Abdominal tuberculosis

Abdominal
Tuberculosis
Dr. Sudhir. K. Jain
Professor of Surgery
7/7/2015 Dr.S.K.Jain, Prof Surgery, MAMC, N.Delhi

Abdominal Tuberculosis:
Presented By:
Dr. Sudhir. K. Jain, M.S, MBA(HCA), FRCS, FICS, FIAS.
Professor of Surgery,
Maulana Azad Medical College and Associated Lok Nayak Hospital,
New Delhi.
With Credits to:
Dr. R.Vishnuraja, PG2, Dept of Surgery, MAMC.
Dr. Maneesh Kumar Jain, PG3, Dept of Surgery, MAMC.

Known Disease, Unknown
Facts!!!

1

Disease of the Artisans…
If u die…die of TB

Disease of the Artisans:
• It is being suggested that Beethovan died of TB and many other
famous personalities of his time.
• People of the 17th and 18th century wanted to die of tuberculosis.
• Because, death due to other diseases like typhoid fever, plague or
War were very painful, sudden and unpleasant.
• Where as tuberculosis gave a slow and a relatively painless death.
British poet Lord Byron wrote, "I should like to die from consumption,"
helping to popularize the disease as the disease of artists.

2

The King’s Evil

Fashion Designer – Tuberculosis:
• The picture shows the pictures of French and British royals.
• The picture was shown as the effect of Tuberculosis on Fashion.
• Mycobacterium scrofulaceum causes scrofula in the neck.
• In order to cover the scrofula, people wore dresses in such a way, it is
covered their necks.
• It was also called as ‘The Kings Evil’ as it was thought that, scrofula
can be cured by the touch of the King.

3

Anemia-The Fashion Symbol

History of Talcum powder:
• People with Tuberculosis had anemia and pallor.
• Tuberculosis was considered as the status symbol.
• So, people who actually did not have tuberculosis, started mimicking
as if they have tuberculosis.
• In order to appear pale, they applied white powders to their face,
which led to the arrival of talcum powders.

4
•Benedick: Come, I will have thee, but by this
light I take thee for pity.
•Beatrice: I would not deny you, but by this
good day I yield upon great persuasion, and
partly to save your life, for I was told you were
in a consumption. (V.IV.96-101).

Consumption @ Tuberculosis
The Disease of Love

The Disease of Love:
• In this scene, from Shakespeare’s, ‘Play Much ado about Nothing’
Beatrice accepts Benedick’s love since she was told that Benedicks
was in consumption (Tuberculosis).
• CONSUMPTION @ tuberculosis was considered at that time as a
‘Disease arising out of LOVE or BURNING DESIRE’.

Definition:
Mycobacterium tuberculosis infection of:
• Peritoneum
• Hollow viscus (Bowel- From mouth to anus)
• Solid abdominal organs – Liver, spleen, pancreas, adrenals, kidneys

How M.tuberculosis reach GIT?
6 Routes.
1. Hematogenous spread from the primary lung focus in childhood,
with later reactivation.
2. Ingestion of bacilli in sputum from active pulmonary focus
3. From Ingestion of unpasteurized milk (Mycobacerium bovis)
4. Direct spread from adjacent organs
5. Through lymph channels from infected nodes.
6. Retrograde spread from female genital tuberculosis.

Common Clinical Presentation:
• Young adults (21-40 yrs)
With complaints of :
• Abdominal pain
Colicky- With luminal narrowing
Dull aching- With mesenteric lymphnode involvement
• Diarrhea or Constipation
• Alternating constipation and diarrhea
• Weight loss, anorexia and malaise
• Fever

Complications
• Subacute Intermittent Obstruction (SAIO)
• Intestinal obstruction
• Intestinal perforation
• Intestinal bleeding (Uncommon)

Key Words: A small revision
• Granuloma
• Caseating necrosis

• Granuloma
Granuloma:
Focus of chronic inflammation.
Microscopic aggregation of Macrophages-
transformed into epithelium-like cells
Surrounded by a collar of lymphocytes and
occasional plasma cells.

• Granuloma
Caseous necrosis:
Caseous- Cheesy:
Type of Coagulative necrosis. But tissue
architecture not maintained.
Central necrosis surrounded by
amorphous cells and granular material
with clear inflammatory border known as
Granulomatous reaction.

Peritoneal Tuberculosis
• 3 Types and their combinations.
1. Wet type with ascites
2. Encysted (Loculated) type with localized abdominal swelling
3. Dry - Fibrotic type with abdominal masses composed of mesenteric
and omental thickening and caking, with matted bowel loops
leading to abdominal cocoon.
4. A combination of the above.

Intestinal tuberculosis
• Can involve any portion of the GIT from mouth to anus.
• Common in ileo caecal region.
• 4 Types
1. Ulcerative type
2. Ulcerohyperplastic type
3. Hyperplastic type
4. Stricturing type
Immunocompromised and Malnourished with high virulence of the
bacteria: Ulcerative form
Immunocompetent with low virulent bacteria: Hyperplastic form

Common site-Ileo caecal region-Why?
4 Reasons
• Abdundance of abdundant lymphoid tissue at this site (Peyers
Patches)
M Cells of Peyers Patches phagocytose BCG bacillus.
• Increased physiological stasis (Ileocaecal valve competence) with
prolonged contact with the mucosa.
• Increased rate of fluid and electrolyte absorption (Alkaline
Environment)
• Minimal digestive activity

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).

TB- Gastroduodenum (1%)
• Gastric TB- May mimic Peptic ulcer not relieving to anti-secretory
therapy or gastric carcinoma.
• Duodenal TB- Obstruction due to extrinsic compression by lymph
nodes.
• Other presentations:
Perforation
Fistula
Ulcer excavation into pancreas
Obstructive jaundice due to CBD compression.

Why Gastric tuberculosis is Uncommon?
• Acidic environment which prevents the growth of the
mycobacterium.
• Rapid gastric emptying
• Paucity of Peyer’s patches in stomach.

Ileocaecal TB
• Colicky abdominal pain, borborygmi and vomiting.
• Palpation: No abnormality or Doughy RIF lump
• Common complications:
Intestinal obstruction- Hyperplastic TB, Strictures and adhesions
Malabsorption- Bacterial overgrowth in stagnant loop, bile salt
deconjugation, ulceration and involvement of lymphatics and lymph
nodes.

Ileocaecal tuberculosis-Presentations
• Recurrent abdominal pain due to SAIO
• Acute intestinal obstruction
• Ileocaecal mass which can mimic malignancy
• Intestinal perforation

Jejunal TB
Presents with
Single or multiple strictures
Intestinal obstruction
Perforation (proximal to the stricture)

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

Anal TB
Multiple anal fistula with pouting granulation tissue with discolouration
of the surrounding skin- Anal TB should be suspected.

Diagnostic Crieria: Paustian 1964
Rule: One or more of the following 4 criteria should be positive.
1. Histological evidence of tubercles with caseation necrosis
2. A good typical gross description of operative findings with biopsy of
mesenteric nodes showing histologic evidence of tuberculosis
3. Animal inoculation or culture of suspected tissue resulting in
growth of M. tuberculosis
4. Histological demonstration of acid fast bacilli in a lesion

Investigations:
Suggestive but not diagnostic of TB
• Anemia
• Elevated ESR
• Positive Mantoux

Ascitic fluid-Typical Characteristics:
• Straw colour
• Protein > 3 g/dl
• TLC 150-4000/mic litre
• Cytology- Predominantly lymphocytes
• Ascites to blood glucose ratio: <0.96
• SAAG <1.1g/dl
• Adenosine deaminase Positive
• Interferon gamma Positive
• TB PCR Positive

Radiological Investigations

Chest X ray
Evidence of tuberculosis in a chest
X ray supports the diagnosis. But
not always present.

X ray Abdomen
May show features of obstruction,
perforation or intussusception.
Calcified lymphnodes, calcified
granulomas.

X ray Abdomen:
A. Dilated bowel loops
B. Multiple air fluid
levels

Small Bowel Barium Meal
Chicken intestine
Multiple strictures of bowel
loops.

Barium enteroclysis

Barium Enema
Fleischner or
Inverted umbrella sign
Conical caecum
Strictures
Pulled up/subhepatic
caecum

Fleischner or Inverted Umbrella Sign

Conical Caecum

Stricture

Barium Studies- In current age:
• Very rarely used
• Complication – Complete intestinal obstruction

Current Investigations of Choice:
• Ultrasonography
• CECT abdomen
• Colonoscopy
• Capsule endoscopy

Ultrasonography:
Can be used to visualize:
• Matted lymphnode enlargement,
bowel wall thickenings and
• fluid collection in the abdomen

CECT abdomen:
Can visualize:
• Lymphnode enlargements
• Bowel wall thickening
• Luminal narrowing
• Solid organ involvement
• Ascitic collection
• Bowel perforation

Colonoscopy:

Capsule endoscopy:
Should be used with caution,
As it can cause obstruction at the
stricture site.

Management of Complications
Intestinal Obstruction:
1. Strictures- Stricturoplasty
2. Adhesions- Adhesiolysis
3. Hyperplastic TB- Limited resection with end ileostomy and mucous
fistula followed by ATT; followed by ileostomy closure later.

Management of Complications
Subacute Intermittent Obstruction:
• Conservative Management
• ATT

Management of Complications:
Intestinal perforation:
• Primary Repair- High chances of leak in active tuberculosis
• Resection anastomoses or Resection with ileostomy
- Preferred techniques

Thank You

Abdominal tuberculosis

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