EXTRAPULMONARY TB (SMALL INTESTINE)

1. TB of SMALL INTESTINE
BY
K. MANIEVELRAAMAN

2. TB
Pulmonary Extra-pulmonary

3. Mycobacterium tuberculosis
3

4. Mycobacterium tuberculosis
• Obligate aerobe
• Acid fast 20% H2SO4
• Alcohol fast
• Gram variable
• Thin rods
• SLOW growing
• Lipid laden cell wall

6. Modes of Spread
• Ingestion
• Haematogenous
• Lymphatics
• Retrograde spread
• Direct spread

7. Ileum>caecum >ascending
colon >jejunum >appendix >sigmoid
>rectum >duodenum >stomach >esophagus
In the order of frequency…

8. What makes ILEOCAECAL region
the most common site?
• Abundance of Peyer’s patches
• M – cells
• Stasis  Prolonged contact time
• Increased Fluid and Electrolyte absorption
• Minimal digestive activity

9. ULCERATIVE
60%
ULCEROHYPER
PLASTIC
30%
HYPERPLASTIC
10% 0%

10. ULCERATIVE TYPE
• SECONDARY
• Virulent organism & Poor body resistance (old age)
• Multiple
Transverse
Circumferential ulcers (GIRDLE ulcers)
• Caseation common
• Serosa reddened & edematous

11. HYPERPLASTIC TYPE
• PRIMARY
• Less virulent organisms & Good body resistance (young)
• Chronic Granulomatous lesions
• Caseation uncommon (early nodal involvement)
• Establishes in lymphoid follicles

12. CLINICAL PRESENTATION
• Colicky Abdominal Pain 90%
• Anaemia, Loss of weight, Loss of appetite 80%
• Fever, Malaise 50-70%
• Mass 35% ( Hard, nodular, non-tender, non-mobile)
• Intestinal obstruction, Diarrhoea 20%
• ‘Ball of wind’ rolling in abdomen, Borborygmi
• Age : 25-50 ; Both sexes
• Associated with HIV, Lymphoma, Adenocarcinoma

13. COMPLICATIONS
• ULCERATIVE :
• Stricture ( Napkin ring stricture)
• Intestinal Obstruction
• HYPERPLASTIC :
• Subacute Intestinal Obstruction
• Malabsorption
• Blind loop syndrome
• Dissemination
• Cold abscess formation
• Fistula
• Perforation
• Haemorrhage

14. Obstruction
• Most common complication
Due to :
• Hyperplastic type
• Strictures of the small intestine--- commonly multiple
• Adhesions
• Adjacent LN involvement  traction, narrowing and fixation of bowel loops.

15. Perforation
• 2nd commonest cause after typhoid
• Usually single and proximal to a stricture
• Clue - TB Chest x-ray, h/o SAIO
• Pneumoperitoneum

16. Malabsorption
Due to :
• Bacterial overgrowth in stagnant loop
• Bile salt deconjugation
• Diminished absorptive surface
• Involvement of lymphatics and nodes

17. Less common sites
• GASTRODUODENAL TB ( Gastric – uncommon)
• Mimics Peptic ulcer disease, Gastric CA
• Duodenal obstruction  external compression by lymph nodes
• JEJUNAL TB
• Stricture, obstruction, perforation

18. Investigation and Diagnosis
• CXR
• Blood investigations
• Hb, ESR, TC, DC, Protein, serum transaminase and ALP levels
• Mantoux test
• ELISA, SAFA
• PCR of the tissue

19. Ascitic fluid analysis
• Straw colored
• Protein >2.5g/dL
• TLC of 150-4000/µl, Lymphocytes >70%
• SAAG < 1.1 g/dL

20. Adenosine Deaminase (ADA)
Converts adenosine to inosine
• ADA increased due to stimulation of T-cells by
mycobacterial Ag
• Serum ADA > 54U/L
• Ascitic fluid ADA > 33U/L
• Ascitic fluid to serum ADA ratio > 0.985
• Coinfection with HIV  normal or low ADA

21. PLAIN X-RAY ABDOMEN
• Calcified lymph nodes
• Dilated loops with multiple fluid
levels
• Dilation of terminal ileum and
ascites
• Pneumoperitoneum

22. USG ABDOMEN
• Thickened bowel wall
• Loculated ascites
• Lymph node enlargement
• Pseudokidney sign
• Stellate sign

23. Colonoscopy
• Nodules & Ulcers
• Deformed Ileocecal valve
• Biopsy can be taken

24. CT Abdomen
• Done with CT enteroclysis
• Thickened bowel wall
• Ileocecal valve thickening
• Adhesions
• CT guided aspiration, biopsy,
FNAC can be done

25. Barium study X-ray
• Barium follow through or CT- absent filling as a result of narrowing of the
ulcerated segment
• Barium follow through or small bowel enema– long narrow filling defect in the
terminal ileum
• Narrowed segment with proximal distension
• Pulled up caecum
• Conical caecum
• Pulled down hepatic flexure
• Steirlin sign
• Fleischner sign, goose neck deformity
• String sign, Mega ileum

28. Laparoscopy
• Yellowish white military
nodules on the peritoneum
• Erythematous , thickened
peritoneum
• Adhesions

29. MANAGEMENT
• Medical therapy (No int. obstruction ATT)
• ATT  INH, rifampicin, pyrazinamide, ethambutal  first line
drugs
• 6 to 9 months
• Supportive treatment  TPN, blood transfusion
• Steroids along with ATT  to prevent adhesion

30. Indications for Surgery
• Intestinal obstruction
• Acute abdominal presentation like perforation
• Severe haemorrhage
• Intra-abdominal abscess formation and fistula formation

31. Surgery
• Limited ileocaecal resection
• Stricturoplasty ( solitary or multiple )
• Resection and anastomosis
• Ileotransverse colon anastomosis (bypass)
• Adhesiolysis
• Drainage of abscess