this presentation includes the various forms of abdominal tuberculosis, diagnostic approach and management options

1. ABDOMINAL
TUBERCULOSIS
16th July 2018 Presented by :
Ankit Lalchandani
Moderated by :
Dr Bharati Pandya

2. Mode Of Involvement:
• By Ingestion
Infected food or milk- primary intestinal
tuberculosis
Infected Sputum- Secondary Intestinal Tuberculosis
• Hematogenous spread from distant foci
• Contagious spread from infected adjacent foci
• Through lymphatics

3. Classification:
• Tubercular Lymphadenopathy
• Peritoneal tuberculosis
Acute
Chronic
Wet Ascitic
Fixed fibrotic
Dry Plastic
Encysted/Loculated
• Visceral tuberculosis
• Gastrointestinal tuberculosis

4. PERITONEAL TUBERCULOSIS

5. • 4-10% of Extrapulmonary TB
• Usually post primary
• Symptoms :
1. abdominal pain
2. low grade fever
3. ascites
4. loss of appetite and weight
5. doughy abdomen
May present with symptoms of acute intestinal obstruction

6. • Gross pathology :
1. Thickening of parietal peritoneum
2. Multiple tiny tubercles
3. Dense adhesions in peritoneum and omentum with
small intestine
Wet ascitic type –
large amount of free fluid in abdomen
enormous abdominal distention
Fixed fibrotic type –
Thickening of omentum and mesentry
Matted bowel loops on imaging

7. Dry plastic type –
fibrous peritoneal reaction
peritoneal nodules and adhesions
can present with intestinal obstruction
Encysted /loculated -
exudation with minimal fibrosis,
absence of shifting dullness,
May mimick ovarian cyst, mesenteric cyst

8. TUBERCULAR LYMPHADENOPATHY

9. • 20-25% cases Of Abdominal TB
• More commonly in children
• Involves mesenteric, omental, and portal node
• Detected on imaging as multiple, mildly enlarged nodes, in
clusters with central areas of necrosis and peripheral
enhancement.

10. 1)Acute mesentric lymphadenitis :
Tender mass palpable in Rt iliac fossa
Mimics acute appendicitis
2)Pseudo mesenteric cyst :
Caseating material collected between layers
of mesentry
Forms cold abscess
Mimicks mesenteric cyst
3) Chronic Lymphadenitis :
Failure to thrive,
Protuberant abdomen and emaciation

11. VISCERAL TUBERCULOSIS

12. • 15-20% of all patients with AbdominalTB
• Involvement of solid organs like spleen, liver, pancreas
• Spreads by hematogenous route
• Usually as part of disseminated and military TB
• Granulomatous lesions on imaging
• Only 15% have concomitant pulmonary TB
• Presents with non specific symptoms along with
hepatosplenomegaly

13. GASTROINTESTINAL TUBERCULOSIS

14. • 60-70% % of all Abdominal TB
• Most common site is ileocaecal junction, due to abundance of
lymphoid tissue( peyers patches)
• Followed by jejunum and colon,
• Esophagus, stomach, duodenum rarely involved in
immunocompetent patient
• Extrinsic – secondary to adjacent lymphadenopathy
Intrinsic – ulcerative, hypertrophic or ulcero hypertrophic

15. • Presents with non specific symptoms
• High index of suspicion is required
• Differential Diagnosis : IBD
Lymphoma
Malignancy
Atypical PUD
• Complications : Obstruction
Stricture
Fistula
Perforation

16. Esophageal TB:
• 0.2-1% of GI TB.
• Seen in immunocompromised patients such as with AIDS
• Present with Retrosternal pain, Dysphagia, Odynophagia
• Esophageal involvement is usually secondary to a contiguous
mediastinal nodal involvement

17. • Barium studies show - narrowing and displacement of
esophagus, ulcers, stricture, fistulae( in later stages), traction
diverticulae( in fibrotic mediastinal disease)
• Radiological features are not specific,
• Histopathological diagnosis made by multiple and deep,
esophageal endoscopic biopsies( tubercular granulomas located
deep in submucosal layer).

18. Gastric TB:
• 0.4-2% of all GI TB
• Primary involvement is rare due to bactericidal property of
gastric acid, scarcity of lymphoid tissue in gastric wall and
thick intact gastric mucosa.
• Present with vague discomfort, weight loss, fever and may
present with features of gastric outlet obstruction
• Associated tubercular lymphadenitis is usually present

19. Duodenal TB :
• 2-2.5% of all Gastrointestinal TB
• Most commonly involves third part
• Extrinsic form – secondary to lymphadenopathy in C loop.
• Barium studies reveal band like narrowing of 3rd part of
duodenum( string sign)
• May mimick SMA syndrome

20. Jejunal and ileocaecal TB:
• 64% of all Gastrointestinal TB
• Terminal ileum most commonly involved – stasis, abundant
lymphoid tissue, increased rate of absorption and closer
contact of bacilli with mucosa.
• Present with colicky abdominal pain, borborygmi, and
vomiting , Rt iliac fossa mass
• Complications : Obstruction ( hyperplastic)and Perforation(
ulcerative) and Stricture

21. • May mimick Crohns Disease histologically, differentiated by
presence of caseus necrosis.
• Other differential CA caecum, Amoboma, Appendicular
mass, Psoas Abscess
• Barium studies may show accelerated intestinal transit,
hypersegmentation of barium column( chicken intestine),
luminal stenosis(hourglass stenosis), retracted caecum (
goose neck deformity)
• CT may show circumferential wall thickening associated with
mesenteric lymphadenopathy, asymmetric thickening of IC
valve and medial wall of cecum

22. Colorectal TB :
• Isolated colon involvement see in 10.8% cases of GI TB
• Present with abdominal pain( below the umbilicus) loss of
appetite and weight and altered bowel habits
• Differentials include : Crohns disease
Amoebic colitis
Pseudomembranous colitis
Malignancy

23. INVESTIGATIONS

24. • Blood investigations :
Leucopenia, Raised ESR, Normocytic normochromic anaemia
Serum biochemistry- low albumin, high ALP with normal
AST/ALT( in hepatic TB)
• Montoux test:
Low sensitivity and specificity,
Could be false negative in Immunosupression or malnutrition,
military TB, suppression of PPD reactive T lymphocytes,
False positive after BCG vaccination
• Chest X ray :
To identify pulmonary focus, either healed or active,
Normal Chest Xray does not rule out Abdominal TB

25. • X ray Abdomen :
Calcified lymph nodes
Air fluid levels,
Calcified granuloma in liver

26. • USG abdomen :
Thickened bowel loops
ascites ( loculated/diffuse)
Mesentric thickening
Enlarged Lymph node
Pulled up Caecum ( Pseudo Kidney Sign)

27. • Barium Study:
Best Diagnostic test for intestinal lesions
 Barium Follow through :
Multiple strictures
distended caecum, or terminal ileum
mucosal irregularity
segmentation of barium column,
Stierlin sign (rapid transit and lack of retention of barium in an inflamed
small bowel)

28.  Barium enema :
Thickening of ileocecalvalve with triangular appearance
Fleischners sign(pulled up caecum or wide gaping of the valve
with narrowing of terminal ileum)

29. • CT Scan :
Thickening of bowel wall and mesenteric/omental stranding
Granulomas in liver and spleen
Lymphadenopathy with peripheral rim enhancement seen in CECT

30. • Endoscopy :
hyperemic friable mucosa
ulcers and mucosal nodules
pseudopolyp and cobblestone appearance
Endoscopic biopsy may be subject to PCR for AFB

31. • Laparoscopy :
Facilitates direct visualization of inflamed thickened peritoneum
studded with military tubercles, adhesions and fibrotic strands
Biopsy specimens reveal AFB in 75% of cases and caseating
granulomas in 85-90%
• Ascitic tap :
Exudative (proteins >3gm% and SAAG< 1.1),
TLC 150-4000 cells/mm3( predominantly lymphocytes),
Ascitic fluid ADA is shown to have a sensitivity and specificity of
100 and 97% respectively for a cutoff value of 33U/L,

32. • Serodiagnosis:
ELISA detects IgG or IgM depending on the phase of TB,
sensitivity of 83%, but poor reproducibility
Remains positive even after treatment
Cost factor
• PCR is highly specific, detects mycobacteria and non
mycobacteria simultaneously
But variable sensitivity depending on the source of specimen

33. MANAGEMENT ALGORITHM

34. TREATMENT:

35. • Most pt with Abdominal TB respond to medical management with
standard 6 month ATT regime
• 6 months regimen (HRZE x 2mo followed by HR x 6 mo) is
recommended as per revised national TB program guidelines
• It may be extended to 9 mo or 12 mo based on clinicians preference
• However, no difference seen in effectiveness between 6 mo short
course and and 12 mo standard regime.

36. ROLE OF SURGERY

37. • Reserved for those with acute complications like
Free Perforation
Confined perforation with abscess or fistula
Massive bleeding
Complete obstruction
Obstruction not responding to medical therapy
• About 20-40% of patients with Abdominal Tb present with acute
complications and need surgery.

38. Types of surgery :
• Bypass the involved segment of bowel via Enteroenterostomy,
Ileotranverse colostomy
Complications : blind loop syndrome, fistula formation,
recurrence in remaining segments
Not routinely done
• Segmental resections such as limited ileocecal resection
Not possible with malnourished candidates or extensive bowel
involvement.
Complications : Anastomotic leaks, fecal fistula, peritonitis,
intraabdominal sepsis, persistent obstruction.

39. • Stricturoplasty
For multiple strictures involving long segment.
Done using heineke mikulikz pyloroplasty technique
Inflamed and friable strictures and multiple structures
involving short segment may be amenable to
resection.
Strictures of recent origin or not very tight may be
dilated via an enterotomy

40. TAKE HOME MESSAGE
• Abdominal TB may have protean manifestations
• Presents a diagnostic challenge
• Neither clinical, laboratory, endoscopic nor radiological
findings are gold standard
• A high index of suspicion is required
• Can affect any part of Gastrointestinal system
• Most cases respond to medical therapy
• Due to diagnostic delay many cases present with complications
requiring surgery

41. THANK YOU