Tuberculosis of GIT,role of imaging and its radiological features

1. Tuberculosis of GIT
Dr Parvathy S Nair

2. Introduction
• TB can involve any part of GIT from mouth to
anus, peritoneum & pancreatobiliary system.
• TB of GIT- 6th most frequent extrapulmonary site.

3. • Mycobacterium tuberculosis is the pathogen in
most cases.
• Mycobacterium bovis in some parts of the world
• Mycobacterium avium intracellulare has become
a major pathogen in HIV patients.

4. Etiopathogenesis
• Mechanisms by which M. tuberculosis reach the
GIT:
– Hematogenous spread from primary lung focus
– Ingestion of bacilli in sputum from active
pulmonary focus.
– Direct spread from adjacent organs.
– Via lymph channels from infected LN

5. PATHOGENESIS

6. Bacilli in the depth of mucosal
glands
Inflammatory Reaction
Phagocytes carry bacilli to Peyer’s
Patches
Formation of tubercle and necrosis
Endarteritis,edema and sloughing

7. Ulcer formation
Accumulation of collagenThickening and stenosis
Inflammation spreads from
submucosa to serosa
Bacilli via lymphatics – Lympahtic
obstruction and Regional
Lymphadenitis

8. Pathology
• (A) Ulcerative form: Ulcers wit their long axis
perpendicular to the axis of the intestines;
with pseudopolyps
• (B) Hypertrophic form: Thickeningof bowel
wall
• (C) Mixed type

9. Distribution of tuberculous lesions
Ileum > caecum > ascending colon > jejunum
>appendix > sigmoid > rectum > duodenum
> stomach > oesophagus
• More than one site may be involved

10. Illeoceacal TB (80-90%)
PLAIN XRAY
• Enteroliths with features of obstruction
• Small or large lamellated stones

11. BARIUM ENEMA
• Irregular thickened nodular folds in the
terminal illeum
• ‘Stierlin sign’: on Ba enema -rapid emptying of
narrowed terminal illeum into the cecum
which is shortened and rigid
• Thickened illeoceacal valve

12. • ‘Fleischner sign’: Inverted umbrella defect:wide gaping patulous IC valve associated with
narrowing of the immediately adjacent
terminal illeum
• Deep fissures and large shallow linear/stellate
ulcers with elevated margins
• Sinus tracts and fistulas
• Symmetric annular ‘napkin ring ‘ stenosis

13. Enema shows wide gaping of ileocecal valve
with thickening of valve

14. Contrast barium enema
image demonstrates
marked narrowing of the
caecum, ascending colon
and terminal ileum.
Dilatation of the small
intestine proximal to the
narrowed segment of
ileum is also seen.

16. CT
• Circumferential wall thickening of cecum and
terminal ileum
• Asymmetric thickening of ileoceacal valve and
medial wall of ceacum
• Localized mesenteric lymphadenopathy with
areas of central low attenuation

18. USG
• Thickening of IC valve and adjacent medial wall
of cecum- asymmetrically thickened.
• Crohn’s – Eccentric thickening in mesenteric
border.
• Carcinoma- Variegated appearance.
• Pseudokidney mass.
• Advanced cases – Complex mass - wall
thickening, adherent loops, regional
nodes, mesenteric thickening.

21. Colonic TB (9%)
• Segmental colonic involvement-rt sided
• Imaging:
– Rigid,contracted cone shaped ceacum
– Spiculations with wall thickening
– Diffuse ulcerative colitis and pseudopolyps
– Short hour glass strictures
– Ulcer- Circumferential in TB, along the
mesenteric border in Crohn’s.

23. Gastroduodenal TB (1%)
• Simultaneous involvement of antrum,pylorus
and duodenum
• Imaging:– Stenotic pylorus with GOO
– Narrowed antrum –linitis plastica appaearance
– Antral sinus tracts/fistula
– Multiple, large and deep ulcerations on the lesser
curvature
– Thickened duodenal folds wit irregular contour

25. TB of esophagus(0.2%)
•
•
•
•
More assc with HIV
Deep ulceration-mid esophageal
Strictures
Intramural dissection/fistula formation

26. Peritoneal tuberculosis occurs in 3 forms.
• Wet type – 90 %. - Ascitis, free or encysted fluid
High density 25-45HU.- Cellular / fibrin content.
• Fibrotic fixed type – Mescentric and omental
thickening, matted lymph nodes with occasional fluid.
• Dry or plastic type – Caseous nodules, fibrotic peritoneal
reflections.

27. Imaging
• Omental cake.
- Irregular thickened outer contour- Malignancy.
-Thin omental line, fibrous wall –TB
- Extra peritoneal spread-TB
• Mesentery- Stellate sign- Mesentric
contraction results in fixed loops of bowel and
mesentery standing out as spokes from the
root.
• Club sandwich sign – localised ascites in
between the radially oriented bowel loops.

28. Omental cake and ascites

30. THANKYOU