This document discusses abdominal tuberculosis, including its etiology, pathogenesis, clinical presentation, diagnosis and treatment. Some key points include: - Abdominal tuberculosis can involve the gastrointestinal tract, peritoneum, liver and spleen and is caused by Mycobacterium tuberculosis spreading hematogenously from a primary pulmonary infection. - Clinical manifestations depend on the site of involvement but commonly include abdominal pain, weight loss, fever and intestinal obstruction or perforation from strictures or ulcers. Chest x-rays often do not show evidence of pulmonary lesions. - Diagnosis involves biopsy of affected tissue to identify granulomas and acid-fast bacilli on staining, and culturing bacteria. Abdominal tuberculosis is more common

1. ABDOMINAL TUBERCULOSIS
DR. ANIL KUMAR JHAJHRIA

2. • The term abdominal tuberculosis includes
tuberculous infection of the gastrointestinal
tract, the mesentry, its nodes, and omentum,
the peritoneum, and the solid organs related
to the gastrointestinal tract, such as the liver
and spleen.
• Tuberculosis can involve any part of GI tract
and is the sixth most common site of extra
pulmonary involvement.
• Chest X-rays show evidence of concomitant
pulmonary lesions in less than 25 per cent of
cases.

3. • Extra-pulmonary forms of TB which
account for 10-15 per cent of all cases
may represent up to 50 per cent of
patients with AIDS.
• TB of the gastrointestinal tract is the
sixth most frequent form of extra-
pulmonary site, after lymphatic,
genitourinary, bone and joint, miliary and
meningeal TB.

4. • There is a sharp contrast in the incidence of
intestinal tuberculosis between the West and
India:
• 15 of 4222 patients admitted to the University of
Michigan for tuberculosis had intestinal
tuberculosis over a 22-year period, compared to
300 cases over 14 years in one Indian series, and
557 cases over 12 years in another series in
similar number of patients.
HISTORY-
• Tuberculosis was recognized as early as the
fourth century bc, and was known as phthisis,
lupus, scrofula, or Pott's disease, until the identity
was established by Robert Koch in 1882.

5. Some interesting facts about history-
• Initially called CONSUMPTION( because of severe
weight loss and the way the infection appeared
to consume the patient),then,
• WHITE PLAGUE- (Because of the extreme pallor
seen among those infected)
• IN ANCIENT TIMES- Existed 15000-20000 years
ago. Among Egyptian mummies spinal TB called
Pott’s disease has been detected by
archaeologists.
• IN MIDDLE AGES- called as King’s evil (was widely
believed that the kings of England and France
could cure scrofula simply by touching those
affected.)

6. ETIOPATHOGENESIS-
• The postulated mechanisms by which the tubercule
bacilli reach the gastrointestinal tract are: (i)
hematogenous spread from the primary lung focus in
childhood, with later reactivation; (ii) ingestion of
bacilli in sputum from active pulmonary focus; (iii)
direct spread from adjacent organs; and (iv) and
through lymph channels from infected nodes.
• Abdominal tuberculosis is rare in the Western
population and is declining in incidence in certain parts
of India.
• Strict control of tuberculosis in dairy herds and
pasteurization of milk have almost eliminated bovine
tuberculosis in many countries; however, despite
efforts aimed at effective treatment of tuberculosis,
the disease is not uncommon in developing countries.

7. • The earlier belief that most cases are due to
reactivation of quiescent foci is being
challenged with a recent study using DNA
fingerprinting showing that 40 per cent cases
are due to reinfection. In India, the organism
isolated from all intestinal lesions has been
Mycobacterium tuberculosis and not M.bovis.

10. • The tubercle bacillus is a Gram-positive, aerobic,
non-motile, non-spore bearing organism, and it is
identified by the Ziehl - Nelson acid-fast
differential staining method.
• The organism is cultured in Lowenstein - Jensen
medium for 4 weeks.
• Several other atypical or anonymous
mycobacteria whose pathogenicity is not yet
established have been identified.
• The virulence of Mycobacterium tuberculosis is
established by guinea-pig inoculation.

11. • Intestinal infection is more prevalent in
populations from lower socioeconomic strata,
contributing factors being poor hygiene,
crowded living conditions and poor nutrition.
• The incidence is higher in those with caseo-
pneumonic and late disease than in those
with fibrotic lesions or early disease.

18. • Tuberculous granulomas are initially formed in
the mucosa or the Peyer’s patches.
• These granulomas are of variable size and
characteristically tend to be confluent, in
contrast to those in Crohn’s disease.
• Granulomas are often seen just beneath the
ulcer bed, mainly in the submucosal layer.
Submucosal oedema or widening is
inconspicuous.
• Tubercular ulcers are relatively superficial and
usually do not penetrate beyond the
muscularis.

19. • They may be single or multiple, and the
intervening mucosa is usually uninvolved.
• These ulcers are usually transversely oriented
in contrast to Crohn’s disease where the ulcers
are longitudinal or serpiginous.
• Cicatrical healing of these circumferential
'girdle ulcers' results in strictures. Occlusive
arterial changes may produce ischemia and
contribute to the development of strictures.
• Endarteritis also accounts for the rarity of
massive bleeding in cases of intestinal
tuberculosis

32. OTHER SIGNS-
• Conical caecum- shrunken in size and pulled
out of the iliac fossa due to contraction and
fibrosis of the mesocolon. The hepatic flexure
may also be pulled down.
• Early involvement of the ileocaecal region
manifesting as spasm and oedema of the
ileocaecal valve. Thickening of the lips of the
ileocaecal valve and/or wide gaping of the
valve with narrowing of the terminal ileum
(“Fleischner” or “inverted umbrella sign”) are
characteristic.

33. • “String sign” – persistant narrow stream of
barium indicating stenosis.
• Purse string stenosis– localized stenosis
opposite the ileocaecal valve with a rounded
off smooth caecum and a dilated terminal
ileum.

66. OESOPHAGEAL TB
• Oesophageal tuberculosis is a rare entity,
constituting only 0.2 per cent of cases of
abdominal tuberculosis .
• Oesophageal involvement occurs mainly by
extension of disease from adjacent lymph
nodes.
• The patient usually presents with low grade
fever, dysphagia, odynophagia and an ulcer,
most commonly midoesophageal.
• The disease usually mimics oesophageal
carcinoma and extraoesophageal focus of
tuberculosis may not be evident.

67. GASTRODUODENAL TB
• Stomach and duodenal tuberculosis each
constitute around 1 per cent of cases of
abdominal tuberculosis.
• Gastroduodenal tuberculosis may mimic
peptic ulcer disease with a shorter duration of
history and non response to anti-secretary
therapy. It may also simulate gastric
carcinoma.
• Surgical bypass has been required in the
majority of cases to relieve obstruction but
successful endoscopic balloon dilatation of
duodenal strictures has been reported.