This document discusses the diagnosis of abdominal tuberculosis through imaging. It provides details on the pathological spectrum of abdominal TB and its clinical presentations. Key findings on imaging investigations like ultrasound, barium studies, CT and MRI are described. These include lymphadenopathy, bowel wall thickening, ascites, omental thickening and mesenteric involvement. Imaging plays an important role in the diagnosis of abdominal TB and distinguishing it from other conditions.

1. DIAGNOSIS OF ABDOMINAL
TUBERCULOSIS : ROLE OF
IMAGING

2. • Published in journal, indian academy of
clinical medicine
• Vol. 2, no.3 july - september 2001
• By Rita sood
Additional professor
Deparment of medicine
AIIMS, NEW DELHI.

3. INTRODUCTION
• Tuberculosis has been declared a global
emergency by the WHO.
• The prevalence of extra-pulmonary
tuberculosis seems to be rising, due to
increasing prevalence AIDS.
• In patients with extrapulmonary tuberculosis,
abdomen is involved in 11% of patients

4. PATHOLOGICAL SPECTRUM
• The involvement of the GIT is seen in 65%-
78% of patients of abdominal tuberculosis.
• common sites are the terminal ileum and the
ileocaecal region, followed by colon and
jejunum.
• Rarely stomach, duodenum, and oesophagus.

5. PATHOLOGICAL SPECTRUM
• The intestinal lesions produced by
tuberculosis are of three types -
ulcerative
hypertrophic
stricturous.
• A combination of the three morphological
forms of lesions i.e., ulcero-constrictive or
ulcerohypertrophic may occur.

6. PATHOLOGICAL SPECTRUM
• GI tuberculosis have mostly associated nodal
and peritoneal involvement.
1. Peritoneal involvement - adhesive or ascitic.
2. nodal involvement - commonly mesenteric
or retroperitoneal shows caseation or
calcification
• Hepatosplenic tuberculosis is common as a
part of disseminated and miliary tuberculosis.

7. CLINICAL SPECTRUM
• Most commonly in young adults can present
at any age.
• Modes of presentation can vary from
acute,
acute on-chronic
chronic,
incidental finding on laparotomy for unrelated
causes.

8. CLINICAL SPECTRUM
• Chronic diarrhoea and malabsorption -
Ulcerative type
• Rarely rectal bleeding - colonic tuberculosis.
• subacute intestinal obstruction - Stricturous
type in the form of obstipation, vomiting,
abdominal distension, and colicky abdominal
pain.

9. CLINICAL SPECTRUM
• Ano-rectal tuberculosis can present as
strictures and multiple fistula-in-ano.
• caecum and large intestine, lesions are usually
hypertrophic -obstruction or as abdominal
lump.
• Gastroduodenal tuberculosis may present as
peptic ulcer with or without gastric outlet
obstruction or perforation and may mimic
malignancy.

10. CLINICAL SPECTRUM
• Focal lesions in the liver and spleen are
generally seen as a part of disseminated
tuberculosis.
• Tuberculosis at unusual sites like pancreas,
and oesophagus, mimics malignancy.
• Peritoneal tuberculosis often presents as
abdominal distension and ascites or
sometimes as a soft cystic lump due to
loculated ascites.

11. CLINICAL SPECTRUM
• LN involvement - lump in central abdomen, or
as vague abdominal pain.
• constitutional symptoms like lowgrade fever,
malaise, night sweats, anaemia, and weight
loss are present in about one-third of patients

12. DIFFERENTIAL DIAGNOSIS
• Abdominal tuberculosis can mimic a large
number of medical and surgical conditions
because of wide clinical spectrum.
• Hypertrophic form mimic malignant
neoplasms such as lymphoma or carcinoma.
• ulcero-hypertrophic form - inflammatory
bowel disease.

13. DIFFERENTIAL DIAGNOSIS
• Nodal form may closely mimic lymphomas.
• Ascitic form can be difficult to distinguish from
malignant peritoneal disease and sometimes
ascites due to chronic liver disease.
• However, a high index of suspicion needs to
be maintained for an early diagnosis and
timely treatment.

14. INVESTIGATIONS
• Haematological examination may show
presence of anaemia, hypoalbuminaemia and
an elevated ESR.
• Mantoux Test may be positive but is of not
much value as it does not differentiate
between an active and inactive disease.

15. Mantoux Test
• Induration of 10–14 mm in children <5 years
of age strongly indicates active infection.
• Patients with an induration >14 mm are four
times more likely to have an active disease
than those with the range of 10–14 mm.
(Paediatric Surgery CHAPTER 18 Tuberculosis
Shilpa Sharma Devendra K. Gupta)

16. INVESTIGATIONS
• Serological tests like soluble antigen
fluorescent antibody (SAFA) and enzyme-
linked immunosorbent assay (ELISA) are not
sensitive and are non-specific and can only
suggest a probable diagnosis.

17. Enzyme-Linked Immunoassay Test
• The test basically detects the presenceof interferon
gamma release protein (IFN-g) from the blood of
sensitised patients when incubated with the early
secretory antigenic target-6 (ESAT6) and culture filtrate
protein 10 (CFP10) peptides.
• The test is as sensitive as, and more specific than, the
tuberculin skin test.
• It is recommended as a screening tool for diagnosing
disease as well as infection.
 (Paediatric Surgery CHAPTER 18 Tuberculosis Shilpa
Sharma Devendra K. Gupta)

18. INVESTIGATIONS
• In patient with ascites, peritoneal fluid
analysis shows- straw coloured
1. proteins more than 30g/l,
2. cells more than 1,000/cu.mm (mostly
lymphocytes),
3. ascitic/blood glucose ratio of less than 0.96,
and
4. adenosine deaminase (ADA) levels of more
than 33 U/l.

19. INVESTIGATIONS
• Adenosine deaminase (ADA) is increased in
tuberculous ascitic fluid due to the stimulation of
T-cells by mycobacterial antigens.
• In coinfection with HIV, the ADA values can be
normal or low.
• High interferon levels in tubercular ascitis have
been found to be useful diagnostically.
• Combining both ADA and interferon estimations
may further increase the sensitivity and the
specificity.

20. INVESTIGATIONS
• AFB are rarely seen on smear but may be
cultured from the ascitic fluid. The yield may
be increased centrifugation of a litre of fluid.
• Confirmation of the diagnosis of tuberculosis
at any site is ideally established by
1. demonstrating AFB on smear or
2. mycobacterial culture from the tissue or by
3. demonstrating caseating granulomas at
histopathology.

21. RADIOLOGICAL INVESTIGATIONS
• An erect radiograph is also invaluable at the time
of abdominal pain in demonstrating
dilated jejunal and ileal loops with multiple air
fluid levels, with an absence of gas in the colon
and fixed bowel loop in cases of obstruction,
pneumoperitoneum in cases of perforation,
Enteroliths, mottled calcification in the
mesenteric lymph nodes, and
any evidence of ascitis may be suggested on the
plain film.

22. RADIOLOGICAL INVESTIGATIONS
• Evidence of tuberculosis in a chest radiograph supports the
diagnosis, but a normal chest radiograph does not rule it
out.
• The findings can be
1. miliary tuberculosis
2. atelectasis, emphysema, bronchiectasis, or parenchymal
opacity—any of these when present with pleural effusion
or hilar lymphadenopathy indicates active disease; or
3. patchy consolidation or infiltration.
• Signs of “old” tuberculosis (e.g., obliterated costophrenic
angle, calcified hilar lymph nodes, or a fibro-calcific lesion)
are present in 20% of patients.

23. BARIUM STUDY
• Barium meal follow through examination as
the best diagnostic test, demonstrating bowel
lesions highly suggestive of tuberculosis such
as multiple strictures and distended caecum
or terminal ileum in 84% of cases.

24. Barium meal:
• mucosal irregularity and rapid emptying (ulcerative);
• flocculation and fragmentation of barium
(malabsorption);
• stiffened and thickened folds;
• luminal stenosis with smooth but stiff contours (“hour
glass stenosis”);
• dilated loops and strictures;
• displaced loops (enlarged lymph nodes); and
• adherent fixed and matted loops (adhesive peritoneal
disease).

25. Barium enema:
• The following characteristics may be seen:
• spasm and oedema of the ileocaecal valve (early
involvement);
• characteristic thickening of the ileocaecal valve lips or
wide gaping of the valve with narrowed terminal ileum
(“Fleischner” or “inverted umbrella sign”);
• “conical caecum”, a deformed and pulled-up caecum
due to contraction and fibrosis;
• increased (obtuse) ileocaecal angle and dilated
terminal ileum, appearing suspended from a retracted,
fibrosed caecum (“goose neck deformity”) ;
• deformed and incompetent ileocaecal valve;

26. Barium enema:
• “purse string stenosis”—localised stenosis opposite
the ileocaecal valve with a rounded-off smooth caecum
and a dilated terminal ileum ;
• “Stierlin’s sign”—appears as a narrowing of the
terminal ileum with rapid empyting into a shortened,
rigid, or obliterated caecum; and
• “string sign”—a narrow stream of barium, indicating
stenosis
• Both Stierlin and String signs can also be seen in
Crohn’s disease.
• Enteroclysis followed by a barium enema may be the
best protocol for evaluation of intestinal tuberculosis.

27. Barium enema:
• increased (obtuse)
ileocaecal angle
• retracted, fibrosed
caecum (“goose neck
deformity”) ;

28. ULTRASONOGRAPHY
• Ultrasonography being a widely available
investigation, is now a ‘low threshold’
diagnostic procedure.
• It can accurately demonstrate small quantities
of ascitic fluid and is an effective method for
detection of peritoneal disease.

29. ULTRASONOGRAPHY
• Free or loculated ascitis.
• “Club sandwich” or “sliced bread” sign, due
to localised fluid between radially oriented
bowel loops.
• Multiple, thin, complete and incomplete
septae are seen.
• Strands of septae may be due to high fibrin
content of the exudative ascitic fluid.

30. ULTRASONOGRAPHY
• Floating echogenic
debris.

31. ULTRASONOGRAPHY
• Lymphadenopathy is usually occurs in
mesenteric, peri-pancreatic, periportal, and
para-aortic groups of lymph nodes.
• Lymphadenopathy may be discrete or
conglomerated (matted). The echotexture is
mixed heterogenous(necrosis), in contrast to the
homogenously hypoechoic nodes of lymphoma.
• Both caseation and calcification are highly
suggestive of a tubercular aetiology.

32. ULTRASONOGRAPHY
• Multiple enlarged
hypoechoic nodes
• Thickened hyperechoic
mesentry.

33. ULTRASONOGRAPHY
• Bowel wall thickening—best appreciated in
the ileocaecal region.
• A thickening of the small bowel mesentery of
15 mm or more and an increase in mesenteric
echogenicity combined with mesenteric
lymphadenopathy has been reported as the
characteristic sonographic feature of early
abdominal tuberculosis.

34. ULTRASONOGRAPHY
• Pseudo-kidney sign—involvement of the
ileocaecal region that is pulled up to a
subhepatic position.
• Peritoneal thickening and nodularity are the
other sonographic features of abdominal
tuberculosis.
• Ultrasound-guided fine-needle aspiration
(FNA) biopsy has been used successfully in the
diagnosis of abdominal tuberculosis

35. COMPUTED TOMOGRAPHY
• Till a few years ago, the only feature of abdominal
tuberculosis reported on CT was the nonspecific
appearance of high density ascites.
• The most common findings on CT that are highly
suggestive of abdominal tuberculosis are
high density ascites,
lymphadenopathy,
bowel wall thickening, and
irregular soft tissue densities in the omental
area

36. COMPUTED TOMOGRAPHY
• Abdominal lymphadenopathy is the
commonest manifestation of tuberculosis on
CT
• the lymph nodes involved most commonly
include mesenteric, peri-portal, peri-
pancreatic, and upper para-aortic groups of
nodes.

37. CECT
• The CECT have been described as –
peripheral rim enhancement,
non-homogenous enhancement,
homogenous enhancement and
homogenous non-enhancement, in that order of
frequency.
• Different patterns are seen same nodal group,
possibly related to the different stages of the
pathological process.

38. CECT
• Though not
pathognomonic, the
pattern of peripheral
rim enhancement,
could be highly
suggestive of
tuberculosis in an
appropriate clinical
setting.

39. CECT
• Conglomerate mass of
6cm.
• Enlarged nodes with
hypo enhancing areas
are seen.

40. CECT
• The presence of nodal calcification in the
absence of a known primary tumour in
patients from endemic areas suggests a
tubercular aetiology .
• CECT imaging criteria differentiating
abdominal lymph node enlargement due to
tuberculosis or lymphoma suggested some
differences in the anatomic distribution and
the CT enhancement patterns

41. CECT
CECT FINDINGS Tuberculosis lymphoma
Lymph nodes lesser omental,
mesenteric, and upper
para-aortic
lower para-aortic lymph
nodes
Lymphadenopathy features peripheral rim
enhancement, frequently
with a multilocular
appearance
homogenous
attenuation.

42. CECT
• Ascites can be free or loculated.
• Characteristically, it is a high density ascites which could be
because of high protein and cellular contents of the fluid.
• Mesenteric involvement and presence of
 macronodules (> 5mm in diameter),
 a thin omental line (fibrous wall covering the infiltrated
omentum),
 peritoneal or extraperitoneal masses with low density
centres and calcification,
 and splenomegaly or splenic calcification have been more
commonly seen with tuberculous peritonitis.

43. CECT
• High density ascitic fluid
• Peritonial and
mesenteric thickening
and enhancement are
seen.

44. CECT
• The diagnosis of tuberculosis is suggestive when
loculated fluid collections are detected in the
presence of omental infiltration,
peritoneal enhancement,
transperitoneal reaction, and
mesenteric or bowel involvement.
mural thickening affecting the ileocaecal region.

45. CECT
• Involvement of the liver and spleen in miliary
tuberculosis may appear on CT as tiny low
density foci widely scattered throughout the
organ.
• The macronodular form of hepatosplenic
tuberculosis may be seen as multiple low
attenuation (15-50 HU), 1-3 cm round lesions
or simple tumour like masses.

46. CECT
• Multiple small
hypoenhancing focci in
liver parenchyma.

47. CECT
• Multiple hepatic and
splenic abcess
appearing as
hypoenhancing
nodules, well defined
lesions.

48. CECT
• CT is more accurate than ultrasound in
detecting abnormalities such as periportal and
peripancreatic lymph nodes and bowel wall
thickening.
• However, bowel wall dilatation can be better
appreciated on ultrasound than on a CT scan.
• Magnetic resonance imaging (MRI), when
compared to a CT scan, provides no additional
information.

49. Imaging Bacterial Infection with
Infecton
• A new radioimaging agent, Tc-99m
ciprofloxacin (Infecton) has been used to
detect deep-seated bacterial infections, such
as intraabdominal abscesses.
• Patients with suspected bacterial infection
have been subjected to Infecton imaging and
microbiological evaluation, reporting an
overall sensitivity of 85.4% and a specificity of
81.7% for detecting infective foci.

50. Infecton
• Infecton may aid in the earlier detection and
treatment of deep-seated infections, and
serial imaging with Infecton might be useful in
monitoring clinical response and optimising
the duration of antimicrobial treatment.

51. ENDOSCOPY
• Endoscopic appearances in tuberculosis
include hyperaemic nodular friable mucosa,
irregular ulcers with sharply defined margins
and undermined edges, and pseudopolyps.
• These may mimic inflammatory bowel disease
and malignancy.

52. ENDOSCOPY
• Endoscopic biopsy may not reveal granulomas
in all cases, as the lesions are submucosal.
• Biopsies from the edges and the base of the
ulcer or multiple biopsies from the same site
may increase the yield.
• Endoscopic biopsy specimens may be
subjected to PCR for detection of AFB.

53. LAPAROSCOPY
• In peritoneal tuberculosis, laparoscopic
appearances of thickened peritoneum along
with whitish to yellowish miliary tubercles
studded over the peritoneum and other
viscera have been found to be more helpful in
diagnosis of tuberculosis than either
histological or bacteriological examination.

54. OTHER ARTICLES
• Diagnostic Laparoscopy Overtaking Other Diagnostic
Modalities in Peritoneal Tuberculosis.
• Establishing the histological diagnosis can be difficult,
frequently delaying treatment. In patients with the relevant
background and clinical history, laparoscopy is the
investigation of choice,and has the ability to take
peritoneal biopsy ( histological confirmation) in a minimal
invasive way. CT reliably demonstrates the entire range of
findings which need interpretation in the light of clinical
and laboratory data. Other diagnostic tests can supplement
the diagnosis of peritoneal tuberculosis.

55. Results
• Diagnostic laproscopy was positive in 46 patients out of 50
biopsy proven cases of peritoneal tuberculosis with a
sensitivity of 92% .
• CECT abdomen detected 30 out of 50 cases of abdominal
tuberculosis with a sensitivity of 60%.
• Zeil Neilson staining for mycobacterium tubercle bacilli
(MTB) of ascitic fluid was positive in 2 cases (4%).
• Culture for MTB was positive in 8 cases (16%).
• Ascitic fluid analysis for ADA (> 33 U/L) showed a sensitivity
and specificity of 100% and 96% respectivily.
• Mantoux test was positive in 23 cases (46%). Sensitivity of
ESR was 90%.

56. MANAGEMENT
• Management All patients with abdominal
tuberculosis should be given standard full
course of ATT.
• Conventional regimens suggest ATT for 12 to
18 months. However, the use of short course
regimens for 6-9 months have been found to
be equally effective.

57. MANAGEMENT
• Some authors have recommended the
addition of corticosteroids in patients with
peritoneal disease in order to reduce
subsequent complications of adhesions. No
controlled studies have been performed to
show their benefit.
• Patients with intestinal obstruction due to
strictures and hypertrophic lesions require
surgical treatment.

58. MANAGEMENT
• Subacute intestinal obstruction or acute-on-
chronic obstruction responds usually to
conservative management and patients can be
investigated later and managed electively.
• Despite being a treatable disease, abdominal
tuberculosis carries a mortality of 4-12% which is
largely due to associated problems of
malnutrition, anaemia, and hypoalbuminaemia
and due to acute complications.

59. CONCLUSION
• Abdominal tuberculosis, a frequently
recognized form extrapulmonary tuberculosis
is increasing with increasing frequency of HIV
infection. A high index clinical suspicion,
appropriate and timely investigations, early
diagnosis and treatment can considerably
reduce the morbidity and mortality from this
curable but potentially lethal disease.

60. Imaging bacterial infection with
99mTc-ciprofloxacin
(Infecton)
K E Britton, D W Wareham, S S Das, K K Solanki, H
Amaral, A Bhatnagar,
A H S Katamihardja, J Malamitsi, H M Moustafa, V E
Soroa, F X Sundram, A K Padhy
J Clin Pathol 2002;55:817–823

61. Aims:
• The diagnosis of deep seated bacterial
infections, such as intra-abdominal abscesses,
endocarditis, and osteomyelitis, can be
difficult and delayed, thereby compromising
effective treatment.
• This study assessed the efficacy of a new
radioimaging agent, Tc-99m ciprofloxacin
(Infecton), in accurately detecting sites of
bacterial infection.

62. Patient selection:
• 879 patients, suspected to have bacterial
infection from the different countries are
included in this study to the types of infection
imaged.
• Pregnant and lactating women or those with
known hypersensitivity to quinolone
antibiotics were excluded.

63. Preparation of Infecton
• Infecton was produced by reducing 2 mg of
ciprofloxacin with 500 mg of stannous
tartrate, at a buffered pH of 4.0, and
radiolabelling with Technetium-99m up to 10
mCi (370 MBq).
• The agent was produced in house at St
Bartholomew’s Hospital, London, and supplied
as a two phase kit formulation, requiring 10
minutes to prepare.

64. Imaging protocol
• 10 mCi (370 MBq) of Tc-99m Infecton was
injected intravenously over 40 seconds.
• 300 to 500 Kcounts were collected by the local
single or double headed g camera, set with a low
energy parallel hole general or high resolution
collimator and peaked for 140 Kev with a 15%
window.
• Anterior and posterior whole body static images
were acquired at approximately one and four
hours, and where indicated 24 hours after the
injection.

66. Criteria for the interpretation of
Infecton images
• A true positive result was one in which the image
showed an area of abnormal uptake of the agent
together with evidence of focal infection at the
same site within five days of the image. A positive
scan in a patient with probable infection was
considered true positive.
• A false positive result was one in which the
image findings were abnormal but there was no
evidence of infection at the same site within five
days of the image.

67. • A true negative result was one in which imaging
was and there was no evidence of focal infection
within five days of imaging. This included patients
whose infection had resolved with antibiotic
treatment at the time of imaging.
• A false negative result was one in which the
image showed no abnormality but there was
evidence of focal infection within five days of
imaging. A negative scan in a patient with
infection was considered false negative.

68. • A set of blood
pool, 1, 3.5,
and 24 hour
images show
focally
increased and
persistent
uptake in the
left index
finger

70. DISCUSSION
• This multicentre study shows that Tc-99m
labelled ciprofloxacin (Infecton) is able to
diagnose and localise a wide range of bacterial
infections accurately.
• The infections detected included
osteomyelitis, septic arthritis, prosthetic
device infections, endocarditis, deep seated
abscesses, and extrapulmonary tuberculosis.

71. • In this study, the most successful results were seen in
 osteomyelitis (sensitivity 90.5%, specificity 72.8%)
 orthopaedic prosthesis (sensitivity 96%, specificity
91.6%),
 with good sensitivity in microbiology positive
tuberculosis (90%),
 soft tissue (94.4%),
 abdominal infections (93.3%),
 excellent specificity in bacterial endocarditis (100%)
 surgical wound infections (100%).

72. Take home messages
• Infecton gave an overall sensitivity of 85.4% and a
specificity of 81.7% for detecting infective foci
• Sensitivity was higher (87.6%) in microbiologically
confirmed infections
• Thus, Infecton is a sensitive technique, which could result in
the earlier detection and treatment of a wide variety of
deep seated bacterial infections
• The ability to localise infective foci accurately is also
important for surgical intervention, such as the drainage of
abscesses
• Serial imaging with Infecton might be useful in monitoring
clinical responses and optimising the duration of
antimicrobial treatment.

73. Thank you