abdominal TB

1. ABDOMINAL TUBERCULOSIS
DR SASIDHAR
Post graduate
Department of pediatric surgery

2. HEADINGS
ABDOMINAL
TUBERCULOSIS
DEFINITION1
• The term abdominal
tuberculosis refers to
tuberculous infection of the
gastrointestinal tract,
mesenteric lymph nodes,
peritoneum and omentum,
and of solid organs related to
the gastrointestinal tract
such as the liver, spleen and
pancreas .
Definition
history
Agent
Epidemiology
Routes of transmission
Pathology and Pathogenesis
Classification of abdominal TB
Individual types
Investigations
management
Note on HIV and tuberculosis

3. History1
• Tuberculosis was first recognized in the fourth
century BC
• Hippocrates described a condition resembling
tuberculosis in a patient with pulmonary
lesions and intestinal disease.
• major cause of intestinal strictures and bowel
obstruction In the nineteenth century and the
early part of twentieth century,

4. 1882 - identification of the causative organism,
Mycobacterium tuberculosis, by Robert Koch
Koch’s Postulates
1998 - the complete genetic sequence of M.
tuberculosis was identified.

5. Bacterial agent1, 2
• Mycobacterium tuberculosis (90%), M. bovis (largely eliminated )
• The tubercle bacillus is a Gram-positive, aerobic, non-motile, non-
spore-bearing organism that is identified by the Ziehl–Neelson acid-
fast differential staining method (high content of mycolic acids in
the cell wall)
• Culture of the organism is Löwenstein–Jensen medium, which
requires an incubation period of 4 to 6 weeks.
• Liquid culture medium, may provide faster results and is more
sensitive.
• The virulence of M. tuberculosis is established by guinea-pig
inoculation.

6. Mycobacterium tuberculosis:
Ziehl-Neelsen stain
Lowenstein-Jensen Medium.

7. Epidemiology
• It is common in India and developing countries, more frequently in
people of poor socioeconomic circumstances.
• It is the 6th most common type of extrapulmonary tuberculosis
following lymph nodes, pleura, genitourinary tract, bones and
joints, meninges2.
• Its incidence is high in HIV infected patients
• 24th March - World Tb day3.
• TB declared as notifiable disease by INDIAN GOVERNMENT on may
9th 2012

9. Routes of transmission
• 6 Routes.
1. Ingestion of contaminated food may cause primary intestinal tuberculosis.
2. Hematogenous spread- during the bacteraemic phase that may follow primary
pulmonary tuberculosis
3. swallowed sputum containing tuberculous bacilli
4. spread from adjacent organs or Retrograde spread from female genital
tuberculosis.
5. Through lymph channels from infected nodes.
6. disseminated in the bile, since they are sequestrated and excreted from
granulomas in the liver.

10. Pathology and pathogenesis
• Abdominal tuberculosis is either primary or
secondary.
• Primary abdominal tunerculosis results from the
ingestion of the milk or food infected with
M.bovis.
• Secondary abdominal tuberculosis is caused by
M.tuberculosis and is due to the other routes
described.

11. Pathogenesis of M. tuberculosis

12. Pathogenesis
Bacilli in depth of mucosal glands  Inflammatory reaction 
Phagocytes carry bacilli to Peyer’s Patches  Formation of tubercle
Submucosal tubercles enlarge  undergo necrosis  Endarteritis &
edema  Sloughing  Ulcer formation  Accumulation of collagenous
tissue Thickening & Stenosis
Inflammatory process in submucosa penetrates to serosa Tubercles on
serosal surface  Bacilli reach lymphatics
•Lymphatic obstruction of
mesentery and bowel
•Thick fixed mass
•Regional lymph nodes
•Hyperplasia
•Caseation necrosis
•Calcification

13. Types4
1. Intestinal
– Ileocaecal region
 Ulcerative—60%.
 Hyperplastic.
 Ulcero-hyperplastic.
– Ileal region, commonly:
 Stricture type.
2. Peritoneal tuberculosis
• a. Acute.
• b. Chronic.
– i. Ascitic type.
– ii. Encysted (loculated) type.
– iii. Plastic (fi brous/adhesive) type.
– iv. Purulent type.
3. Tuberculosis of mesentery and its
lymph nodes
4. Ano-recto-sigmoidal—present as
fistula, fissure, abscess, mass.
5. Involvement of liver, spleen and
other organs as a part of miliary
tuberculosis.
6. Tuberculosis of the omentum.
7. Rare types:
– Oesophageal (0.2% of abdominal
tuberculosis)
– gastroduodenal (1% of abdominal
tuberculosis)
– retroperitoneal tuberculosis.
Intestinal tuberculosis is called as
Konig’s syndrome (1892)5.

14. Types

15. ILEOCAECAL TUBERCULOSIS
• Most common site of abdominal tuberculosis
• due to:
– Stasis
– Abundant payer’s patches
– Alkaline media
– Bacterial contact time is more
– Minimal digestive activity
– Maximum absorption in the area
• Types
 Ulcerative—60%.
 Hyperplastic.
 Ulcero-hyperplastic.

16. Ileocaecal tuberculosis with rolled up omentum. Note the sites and
tubercles in ileocaecal valve, which will be incompetent due to fibrosis.

17. Ileocaecal tuberculosis. (A) Note the multiple transverse
undermined ulcers.
(B) Note the ileocaecal tuberculosis with stricture.
A B

18. Types
A. Ulcerative—
• most common 60%.
• Circumferential transverse ulcers—with skip lesions.
• common in old, malnourished people.
• Long-standing ulcers cause fibrosis and later stricture formation.
(Napkin ring stricture-- is common in ileal part).
• Bowel adhesions are common.
• Patient mainly presents with diarrhea, blood in stool, loss of appetite and
reduced weight.

19. B. Hyper plastic ----
• 10% common, less virulent, seen in young well nourished individuals
• Fibroblast reaction in submucosa and subserosa causes thickening of bowel wall
and lymph node enlargement, leading to nodular mass (tumor-like) formation.
• It is common in caecal part.
• It causes extensive chronic inflammation, fibrosis, bowel adhesions, nodal
enlargement, often presents with mass in the right iliac fossa.
• When present as a mass, it can cause sub acute intestinal obstruction.
• Commonly primary form.

20. Differences between ulcerative and
hyperplasic types
• ULCERATIVE (60%)
1.Secondary to pulmonary
tuberculosis
2. Virulent organism
3. Poor body resistance, old people
4. Multiple transverse ulcers
commonly in the ileum, often in
the caecum
5. Clinically presents with diarrhoea,
bleeding P/R, loss of appetite and
reduced weight
6. Complications: Stricture, intestinal
obstruction
7. Chest X-ray shows primary lesion.
8. Barium study shows ileal strictures
with hypermotility
• HYPERPLASTIC (10%)
1. Primary GIT tuberculosis, could be
due to bovine bacilli
2. Less virulent organism
3. Good body resistance, young
individual
4. Chronic granulomatous lesion in
the ileocaecal region
5. Presents as a mass in right iliac
fossa
6. Complication: Subacute intestinal
obstruction
7. No primary lesion in chest X-ray
8. Barium study—pulled-up caecum,
obtuse ileocaecal angle

21. Ileocaecal and mesenteric tuberculosis.
Ileocaecal tuberculosis or tuberculous
mesenteric lymphadenitis presenting as mass
in the right iliac fossa

22. ILEAL TUBERCULOSIS
• It is usually stricture type.
• It may be multiple.
• It presents usually with intestinal obstruction.
• Bowel adhesion, localisation, fibrosis,
secondary infections are quiet common.
• Perforation (5%) though rare may lead to
peritonitis.

23. PERITONEAL TUBERCULOSIS
Pathology in Peritoneal Tuberculosis
Enormous thickening of the parietal
peritoneum with multiple tiny yellowish
tubercles.
 Dense adhesions in peritoneum and
omentum with content inside as small
bowel looking like abdominal cocoon. It
may precipitate intestinal obstruction.
 Multiple dense adhesions between
bowel loops and between bowel and
peritoneum and omentum

24. A
B
C
A to C: On-table findings in intestinal
tuberculosis, of extensive involvement with
multiple tiny tubercles, thickening,
adhesions and involvement of mesenteric
lymph nodes.

25. PERITONEAL TUBERCULOSIS
• a. Acute.
• b. Chronic.
– i. Ascitic type.
– ii. Encysted (loculated) type.
– iii. Plastic (fibrous/adhesive) type.
– iv. Purulent type.

26. Acute type
• Mimics Acute Abdomen
• It is an on-table diagnosis
• Presents with features of peritonitis.
• It is due to perforation or rupture of
mesenteric tuberculous lymph nodes

27. Chronic type
– Types
a) Ascitic form
b) Encysted form
c) Plastic form
d) Purulent form

28. Ascitic form
distension of abdomen with dilated veins +.
presents with hydrocele in male with patent processus vaginalis, umbilical hernia,
shifting dullness, fluid thrill
Ascitic tap reveals straw coloured fluid from which AFB can be isolated. Fluid is
pale yellow, clear, rich in lymphocytes, with high specific gravity.

29. Encysted (Loculated) ascites
• Ascites gets loculated because of the fibrinous
deposition.
• Dullness, which is not shifting, is the typical
feature.
• They may present as intra-abdominal mass,
which may mimic ovarian cyst, retroperitoneal
cyst or mesenteric cyst.

30. Plastic type
wide spread adhesions
c/o recurrent colicky abdominal pain, diarrhoea, wasting, and loss of weight, mass
abdomen, and doughy abdomen
Differential diagnosis: Peritoneal carcinomatosis

31. Purulent form
• It is invariably due to tuberculous salpingitis
• presents as a mass in the lower abdomen
containing pus, omentum, fallopian tubes,
small and large bowel.
• Cold abscess gets adherent to the abdominal
wall, umbilicus and may form an umbilical
fistula.
• Patient commonly has got genitourinary
tuberculosis

32. TUBERCULOUS MESENTERIC
LYMPHADENITIS
• Infection is usually through the Peyer‘s patches
• Commonly right-sided lymph nodes are involved
• presents with general symptoms, Pain in umbilical
region and right iliac fossa, mass in right iliac fossa, or
features of acute appendicitis.
• Often coils of intestine get adherent to the caseated
mesenteric lymph nodes leading to intestinal
obstruction.

33. caseating material may collect between the layers of the mesentery, forming
a cold abscess -- Pseudomesenteric cyst
Massive enlargement of mesenteric lymph nodes due to tuberculosis is called as
tabes mesenterica.
more common in children, Present with anaemia, fever, loss of appetite and
reduced weight, failure to thrive, palpable mass in right iliac fossa which is firm
and nodular.

34. Differential Diagnosis
• Carcinoma caecum.
• Lymphoma.
• Retroperitoneal tumour.
• Nonspecific lymphadenitis.
(Acute nonspecific mesenteric lymphadenitis is called as nurses’ syndrome).

35. ANO-RECTO-SIGMOIDAL
TUBERCULOSIS
• It mimics carcinoma rectum.
• It presents as tenesmus, diarrhoea, and discharge
from the fistula and occasionally as mass per abdomen.
• Rectal tuberculosis occurs usually within 10 cm of anal
verge.
• Fistulas are painful and characteristically not
indurated.
• Tuberculous fistulas are commonly multiple.
• Tuberculous anal ulcers when occur are shallow,
bluish, with undermined edges.

36. TUBERCULOSIS OF THE OMENTUM
• It usually occurs as a part of the other types of
abdominal tuberculosis.
• Rolled up omentum with thickening is
characteristic.
• Often cold abscess can develop -- can be dealt
with laparoscopy safely under the cover of ATDs.
• In all abdominal tuberculosis, drug treatment is
for one year
• In adrenal tuberculosis and severe adhesions
steroids may be beneficial.

37. Omental tuberculosis showing tubercles

38. Different clinical presentations of
abdominal tuberculosis
• Clinical presentation may be:
– Acute
– Acute on chronic
– Chronic
• Common in 25-50 years age group. Equal in both
sexes.
• Constitutional symptoms:
– Anaemia, loss of weight and appetite (80%).
– Diarrhoea—10-20%.
– Fever—50-70%.
– Over all Observed in 30% of patients

39. • Abdominal pain -most common symptom
(90%), dull in mesenteric type; colicky in
intestinal type
• Mass in right iliac fossa, (35%) which is hard,
nodular,nonmobile, nontender with impaired
resonance ---may mimic carcinoma caecum.
• can be associated with adenocarcinoma of
caecum, or large bowel lymphoma or HIV.

40. Types:
• Ulcerative—diarrhoea and malabsorption
• Stricture—subacute or acute intestinal obstruction
• Hyperplastic—mass abdomen (RIF) and obstruction
• Ascites—generalised distension of abdomen
• Localised -- intra-abdominal mass, which may mimic ovarian cyst,
retroperitoneal cyst or mesenteric cyst.
• Peritoneal—abdominal cocoon; vague abdominal pain,
• parietal peritoneal thickening as doughy abdomen; mass abdomen
• Mesenteric—tabes mesenterica, obstruction, mass
• Associated tuberculosis of other organs is seen in 30% of cases

41. Atypical presentations:
• Lower GI bleed, fistula-in-ano, PID like pain,
gastric disease symptoms, dysphagia, GI
fistulae, perforation

42. Investigations
1. Chest Xray – for primary focus
2. Blood investgations: Mantoux, ELISA,
serum IgG
3. ESR- raised
4. Plain X-ray abdomen
I. Intestinal obstruction
II. Calcified lymph nodes
III. Hollow viscous perforation
IV. Calcified Granuloma in liver

43. Barium study X-ray (Enteroclysis followed by barium enema or
barium meal follow through X-ray) (efficacy—75%)
 Pulled up caecum, conical caecum, pulled down hepatic flexure,
 Obtuse ileocaecal angle
 Steirlin sign --Hurrying of barium due to rapid flow and lack of
barium in inflamed segment due to Incompetent ileocaecal valve,
ileocaecal spasm
 Napkin lesions --Ulcers and strictures in the terminal ileum and
caecum
 Earliest signs are—increased transit time; hyper segmentation
(chicken intestine); flocculation of barium
 Other signs are—persistent narrow stream (string sign); multiple
strictures with enormous dilatation of proximal ileum (mega ileum);
straightening of ileocaecal junction with ‘goose neck’ deformity.

44. Pulled-up caecum, obtuse
ileocaecal angle—
ileocaecal tuberculosis
multiple strictures with enormous dilatation of
proximal ileum (mega ileum);

45.  Fleischner sign or Inverted umbrella sign --
Narrow ileum with thickened ileocaecal valve
string sign-- persistent narrow stream

46. hyper
segmentation-
chicken intestine

47. Ultrasound features observed in abdominal tuberculosis
• Thickened bowel wall, mesentery, omentum, peritoneum
• Loculated ascites with fine septae
• Interloop ascites with alternate echogenic and echofree areas— Club-
sandwich appearance
• Bowel loop radiates from its mesenteric root—stellate sign
• Mesenteric thickness more than 15 mm
• Hepatosplenomegaly
• Lymph nodal enlargement matted
• Pulled up caecum presenting with a mass in subhepatic region—
“pseudokidney sign”( also seen in intussuception)
• Concentric uniform mural thickening
Club-sandwich appearance

48. CT scan in abdominal tuberculosis
It is very useful and reliable investigation
It is done with oral contrast- CT enteroclysis
Findings are:
– Thickened bowel wall, thickened peritoneum
– Ileocaecal valve thickening
– Enlarged/necrosed/matted mesenteric nodes
often with cold abscess
– Adhesions
– Mesenteric thickening and nodules
– Nodules in the peritoneum/solid organs like
liver
– Adhesions in the bowel/stricture/dilatations
of the bowel/ features of obstruction
– Loculated ascites
CT guided FNAC/biopsy/aspiration of fl uid can
be done

49. Colonoscopy
•To rule out carcinoma
•Shows mucosal nodules, ulcers,
strictures, deformed ileocaecal valve,
mucosal oedema and diffuse colitis
•Biopsy can be taken to eslablish the
diagnosis
Capsule endoscopy is also useful to see small
intestinal (tuberculous) pathology in difficult
cases. Can cause obstrction at stricture site.

50. Laparoscopy
•aids in direct visualisation,
•to collect ascitic fluid for analysis
•to take biopsy
Blind percutaneous needle peritoneal biopsy using Cope’s/ Abraham’s needle is
also practiced.
Ascitic tap fluid analysis
Bactec MGIT broth culture

51. Recent serological investigations are
• Interferon-γ Release Assays -- IGRAs Based on the detection
of IFN-γ - Released by sensitized T cells on stimulation with
very specific Ags .
– T-Spot TB test - Directly count the number of IFN-γ- secreting T
cells
– Quantiferon TB Gold In-Tube test - Measures the concentration
of IFN-γ secretion
• Early secretory antigen target-6 (ESAT 6) & Culture filtrate
protein-10 (CFP 10)
– Both derived from a very specific region of MTb, the region of
difference 1 (RD1). This segment (RD1) is deleted from all strains
of BCG and the majority of environmental mycobacteria.
– Advantage - Discriminate between MTB infection and previous
use of BCG vaccine.

52. • polymerase chain reaction (PCR) -- molecular tests for detection of nucleic
acids
• Nucleic acid amplification assays –
– assays amplify M. tuberculosis-specific nucleic acid sequences using a nucleic
acid probe
– major limitation of NAA tests is that they give no drug-susceptibility
information.
– Require as few as IO bacilli from a given sample
– specificity in the range of 98% to 99%.
– various types
• AMPLICOR M. TUBERCULOSIS assay
• Amplified M.tuberculosis Direct (AMTD2) assay
• LCx MTB assay, ABBOTT LCx probe system
• BD ProbeTec energy transfer (ET) system (DTB)
• INNO-LiPA RIF.TB assay
• 16S rRNA gene sequence analysis

53. Ascitic fluid in abdominal tuberculosis
• Exudate with protein level > 2.5 g/dl
• Serum-ascitic fluid albumin gradient is < 1.1
• Lymphocyte predominant cells with count as high as 4000/mm3
>250/cumm
• AFB in ascitic fluid is seen only < 3% cases
• ADA (Adenosine deaminase activity) in ascitic fluid (95% specificity and
98% sensitivity)
• Specific gravity >1.016
• Glucose < 30 mg
• Decreased pH
• LDH more than 90 units/litre

54. Complications of abdominal
tuberculosis
• Obstruction—20%
• Malabsorption, blind loop syndrome
• Dissemination of tuberculosis to other areas
of abdomen as well as extra-abdominal sites
• Faecal fistula
• Cold abscess formation
• Haemorrhage, perforation (rare)

55. treatment
• Medical
– first line of management
– Anti tuberculous therapy (ATT)
• surgical

56. Medical management2
DRUG DOSAGE
(mg/kg)
ADVERSE EFFECTS
ISONIAZID 5 PERIPHERAL NEURITIS, hepatitis, fever,
rashes, acne.
RIFAMPACIN 10 HEPATITIS, orange urine, skin rashes, ‘flu
syndrome’, purpura
ETHAMBUTOL 15 OPTIC NEURITIS,hyperurecemia
PYRAZINAMIDE 25 Hepatotoxicity, hyperurecemia, arthralgia,
rashes.
STREPTOMYCIN 15 OTOTOXICITY, NEPHROTOXICITY
-WHO recommends 6-9 months course
-Commonly patient presents with complications and late presentations are also
common in many. So, more often treatment for one year may be required in these
patients.

57. SECOND LINE DRUGS
Amikacin
 Kanamycin
 Paraaminosalicylic acid
 Ciprofloxacin
 Ofloxacin
 levofloxacin
 Clarithromycin
 Azithromycin
 Rifabutin
In drug resistance cases second line drugs are needed.
Directly observed therapy (DOT-S)
If facilities for directly observed therapy are available, initial treatment is the same
as in short-term therapy

58. Indications for steroids in tuberculosis
• Miliary tuberculosis
• Tuberculous meningitis
• Adrenal tuberculosis
• Tuberculous pericarditis
• Pleural and endobronchial tuberculosis
• In abdominal tuberculosis to prevent adhesions
• Tuberculosis of the mediastinal lymph nodes (Rapidly
• progressive)
• Genitourinary tuberculosis
• Ocular tuberculosis

59. Surgical management
• Indications are
Intestinal obstruction
Severe haemorrhage.
 Acute abdominal presentation like perforation.
 Intra-abdominal abscess formation or fistula formation.
 Uncertain diagnosis.

60. Surgical Management
1. Ileocaecal resection with 5 cm margin
2. Stricturoplasty- single stricture

61. 3. Single strictutre with friable bowel or Multiple Strictures or stricture within 10
cm of ileocaecal valve : Resection and anastomosis
4. Multiple strictures with long segment gaps: Multiple stricturoplasty
5. If Perforation - resection and anastomosis is done, In severely contaminated
peritoneum, resection and exteriorisation is done. Bowel continuity is maintained
after proper antituberculous chemotherapy and proper nutritional improvement.
6. During therapy, if patient develops ileocaecal obstruction, ileotransverse colon
anastomosis (bypass) can be done.
7. Adhesive obstruction may be released through laparoscopic adhesiolysis.
8. Drainage of intra-abdominal abscess, perianal abscess and treatment for
tuberculous fistula-in-ano is done when necessary.

62. Exploratory laparotomy --reveals straw-coloured fluid with tubercles in
the peritoneum, greater omentum and bowel wall.
Fluid is evacuated and collected for AFB study and culture.
Omental biopsy is taken.
Abdomen is closed (without a drain) with tension sutures to prevent
burst abdomen and ATD is started.
Management of acute type of peritoneal tuberculosis include:

63. 9. Treatment of loculated form of peritoneal tuberculosis is U/S guided
aspiration or laparoscopic aspiration along with ATD‘s.
Laparoscopic picture of loculated ascites due to abdominal tuberculosis. Fluid is
getting aspirated using a needle under laparoscopic vision.
Straw coloured ascitic fluid

64. Treatment of purulent form of peritoneal tuberculosis is ATD, exploration of
umbilicus, exploration of fistula and bowel by pass is done. Prognosis is poor in this
type.
ANO-RECTO-SIGMOIDAL TUBERCULOSIS : Treatment is ATD‘s, fistulectomy, often sigmoid
resection.

65. Rarer types of GI tuberculosis

66. TB- Oesophagus (0.2%)
Mimics oesophageal carcinoma
Mid oesophageal ulcer, dysphagia and
odynophagia, Low grade fever
Pathology: Extension from nearby tubercular
lymph nodes into esophagus.
Barium Swallow
•Patient with mediastinal lymphadenopathies
that produced a fistula demonstrated by
endoscopy.
•Extensive esofageal ulceration (black arrows).
• Extrinsic compression due to
lymphadenopathies is appraised
(white arrow).

67. TB- Gastroduodenum
• occurring in 0.3 to 2.3 per cent of patients with pulmonary
tuberculosis.
• Uncommon
– Acidic environment
– Rapid gastric emptying
– Paucity of Peyer’s patches in stomach.
• Gastric TB- May mimic Peptic ulcer not relieving to anti-secretory
therapy or gastric carcinoma, or gastric sarcoidosis. Similar
appearances are also seen in syphilis of the stomach.
• Tuberculosis of the stomach presents as an ulcerative,
granulomatous, or fibrosing lesion. the last two types may result in
gastric-outlet obstruction.
• Duodenal TB- Obstruction due to extrinsic compression by lymph
nodes.

68. Other presentations:
– Perforation
– Fistula
– Ulcer excavation into pancreas
– Obstructive jaundice due to CBD compression
• Antituberculous chemotherapy should be initiated in
all patients; this is curative in most, especially those
with ulcerative lesions.
• Surgical intervention is required if gastric-outlet
obstruction persists despite treatment.
• usual surgical approach is a partial gastric resection
such as a Billroth gastrectomy or a sleeve resection.

69. Jejunal TB
• Presents with
– Single or multiple strictures
– Intestinal obstruction
– Perforation (proximal to the stricture)

70. Segmental Colonic TB (9.2%)
• It is involvement of colon without ileocaecal
region.
• Involves sigmoid, ascending and transverse
colon.
• Pain and hematochezia is common.

71. Appendiceal
• Tuberculosis of the appendix is reported in 0.1
to 3 per cent of patients with tuberculosis.
• Isolated tuberculosis of the appendix is rare.
• Appendectomy followed by antituberculosis
chemotherapy is the treatment of choice.

72. TUBERCULOSIS OF SOLID ABDOMINAL
ORGANS
Hepatic tuberculosis
– exceedingly rare these days
– diagnosis is usually made accidentally during exploratory laparotomy
or at autopsy
– lesions typically are granulomas, with or without central caseating
necrosis,calcified masses, and biliary strictures
– Tuberculous periportal lymph nodes may cause obstructive jaundice
by compressing the bile duct
– usually have hepatomegaly, with or without jaundice
– Liver enzymes, in particular serum alkaline phosphatase, are usually
elevated
• differentiated from other conditions associated with hepatic
granulomas such as leprosy, sarcoidosis,Hodgkin disease,
brucellosis, infectious mononucleosis, inflammatory bowel disease,
drug-induced liver damage, and syphilis

73. • treatment of hepatic tuberculosis is chemotherapy
It should be remembered that most
antituberculous drugs (except ethambutol) are
hepatotoxic, and may aggravate the liver
damage and worsen the jaundice.
These patients therefore should be kept under
close observation during antituberculous
chemotherapy.

74. Splenic tuberculosis
rare and may present as a splenic abscess or with hypersplenism
presence of multiple hypoechoic lesions on ultrasonography of the
spleen in a HIV-positive patient is highly suggestive of disseminated
tuberculosis.
The diagnosis is usually made following surgical resection of the
diseased spleen.

75. Tuberculosis of pancreas:
Like or part of miliary tuberculosis
Common in immunocompromised
Usually presents as acute or chronic pancreatitis
Pancreatic mass or abscess may develop
Can mimic malignancy

76. HIV & TUBERCULOSIS
• Progresses faster
• Fatal – Left untreated
• TB occurs earlier in the course of HIV
• TB is the only major AIDS-related
opportunistic infection that poses a risk to
HIV-negative people

77. • The most common cause of death in patients with
AIDS.
• Accelerate the clinical course of HIV infection.
• Atypical radiographic manifestations.
• More frequent extrapulmonary involvement
• Multi drug resistant

78. Thank you

79. References
1. Oxford Textbook of Surgery 2nd ed.
2. Harrisons priciples of internal medicine, 18th edition
3. https://en.wikipedia.org/wiki/World_Tuberculosis_Day
4. SRB's Manual of Surgery 4th edition
5. https://en.wikipedia.org/wiki/K%C3%B6nig%27s_syndrome