Abdominal tuberculosis

1. ABDOMINAL TB
By :Darayus P.Gazder (DPG)

2.  A common disease in Pakistan and other developing countries
 Its prevalence is estimated to be 175 per 100,000 of population
 40% of Pakistanis harbour tb bacilli
 Diagnosis of abdominal TB is usually very difficult, due to nonspecific symptoms and signs.
 Diagnostic confirmation often requires histopathological examination of the surgical specimen
 TB can be seen in any age group that is Immunocomprimised
 -WHO
 Epidemiology:
 Both gender: equally affected
 Most common age: 35-45 years
[Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700]
Introduction

3. Mode of infection
Swallowing of
infected sputum
Hematogenous spread
from pulmonary focus
Ingestion of contaminated
milk products
Direct spread from
adjacent organs
Pathogenesis of Abdominal TB

4. 1)Bacilli in depth of mucosal glands
2) Phagocytes carry bacilli to Peyers patches
3) Formation of Tubercles, which undergo necrosis
4) Ulcer Formation
5) Accumulation of collagen, with thickening and stenosis
6) Inflammation in Submucosa that reaches the serosa
7) Bacilli reach lymphatics
A) Lymphatic obstruction of bowel
-----Thick fixed mass
B) Regional lymph nodes
-Hyperplasia
-Caseation necrosis
-Calcification
PATHOLOGYPATHOLOGY

5. 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
1. Hematogenous spread from lungs
2. Through lymphatics (neck)
3. Fallopian tubes (retrograde spread)
Mode Of Spread

6. Intestinal tubercu
Ileocaecal
region
Small bowel
& colon
Niall O, et al. World J Surg 1997;21:492-499
Constitutes 70-78% cases of
abdominal
tuberculosis
Most common site of gastrointestinal
tuberculosis is ileocaecal region
Stasis
Abundant peyer’s patches
Alkaline media
Bacterial contact time is more
Minimal digestive activity
Maximum absorption in the area

7. Intestinal tuberculosis
Ulcerative type
Formation of mucosal ulcers
• Bleeding
• Perforation
• Fistulation
• Stricture
Hyperplastic type
Extensive inflammatory changes
• Obstruction
• Mass
Aston NO. World J Surg 1997;21:492-499

10. Clinical Presentation
Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700

11. To diagnose abdominal
tuberculosis…
Clinical
presentation
Concomitant
PTB
Blood tests
Tuberculin
test
Radiological
test
Microbiology
& histology

12. Concomitant PTB
 Concomitant PTB
 Present in 15-25% only
 Sputum smear and culture
for AFB:
 Low diagnostic yield
 Abnormal CXR:
 19-83%
 Average = 38%Marshall JB, et al. Am J Gastroenterol 1993;88:989-999
Horvath KD, et al. Am J Gastroenterol 1998;93:692-696
Faylona JM, et al. Ann Coll Surg 1993;3:65-70

13. Blood tests
 No specific diagnostic blood tests available
 Common blood parameters:
 Elevated ESR
 Almost always raised but not exceed 60 mm/hr
[Manohar, et al. Gut 1990;31:1130-2]
 Mild anemia
 normochromic/ normocytic
[Marshall JB, et al. Am J Gastroenterol 1993;88:989-999]
 Mild leukocytosis
[Manohar, et al. Gut 1990;31:1130-2]

14. Tuberculin test
Huebner, et al. Clin Infect Dis 1993; 17:968-75
IGRA:
The test involves incubating the patient’s blood with synthetic
proteins which represent M. tuberculosis proteins; interferon
gamma released by sensitized leucocytes is measured.

15. GeneXpert TB Test
 The Genexpert test is a new molecular test for TB. The test is
a molecular test which detects the DNA in TB bacteria. It uses
a sputum sample and can give a result in less than 2 hours. It
can also detect the genetic mutations associated with
resistance to the drug Rifampicin.

16. 1)Thickened bowel wall/ Loculated ascites/
Mesenteric thickening/Lymph node
enlargement /Pulled up caecum
(Pseudokidney sign)

19.  Endoscopy and biopsy
• Evaluation of diseased area
• Histopathology: granulomas, caseation
necrosis, staining for AFB
 • Culture for M. tuberculosis
 • PCR for M. tuberculosis: 100% sensitivity
Uzunkoy, et al. World J Gastroenterol 2004;10(24):3647-3549
Tzoanopoulos, et al. Eur J Intern Med 2003;14:367-371

20.  Ascitic fluid analysis
 • Exudate, high lymphocyte count
 • AFB and culture (low yield)
 • Elevated adenosine deaminase (high yield)

21.  Laparoscopy
 • Peritoneum: thickened, irregular, dull
appearance
 • Adhesions
 • Miliary nodules: high positive yield at
histology

22. Laparoscopy
 Highest diagnostic yield
 Macroscopic appearance 93%
 Peritoneal biopsy for ZN stain 3-25%
 Peritoneal biopsy for culture 38-92%
 Histology 93%
Sanai, et al. Aliment Pharmacol Ther 2005;22:685-700

23.  Medical management:
 First line drugs:
 INH
 Rifampicin
 Pyrazinamide
 Ethambutol
 Second line drugs:
 Amikacin, kanamycin, Ciprofloxacin,
 Clarithrymycin, Azythromycin, Rifabutin
 Treatment to be continued for 6-9 months depending
on the prevalence of drug resistant TB.
Treatment Weight=50kg
Isoniazid
100 mg 3
OD
Rifampicin 450 mg OD
Ethambutol
400 mg 3
OD
Pyrazinamide
500mg 3
OD
DRUG STRENGTH
Isoniazid Tab 100 mg
Rifampicin Tab 300/450/600mg
Ethambutol Tab 400mg
Pyrazinamide Tab 500mg
MYRIN P
I 75+
R150+E275+PZA400
(>71 kg 5 tab/day, 55-70 kg 4
tab/day, 40-54 kg 3 tab/day)
MYRIN I75+R150+E300

24.  There is no difference in efficacy of anti-tuberculosis
therapy delivered for either 6 months or 9 months in
either gastrointestinal or peritoneal tuberculosis.
Clin Infect Dis. 2015 Sep 1;61(5):750-7. doi: 10.1093/cid/civ376. Epub 2015 May 12
 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

25.  With the advent of antituberculous therapy, surgery is usually reserved for
those cases where it is absolutely indicated as in cases of non-resolving
intestinal obstruction, perforation and abscess or fistula formation.
 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

26. THANK YOU!!
 References:
1) SRB MANUAL OF SURGERY
2) Textbook of Clinical Gastroenterology and
Hepatology
THE DPG WAY….ALL
THE WAY!!