This document discusses abdominal tuberculosis, specifically focusing on tuberculosis of the gastrointestinal tract. It covers the pathogenesis, clinical features, diagnosis, and treatment of abdominal tuberculosis. The key points are: 1) Abdominal tuberculosis most commonly involves the ileocaecal region and peritoneum. It typically spreads hematogenously from a primary pulmonary focus or via lymph nodes. 2) Common clinical features include abdominal pain, fever, weight loss, and abdominal swelling caused by ascites. Diagnostic tests include positive Mantoux test, ascitic fluid analysis, imaging, and biopsy showing caseating granulomas. 3) Treatment involves antitubercular therapy for at least 6 months along with surgery for complications like obstruction

1. Abdominal Tuberculosis
Dr.Sujith Mathew Jose
PG in General Surgery
Coimbatore Medical College
Coimbatore

2. Introduction
TB can involve
any part of GIT
from mouth to
anus,
peritoneum &
pancreatobiliary
system.

3. • TB of GIT(peritoneal)- 6th most
frequent extrapulmonary site.
• LYMPHATIC ----- 1st
• GENITOURINARY
• BONE & JOINTS
• MILIARY
• MENINGEAL------ 5th

4. • Most case from
reactivation of
latent peritonial
disease, previously
established
hematogenously
from primary
pulmonary focus

5. Pathogenesis
• 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
• In India, organism from all intestinal lesions – M.
tuberculosis and not M. bovis.

6. • Most common site -
Ileocaecal region
• Types
– Ulcerative
– Hyperplastic
– Ulcero-hyperplastic
• In ileal region commonly
stricture type .

7. • Peritoneal involvement occurs from :
– Spread from Lymph node
– Intestinal lesions
– Tubercular salpingitis
• Abdominal lymph node and peritoneal TB
may occur without GIT involvement in ~ 1/3
cases.

8. Peritoneal tuberculosis occurs in 3 forms.
• Wet type - ascitis.
• Encysted (loculated) type
• Fibrotic type - masses composed of mesenteric &
omental thickening, with matted bowel loops.

9. Clinical Features
• Mainly disease of young adults,
• 2/3 of pts are 21-40 yr with equal sex incidence
• Clinical presentation
– Acute
– Chronic
– Acute on chronic
Abdominal swelling caused by ascitis is
the most common symptom

10. • Constitutional symptoms
– Fever (40%-70%)
– Weight loss (40%-90%)
– Anorexia
– Malaise
• Pain abdomen (80%-95%)
– Colicky (luminal stenosis) ,
– Continous ( LN involvement)
• Alternating constipation and diarrhoea

11. • POSITIVE TUBERCULIN TEST
• ASCITIC FLUID SAAG less
than 1.1g/dl
• Microscopic examination of
ascitic fluid
– ERYTHROCYTES
– Increased LEUCOCYTES
(LYMPHOCYTES)

12. ASCITIC FLUID
ADENOSINE
DEAMINASE
ACTIVITY IS HIGHLY
SENSITIVE AND
SPECIFIC FOR
TUBERCULOUS
PERITONITIS

13. Tuberculosis of esophagus
• Rare ~ 0.2% of total cases
• By extension from adjacent
LN
• Low grade fever/ Dysphagia/
Odynophageal/Midesophage
al ulcer
• Mimics esophageal Ca

14. Gastro Duodenal TB
• Stomach and duodenum each ~ 1% of total cases
• Shorter history, non response to treatment
• Mimics gastric Carcinoma
• Leads to duodenal obstruction due to extrinsic
compression by tuberculous LN ,Hematemesis /
Perforation / Fistulae / Obstructive jaundice
• Chest X-Ray usually normal
• Endoscopic picture - non specific

15. Illeocaecal tuberculosis
• Colicky abdominal pain
,anaemia, weightloss , diarrhoea
,fever
• ‘Ball of wind’ rolling in abdomen
• Borborygmi
• Right iliac fossa lump – due to
mesenteric fat and LN

16. Segmental / Isolated colonic tuberculosis
• Involvement of the colon without involvement of the
ileocaecal region
• 9.2% of all cases
• Multifocal involvement in ~ 1/3 of cases (28% to
44%)
• Median symptom duration <1 year

17. Colonic tuberculosis
• Pain --- predominant symptom ( 78%-90% )
• Hematochezia in < 1/3 - usually minor
Overall, TB accounts for ~ 4% of lower GI
bleeding
• Other features--- fever / anorexia / weight
loss / change in bowel habits

18. Rectal and Anal Tuberculosis
• Hematochezia - most common symptom,
due to mucosal trauma by stool
• Constitutional symptoms
• Constipation
• Rectal stricture
• Anal fistula – usually multiple

19. Complications
• Obstruction
• Perforation -2nd commonest cause after typhoid ,usually
single and proximal to a stricture,Pneumoperitoneum in ~
50% cases
• Mal-absorption
• Fecal fistula
• Cold abscess
• Haemorrhage

20. Diagnosis and Investigations
Raised ESR
Positive Mantoux Test
Chest X Ray Findings
Low Hb ----- anemia
Hypoalbuminemia
ELISA (90%)
SAFA (Soluble Antigen
Fluroscent Antibody)
Serum IgG

21. USG CT
Echogenic material in Ascitic
Fluid
- fine mobile strands or
particulate matter
Thickened Mesentery
Nodules Nodular mesentery
Caecal Thickening Mesenteric
Lymphadenopathy
Lymph Nodes Omental thickening

22. Diagnostic Laproscopy
Whitish Nodules <5mm scattered over peritonium
HPR -------------- Caseating granuloma
Multiple adhesions between organs and parietal
peritonium
Gross appearance mimic Peritonial
carcinomatosis, sarcoidosis and Crohn’s disease
Ascitic Fluid for
microscopy to demonstrate AFB (<3%)
culture (<20%)

23. Colonoscopy
mucosal nodules & ulcers
Nodules-Variable sizes (2 to 6mm)
Tubercular ulcers
– Large (10 to 20mm) or small (3 to 5mm)
– Located between the nodules
– Single or multiple
– Transversely oriented / circumferential contrast to Crohns
• Deformed and edematous ileocaecal valve

24. Barium study X-ray findings
• Pulled up caecum ,
conical caecum
• Obtuse ileocaecal
angle
• Narrow ileum with
thickened ileocaecal
valve (Fleischner
sign)
• Calcifications
• Ulcers and strictures
in ileum and caecum
–napkin lesions

25. Ascitic Fluid Study
• Straw coloured Exudate
• Protein >3g/dL
• Total count of 150-4000/µl,
Lymphocytes >70%
• SAAG < 1.1 g/dL
• ZN stain positive in < 3% cases
• Positive culture in < 20% cases
• ADA positive
• Glucose <30mg

26. Treatment
• ATT for at least 6 months -Rifampicin, INH, Pyrazinamide
and Ethambutol.
• Surgery –Indications
Intestinal obstruction , severe haemorrhage , perforations
, intra-abdominal abscess
• For ileocaecal TB -Limited ileocaecal resection
• Single stricture – stricturoplasty
• In perforation –resection and anastomosis
• In obstruction – ileo-transverse anastomosis
• Drainage of intra-abdominal abscess , perianal abscess

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