all about tuberculosis in surgery

1. TUBERCULOSIS IN SURGERY
PRESENTER-DR INDUMATHI B

2. Introduction
• A common disease in India and other developing countries
• Abdominal tuberculosis is the 6th most common type of extra-
pulmonary tuberculosis.
• 40% of Indians harbour Tb bacilli
• Incidence is high in HIV infected patients
• Commonly caused by Mycobacterium tuberculosis(gram neutral, acid
fast, alcohol fast)
• Occasionally by mycobacterium bovis, M.kanasii, M.fortium,
M.marinum, M.ulcerans

3. • The characteristic lesion is ‘tubercle’, which is an avascular granuloma
composed of central zone containing giant cells ,with or without
caseation necrosis ,surrounded by a rim of epithelioid cells,
lymphocytes and fibroblasts.

4. ABDOMINAL TUBERCULOSIS
• INTESTINAL TUBERCULOSIS
• PERITONEAL TUBERCULOSIS
• TUBERCULOSIS OF MESENTRY AND ITS LYMPH NODES
• ANO-RECTAL-SIGMOIDAL TUBERCULOSIS
• TUBERCULOSIS OF OMENTUM

5. MODE OF SPREAD OF ABDOMINAL TUBERCULOSIS
• By ingestion of food contaminated with tubercle bacilli causing
primary intestinal tuberculosis.
• Ingestion of sputum containing tuberculous bacteria from primary
pulmonary focus causing secondary intestinal tuberculosis.
• Hematogenous spread from tuberculosis of lungs.
• From neck nodes(Tuberculous cervical lymphadenitis -5-10%) through
lymphatics.
• From fallopian tubes by retrograde spread to involve peritoneum.
• Direct spread from adjacent organs.

6. INTESTINAL TUBERCULOSIS
• Intestinal tuberculosis is also called as KOENIGS SYNDROME.
• ILEOCAECAL REGION :
• A)Ulcerative
• B)Hyperplastic
• C)Ulcerohyperplastic
• ILEAL REGION:
• Stricture type

7. ILEOCAECAL TUBERCULOSIS
• It is the most common site of abdominal tuberculosis .
• Causative organism:
• Mycobacterium tuberculosis-Acid fast 20%h2so4.
• It is presently due to mycobacterium tuberculosis ,earlier used to be
due to mycobacterium bovis.
• Atypical mycobacterium can spread directly.
• Mycobacterium avium spreads through lymphatics.

8. TYPES
• ULCERATIVE:
• Most common-60%.
• Circumferential transverse often multiple ‘girdle 'ulcers with skip
lesions.
• Common in old, malnourished people.
• Ulcers-fibrosis-stricture formation.
• Stricture is common in ileal part.
• Intestinal nodes are involved with caseation, abscess formation.
• Bowel adhesions.
• Patients mainly present with diarrhea,blood in stool,loss of appetite
and reduced weight.

9. • HYPERPLASTIC :
• Fibroblast reaction in submucosa and subserosa causing thickening of
bowel wall & lymph node enlargement-nodular mass formation.
• 10%common,less virulent, with adequate host resistance.
• Young, well nourished individuals.
• Common in caecal part.
• Extensive chronic inflammation,Fibrosis,bowel adhesions, nodal
enlargement.
• Patient often presents with mass in the right iliac fossa,

10. • Caseation necrosis is not common.
• It is commonly primary intestinal tuberculosis.
• There is no primary foci in the lungs.
• ULCEROHYPERPLASTIC-30%

11. CLINICAL FEATURES
• Abdominal pain is the most common symptom. It is dull in
mesenteric type; colicky in intestinal type.
• Common in 25-50 years age group, equal in both sexes.
• Anemia, loss of weight & appetite.
• Diarrhea
• Fever
• Mass in right iliac fossa-hard,nodular,nonmobile,nontender .
• Subacute obstruction can occur
• Associated with adeno-carcinoma of caecum, or large bowel
lymphoma or HIV

12. DIFFERENTIAL DIAGNOSIS
• Carcinoma caecum
• Ameboma
• Appendicular mass
• Ectopic kidney
• Retroperitoneal tumor
• Lymph node mass
• Psoas abscess
• Crohn’s disease.

13. INVESTIGATIONS
• Chest X-ray
• Mantoux test, ELISA, Serum IgG.
• ESR-raised.
• Plain Xray abdomen
• -intestinal obstruction
• -calcified lymph nodes
• -calcified granuloma in liver
• -perforation

14. Investigations
• USG abdomen
• -Thickened bowel wall
• -Loculated ascites
• -Interloop ascites(club-sandwich appearance)
• -mesenteric thickening >15mm
• -lymph node enlargement
• -Pulled up caecum presenting with a mass in subhepatic region-
PSEUDO KIDNEY SIGN

15. INVESTIGATIONS
• BARIUM STUDY X-RAY(barium enema or barium follow through Xray)
• -pulled up caecum
• -obtuse ileocaecal angle ;straightening (Goose neck).
• Stierlin sign: Hurrying of barium due to rapid flow and lack of barium
in inflamed site.
• Fleischner sign(inverted umbrella sign): narrow ileum with thick
ileoceacal valve.
• Napkin lesions-ulcers and strictures in terminal ileum & caecum.
• Chicken intestine-Hypersegmentation
• Mega ileum-Multiple strictures with enormous dilatations of the
proximal ileum.

16. Investigations
• COLONOSCOPY
• -To rule out carcinoma.
• -shows mucosal nodules, ulcers, caecal & ileal strictures, deformed
ileocecal valve, mucosal edema & diffuse colitis.
• Biopsy can be taken to confirm the diagnosis.

17. INVESTIGATIONS
• CT ABDOMEN
• -Thickened bowel wall
• -Ileocaecal valve thickening
• -Adhesions.
•

18. INVESTIGATIONS
• DIAGNOSTIC LAPAROSCOPY:
• Direct visualization
• Collect ascitic fluid
• Take biopsy from mass, omentum or peritoneum.

19. Investigations
• PCR of biopsied tissue or ascitic fluid.
• -DNA-PCR can detect 1-2 organism,positive PCR signifies infection but
need not be active disease.
• ASCITIC TAP FLUID ANALYSIS
• Exudate fluid(protein>3.0g/dl)
• Serum ascitic albumin gradient<1.1
• Lymphocytic predominant cells >250/cu mm(up to 4000/cu mm)
• Glucose>30mg
• Specific gravity>1.016
• ADA (ADENOSINE DEAMINASE ACTIVITY) 95%specificity & 98%
sensitivity.
• LDH>90units/litre.

20. COMPLICATIONS
• Obstruction -20%
• Malabsorption ,blind loop syndrome
• Dissemination of tuberculosis
• Cold abscess formation
• Perforation
• Faecal fistula

21. TREATMENT
• DRUGS
• FIRST LINE DRUGS:
• INH
• Rifampicin
• Pyrazinamide
• Ethambutol
• SECOND LINNE DRUGS:
• Amikacin, kanamycin, PAS, Ciprofloxacin ,Clarithromycin
,Azithromycin, Rifabutin.

22. TREATMENT
• SURGICAL MANAGEMENT:
• Indications:
• Intestinal obstruction
• Severe haemorrhage
• Acute abdomen(perforation)
• Intra abdominal abscess or fistula formation.
• Uncertain diagnosis.

23. TREATMENT
• SURGICAL MANAGEMENT:
• Ileocaecal resection with 5cm margin,this may be done in initial
period depending upon the obstructive & other perforations.
• During therapeutic period ,healing with fibrosis causes stricture and
obstruction in 3-6weeks after drug therapy.
• Single ileal stricture-stricturoplasty may be done.
• Single stricture with friable and edematous bowel- Resection.
• Multiple stricture with long segment gaps-multiple stricturoplasty
• Multiple strictures: Resection and anastomosis.

24. Treatment
• SURGICAL MANAGEMENT:
• Early perforations: resection and anastomosis (due to friable bowels).
• Perforation with severe contamination: resection with colostomy
• Adhesiolysis by laproscopy
• Drainage of intra abdominal abscess,perianal abscess and treatment
for tuberculous fistula-in-ano is done when necessary.

25. ILEAL TUBERCULOSIS
• It is usually stricture type
• May be multiple
• Presents with intestinal obstruction
• Bowel adhesions ,localization, fibrosis, secondary infections are
common.
• Perforation(5%)
• Plain Xrays-multiple air fluid levels.
• Resection and anastomosis with anti-Tb drugs.

26. PERITONEAL TUBERCULOSIS
• It is post primary
• Becoming more common
• Activation of long standing latent foci
• Blood spread
• Can develop from diseased mesenteric lymph nodes , intestines or
fallopian tubes.

27. Peritoneal Tuberculosis
• Basic pathology
• Enormous thickening of the parietal peritoneum
• Multiple tiny yellowish tubercles
• Dense adhesions in peritoneum and omentum with small intestines
• May precipitate intestinal obstruction
• Thickening of bowel wall

28. Peritoneal Tuberculosis
• ABDOMINAL COCOON SYNDROME
• Dense adhesions in peritoneum and omentum with contents inside as
small bowel causing intestinal obstruction.

29. Peritoneal Tuberculosis
• TYPES
• 1.Acute –mimics acute abdomen
• Rare
• On –table diagnosis
• Features of peritonitis
• Due to perforation or rupture of mesenteric tuberculous lymph nodes
• Explorarory laparotomy reveals straw coloured fluid with tubercles in
the peritoneum,greater omentum,and bowel wall.
• Fluid evacuated and sent for culture and AFB study.
• Biopsy taken from omentum
• To be closed without drains.

30. Peritoneal Tuberculosis
• 2.CHRONIC
• Present as
• Abdominal pain
• Fever
• Ascites
• Loss of appetite and weight
• Abdominal mass
• Doughy abdomen(10%)
• TYPES
• A) Ascitic B)Encysted C) Plastic D)Purulent form

31. • ASCITIC PERITONEAL TUBERCULOSIS
• Enormous distension of abdomen with dilated veins.
• Intense exudate caused ascites
• Children and young adults
• May presents with congenital hydrocele ,umbilical hernia, shifting
dullness, fluid thrill, and mass per abdomen
• Ascitic tap reveals straw coloured fluid from which AFB can be
isolated . Fluid is pale yellow, clear, rich in lymphocytes , with high
specific gravity.
• Anti –Tb drugs for one year.
• Repeated tapping may be required.

32. Peritoneal Tuberculosis
• ENCYSTED(LOCULATED)PERITONEAL TUBERCULOSIS
• Exudation with minimal fibroblastic reaction
• Ascites gets loculated because of fibrinous deposition
• Non shifting dullness is the typical feature
• May present as intra-abdominal mass mimicking ovarian cyst .
• USG guided aspiration and anti-tubercular drugs to be given.

33. PERITONEAL TUBERCULOSIS
• PLASTIC PERITONEAL TUBERCULOSIS
• Extensive fibroblastic reaction
• Widespread adhesions
• Between the coils of intestine(ileum),abdominal wall,omentum
• Obstruction Distension of abdomen
• Colicky abdominal pain(recurrent)
• Diarrhoea ,loss of weight,,mass per abdomen,doughy abdomen
• Open /laprascopic biopsy (to rule out peritoneal carcinomatosis)
• Anti –tb drugs
• Surgery is indicated if obstruction occurs.

34. • PURULENT PERITONEAL TUBERCULOSIS
• Direct spread from tuberculous salpingitis
• Mass per abdomen containing pus,omentum,fallopian tubes, small
and large bowel
• Cold abscess may get adherent to umbilicus umbilical fistula
• Genitourinary tuberculosis is usually present
• Anti –Tb drugs with exploration of umblical fistula

35. Tuberculous mesenteric lymphadenitis
• 1.CALCIFIED LESION:
• Along the line of the mesentery a single multiple calcified lesions
• Peyer’s patches involved
• No active infection
• May be on right or left side(R>L)
• Anti-tubercular drugs

36. Tuberculous mesenteric lymphadenitis
• 2.ACUTE MESENTERIC LYMPHADENITIS
• Common in children
• Mimics acute appendicitis
• Tender mass of lymph node palpable in right iliac fossa which are
matted and non-mobile.
• Intestines adherent to caseating lymph nodes obstruction
• Surgery for appendicitis or obstruction with lymph node biopsy
• Anti –tubercular drugs.

37. Tuberculous mesenteric lymphadenitis
• 3.PSEUDO MESENTERIC CYST
• Caseating material collected between the layers of mesentery
• Forms cold abscess
• Mimicking a mesenteric cyst.
• 4.TABES MESENTERICA
• Massive enlargement of mesenteric lymph nodes due to tuberculosis
• 5.CHRONIC LYMPHADENITIS
• Children
• Failure to thrive
• Protuberant abdomen and emaciation
• Lymph node on deep palpation in right iliac fossa

38. Tuberculous mesenteric lymphadenitis
• DIFFERENTIAL DIAGNOSIS:
• Carcinoma caecum
• Lymphoma
• Retroperitoneal tumour
• Nonspecific lymphadenitis
• Acute nonspecific lymphadenitis is called as nurses’ syndrome

39. Tuberculous mesenteric lymphadenitis
• INVESTIGATIONS
• X-ray abdomen shows calcifications
• USG may confirm the diagnosis
• Mantoux test may be positive
• Diagnostic laparoscopy-TB lymphadenitis. Mesenteric cold abscess
can be drained safely laparoscopy
• TREATMENT: Anti-TB drugs; laparoscopy and proceed.

40. ANO-RECTAL-SIGMOIDAL TUBERCULOSIS
• Mimics ca rectum
• Occurs within 10cm of anal verge
• Present as tenesmus, diarrhea and multiple discharging fistula in ano
• Haematochezia is the most common symptom
• Fistula is painful ,not indurated
• Tuberculous ulcers are shallow,bluish with undermined edges.
• Investigation:
• Sigmoidoscopy
• USG
• Discharge study
• Fistulectomy and biopsy

41. ANO-RECTAL-SIGMOIDAL TUBERCULOSIS
• TREATMENT:
• Anti-TB drugs
• Fistulectomy
• Sigmoid resection

42. OMENTAL TUBERCULOSIS
• As a part of other abdominal tuberculosis
• Rolled up omentum with thickening
• Cold abscess in omentum
• Age : 25 to 50 yrs
• Equal in both sexes
• Constitutional symptoms:
• Fever
• Anorexia
• Cachexia
• Diarrhoea
• Anemia
• Laparoscopy under the cover of Anti-Tb drugs.

43. FOLLOW UP & PROGNOSIS
• Regular weight check to see for weight gain
• Improvement in appetite
• Reduction of abdominal pain and distension
• Absence of fever
• Normal bowel habits
• Normal haemoglobin
• ESR becoming normal

44. Follow up & prognosis
• Patients who are not responding in 6weeks should be reassessed
again for drug resistance; or associated with malignancy ,crohn’s
disease, eosinophilic enteritis.
• During therapy, patient who is responding for drug therapy can also
go for intestinal obstruction due to fibrosis during healing stage .
• Repeated

45. TUBERCULOUS LYMPHADENITIS
• Most common form of extra pulmonary tuberculosis.
• Scrofula
• SITES:
• Common in neck lymph nodes-80%
• Upper deep cervical(jugulodigastric-54% ;20% B/L)
• Posterior triangle(22%)

46. Tuberculous lymphadenitis
• Mode of infection : Tonsils or adenoids
• Tonsillar infection shows multiple tubercles on its surface
jugulodigastric nodes.
• Infection reach lymph node first subscapsular sinus lymph
node cortex contains plenty of lymph follicles.
• Matting is due to periadenitis
• Adenoids-posterior triangle lymph nodes are involved –
retropharyngeal lymphatics.
• Fibrosis and calcification can occur

47. Tuberculous lymphadenitis
• Gross: firm,matted,lymph node with cut section showing yellowish caseating
material.
• M/S: Epitheliod cells with caseating material are seen along with langhans
type of giant cells.
• Types ; Acute type: infants & childhood below 5 yrs
• Hyperplastic type: lymphoid hyperplasia , lymph nodes-hard & mobile.
• Caseating type: matted nodes with cold abscess, young adults
• Atrophic type: small lymph nodes but caseating type with atrophied nodes,

48. Tuberculous lymphadenitis
• STAGES

49. Tuberculous lymphadenitis
• CLINICAL FEATURES:
• Swelling-firm & matted
• Cold abscess –soft,smooth,nontender,fluctuant.(skin is free)
• Contains cheesy caseating material.
• Increase in pressure-cold abscess ruptures out of deep fascia –collar
stud abscess(adherent to skin)-bursts open –discharging
sinus.(multiple, wide open mouth ,undermined, nonmobile with
bluish colour around the edges.

50. Tuberculous lymphadenitis
• 20% of Tb lymphadenitis is associated with pulmonary tuberculosis.
• Bluish hyperpigmented involved overlying skin is called as
scrofuloderma.
• Sinus may persist due to fibrosis,calcification,secondary infection,
inadequate reach of drug to maintain optimum concentration in
caseation.

51. Tuberculous lymphadenitis
• INVESTIGATIONS:
• Hematocrit, ESR, peripheral smear.
• USG NECK-nodal size,matting,cold abscess, number of nodes
• Doppler usg –hilar vascularity
• FNAC of lymph node and smear for AFB and culture. Epitheliod cells
are diagnostic. Langhans giant cells, lymphocytes, plasma cells.
• Lowenstein-Jensen media is used for culture (6weeks)
• Selenite medium –growth in 5days.

52. Tuberculous lymphadenitis
• TREATMENT
• Antitubercular drugs
• Rifampicin 450mg OD on empty stomach, bactericidal & hepatotoxic.
• INH 300mg OD ,bactericidal, intolerance of GIT, Neuritis ,Hepatitis.
• Ethambutol 800mg OD, bacteriostatic , causes GIT intolerance,
retrobulbar neuritis
• Pyrazinamide 1500mg OD (750mg BD) ,bactericidal, hepatotoxic
,hyperuricemia and increased psychosis.
• Duration -6 to 9 months.

53. Tuberculous lymphadenitis
• TREATMENT
• Aspiration of the cold abscess with wide bore needle in
nondependent site along a ‘’z” track to prevent sinus formation.
• Drainage is done through nondependent incision ;later closure of the
wound without drain.
• Surgical removal of tuberculous lymph node-no response to drugs &
sinus persists.

54. RENAL TUBERCULOSIS
• Commonly secondary
• Primary may be in lung

55. Renal tuberculosis
• PATHOLOGICAL TYPES
• Caseating granuloma coalesce to form a papillary ulcer and other
consecutive different forms:
• Tuberculous papillary ulcer
• Cavernous form
• Hydronephrosis
• Pyonephrosis
• Tuberculous perinephric abscess
• Calcified tuberculous area(pseudo calculi)

56. Renal tuberculosis
• Caseous kidney-putty kidney or cement kidney
• Miliary tuberculosis
• Tuberculous bacilluria occurs with early lesions in renal cortex-
spreads along ureter causing tuberculous ureteritis and stricture
ureter.
• Most common site is ureterovesical junction>pelviureteric junction.

57. Renal Tuberculosis
• Tuberculous cystitis –golf hole ureter(fibrosis causing rigid withdrawn
dilated ureteric orifice) and thimble bladder(entire bladder gets
fibrosed, stiff and unable to dilate and accommodate urine).
• Associated with Tuberculous prostatitis, seminal vesiculitis ,
tuberculous epididymitis and funiculitis.
• Thickened epididymis with ulcer on the posterior aspect of the
scrotum.

58. Renal tuberculosis
• CLINICAL FEATURES
• Males
• Right side
• Frequency both day and night;polyuria.
• Sterile pyuria:pale,puscells without organisms in acid urine-
Abacterial aciduria
• Painful micturition with hematuria
• Fever
• Weight loss

59. Renal Tuberculosis
• INVESTIGATIONS
• Reduced Hb, increased ESR
• Chest Xray, USG abdomen
• Three consecutive early morning samples of urine(EMSU) are
collected and sent for microscopy.
• Plain Xray KUB-calcification
• CT SCAN of abdomen and pelvis to see hydronephrosis,shrunken
kidney, stricture,necrosis.

60. Renal Tuberculosis
• INVESTIGATIONS
• IVU-hydrocalyx , narrowing of calyx, stricture ureter (multiple with
dilatations in between.
• Cystoscopy –multiple tubercles, bladder spasm, oedema of ureteric
orifice forming “Golf hole ureter”,scarring, ulceration ,bleeding ,
stone formation.
• Voiding cystourethrography- Ureteric stricture and reflux.

61. Renal Tuberculosis
• TREATMENT
• Antitubercular therapy is started. Duration-1year.
• After 6-12 weeks of drug therapy, surgical treatment is planned.
• Hanley’s renal cavernostomy-kidney is exposed, pyocalyx is drained,
cut edge of the capsule is sutured.
• Hydronephrosis-Anderson hynes operation
• Renal tuberculous abscess not resolving for 2 weeks should be
drained.

62. Renal tuberculosis
• TREATMENT
• Ureteral stricture-stenting/ reimplantation of the ureter into
bladder/Boari’s flap/ileal conduit
• Thimble bladder-hydraulic dilatation/ileocystoplasty/ caeco
cystoplasty/ sigmoid colocystoplasty is done.
• In U/L lesion with gross impairement of renal function-
Nephroureterectomy .

63. Tuberculous Epididymitis
• Commonly due to retrograde spread from tuberculous cystitis
• It involves globus minor first-later entire epididymis-testis in later
stage.
• Blood spread from lungs involves the globus major first.
• Thickened ,craggy,firm nodular epididymis is common
• Cold abscess or sinus or undermined ulcer may be present on the
posterior aspect of the scrotum.
• Lesion will be present on the anterior aspect in anteverted testis.

64. Tuberculous Epididymitis
• Scrotal skin loses its normal rugosity with wasting of the tissue under
the skin.
• Restricted mobility of the testis.
• Thickened beaded vas( due to tubercles)
• Secondary hydrocele in 30% cases ,60% will be having renal
tuberculosis.
• P/R:tender,thickened ,palpable seminal vesicles and irregular
prostate.

65. Tuberculous Dactylitis
• Refers to phalangeal tuberculosis
• It is called as spina Ventosa,because of its appearance as “air filled
balloon”