Abdominal Tuberculosis by Dr Sabu Augustine for MBBS students. References from Textbooks and journals

1. ABDOMINAL TUBERCULOSIS
DR SABU AUGUSTINE
ASSOCIATE PROFESSOR
DEPT OF GENERAL MEDICINE
DR S.M C.S.I MEDICAL COLLEGE, KARAKONAM

2. INTRODUCTION
 Abdominal tuberculosis (TB) includes
involvement of the gastrointestinal tract,
peritoneum, lymph nodes, and/or solid organs.
 Abdominal TB comprises around 5 percent of all
cases of TB worldwide.

3. RISK FACTORS
 Cirrhosis
 HIV infection,
 Diabetes mellitus,
 Underlying malignancy,
 Malnutrition,
 Treatment with antitumor necrosis factor agents ,
corticosteroids,
 Continuous ambulatory peritoneal dialysis

4. FORMS OF DISEASE
 Can present with involvement of any of the
following sites:
 Peritoneum,
 Stomach,
 Intestinal tract,
 Hepato-biliary tree,
 Pancreas,
 Perianal region (fistula is common),
 Lymph nodes.

5. FORMS OF DISEASE
 Most common forms of disease include involvement
of the peritoneum, intestine, and/or lymph nodes
 May occur via
 reactivation of latent TB infection or
 by ingestion of tuberculous mycobacteria (as with
ingestion of unpasteurized milk or undercooked meat).
 In the setting of active pulmonary TB or miliary TB,
abdominal involvement may develop
 via hematogenous spread
 via contiguous spread of TB from adjacent organs (such
as retrograde spread from the fallopian tubes) or
 via spread through lymphatic channels

6. CLINICAL FEATURES
Depends on the form of disease.
 Fever,
 Weight loss,
 Abdominal pain and/or distension,
 Ascites,
 Hepatomegaly,
 Diarrhea,
 Bowel obstruction, and
 Abdominal mass

7. PERITONEAL TUBERCULOSIS
 Ascites (93 %), abdominal pain (73 %), and fever
(58 %)
 Visceral & parietal peritoneum become studded
with tubercles.
 Ascites secondary to exudation of proteinaceous
fluid from the tubercles.

8. PERITONEAL TUBERCULOSIS
 In 10 % patients - a more advanced "dry" phase with
a "doughy" abdomen, which represents a
fibroadhesive form of the disease.
• The absence of signs of chronic liver
disease (such as palmar erythema, spider
angiomata, and dilated abdominal wall
veins) should increase clinical suspicion
for TB peritonitis.

9. INTESTINAL TUBERCULOSIS
 Most common site of involvement is ileo-cecal
area
 Two types of bowel lesions are seen: ulcerative
(in malnourished) and ulcero-hypertrophic (in
well-nourished).
 Ulcerative and stricturous forms usually in the
small intestine, while colonic and ileocecal
lesions are usually ulcero-hypertrophic.

10. INTESTINAL TUBERCULOSIS
 Clinical manifestations include intestinal colic,
abdominal distension, chronic diarrhea, nausea,
vomiting, constipation, and Lower GI bleeding.
 In adjacent tissue involvement there will be
ascites, lymph node enlargement, and tubo-
ovarian symptoms.

11. HEPATIC TUBERCULOSIS
 two presentations
 miliary hepatic disease and
 isolated hepatic disease.
 in 80 % of cases Liver involvement is seen in
disseminated TB.
 In this form TB reaches the liver via the hepatic
artery.
 Isolated hepatic TB occurs in approximately 20 % of
cases where TB reaches the liver from the intestinal
tract via the portal vein or gastrointestinal lymphatics

12. HEPATIC TUBERCULOSIS
 The most common signs and symptoms of
hepatic TB include hepatomegaly , fever,
respiratory symptoms, abdominal pain , and
weight loss ;
 other signs include splenomegaly , ascites , and
jaundice.

13. DIAGNOSIS
 Histology and culture of tissue is desirable, but
not always possible.
 Specimens obtained by colonoscopy or
laparoscopy but laparotomy is required in some
cases.

14. DIAGNOSIS
 Demonstration of M. tuberculosis in peritoneal fluid
(in the setting of ascites) or
 Biopsy specimen of an involved site (such as
peritoneum, intestine, or liver) sent for mycobacterial
culture and/or nucleic acid amplification test (NAAT).

15. DIAGNOSIS
 Ascitic fluid for routine tests (total & differential
count, albumin and protein, Gram stain).
 As well as adenosine deaminase (ADA) level,
AFB smear, mycobacterial culture, and CbNAAT.
 Straw-colored lymphocytic ascites with serum-
ascites albumin gradient (SAAG) <1.1 g/dL with
an elevated ascites ADA level supports the
diagnosis.

16. DIAGNOSIS
 Non diagnostic ascitic fluid analysis/in absence
of ascites - peritoneal biopsy can be pursued
according to the clinical suspicion.
 Patients with known or suspected TB warrant
testing for HIV infection.
 CT in intestinal TB
 concentric mural thickening in the ileocecal
region, with or without proximal intestinal
dilatation

17. DIAGNOSIS
 CT in peritoneal TB
 ascites, lymph nodes, thickening of the
mesentery, omentum, the peritoneum.
 CT in hepatic TB
 miliary hepatic TB- multiple low-density
micronodules dispersed throughout the liver
 local hepatic TB- large solitary nodule or two
to three low-density nodules with calcification.

18. DIAGNOSIS
 Ultrasound is useful for detecting
lymphadenopathy, ascites, peritoneal thickening,
omental thickening, and bowel wall thickening.
 Small bowel follow-through or barium enema
may demonstrate mucosal ulcerations and
strictures, a deformed cecum, and/or an
incompetent ileocecal valve

19. DIAGNOSIS
 Plain radiography may demonstrate air fluid
levels with dilated small bowel levels (suggestive
of intestinal obstruction) or hepatic calcifications.

20. DIFFERENTIAL DIAGNOSIS
 Differential diagnosis includes Crohn’s disease
and Caecal carcinoma.
 Use of immunosuppressive drugs for a
misdiagnosis of Crohn’s disease may be
associated with clinical deterioration in patents
with TB.

21. DIFFERENTIAL DIAGNOSIS
 Ascites is uncommon in Crohn’s disease.
 TB granulomas tend to be submucosal, large,
and confluent, often with caseation necrosis.
 In Crohn’s disease granulomas are typically
mucosal, infrequent, small, nonconfluent, and
noncaseating.

22. DIFFERENTIAL DIAGNOSIS
 Malignancy is distinguished from abdominal TB
by ascitic fluid for cytology, and biopsy for culture
and histopathology.
 Malignant ascites - bloody exudate.
 Serum CA-125 concentrations can be elevated in
peritoneal TB also and so this test cannot be
used to distinguish from malignancy.

23. MANAGEMENT
 Should be treated with Anti-Tubercular Treatment
same as that for pulmonary TB.
 Fever usually resolves within one week of
commencement.
 Ascites will improve within a few weeks of
initiation in 90 % of cases.

24. MANAGEMENT
 Generally demonstrate clinical improvement
within two to four weeks on empiric therapy.
 Patients who develop bowel obstruction cannot
ingest medications orally, limiting the choice of
drug therapy to injectable agents.

25. MANAGEMENT
 If no clinical response to ATT within four to eight
weeks, repeat evaluation for alternative
diagnoses such as Crohn disease, lymphoma, or
malignancy.
 Surgery in complications such as perforation,
abscess, fistula, bleeding, obstruction.