Diagnosis of abdominal tuberculosis


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Diagnosis of abdominal tuberculosis

  1. 1. 05/12/2007
  2. 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. 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. 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. 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. 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. 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. 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. 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. 10.  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
  11. 11.  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
  12. 12.  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%)
  13. 13.  Culture medium Lowenstein-Jensen Middlebrook 7H11 Liquid medium QuantiFERON-TB test(QFT) BACTEC radiometric system Mycobacterial Growth indicator tubes Animal pathogenicity PCR assay Ligase chain reaction
  14. 14.  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
  15. 15.  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
  16. 16.  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
  17. 17.  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
  18. 18.  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
  19. 19.  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
  20. 20.  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
  21. 21. High index of suspicion USG of abdomenSuggestive Suspicious Normal Contrast CECT Treat barium abdomen studies Classical Suspicious Classical Doubtful Endoscopic Perform Treat Treat biopsy FNAC/biopsy
  22. 22.  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
  23. 23.  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
  24. 24.  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.
  25. 25.  API update 2007 Tuberculosis by Sharma & Mohan Harrison’s principles of internal medicine 16th ed. American journal of gastro enterology