIOPSY AND CLOSURE RESECTION AND ANASTOMOSIS RESECTION AND EXTERIORISATION
HIGH CHANCES OF
LEAK AND FISTULA
CHEMOTHERAPHY AND
PROPER NUTRITION
ILEOSTOMY CLOSURE

38. obstruction
with 5cm margin
LIMITED ILEOCAECAL
RESECTION

39. • ONLY IN POOR G.C
• LIFE SAVING PROEDURE
• CAUSES BLIND LOOP
• RETAINED TUBERCULOUS FOCI
TUBERCULOUS
FOCUS

41. PERITONEAL TB
• ON TABLE DIAGNOSIS
• SURGERY - OBSTRUCTION
PERFORATION
• FLUID EVACUATED
• AFB, CULTURE
• OMENTAL BIOPSY
• DONOT KEEP DRAINS
• TENSION SUTURES
ASCITIC FORM
Asctic tap + ATDs
Repeated tap may be needed
ENCYSTED ACITES
USG guided aspiration + ATDs
PURULENT FORM
ATDs+drainage of pus
exploration of fistula and fistulectomy
bowel bypass
PLASTIC TYPE
ATDs
Surgery if complications+

42. • 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
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