Abdominal tuberculosis is the third most common form of extrapulmonary tuberculosis. It can affect any part of the gastrointestinal tract from mouth to anus. The most common sites of involvement are the ileocecal region and ascending colon. Patients typically present with abdominal pain, weight loss, fever, and diarrhea or constipation. Diagnosis is based on clinical features, imaging, endoscopy, histology, and culture of tissue samples. Treatment involves a 6-month course of anti-tubercular medications with surgery for complications like obstruction or perforation. A high index of suspicion is needed for early diagnosis and management of this potentially lethal but curable disease.

1. 05/12/2007

2.  Most common form of extrapulmonary
tuberculosis (3 to 4%)
 Defined as tuberculosis infection of the
abdomen including gastrointestinal tract,
peritoneum, omentum, mesentery and its
nodes, liver, spleen and pancreas
 Mycobacterium tuberculosis is the most
frequently isolated organism

3.  Ingestion of milk or infected food
 Swallowing of sputum in active PTB
 Hematogenous spread from active pulmonary
lesion, miliary tuberculosis
 Contiguous spread from infected foci like
fallopian tubes, mesenteric lymph node
 Very rarely as a consequence of peritoneal
dialysis

4.  Gastrointestinal  Tuberculosis of the
tuberculosis mesentery and its
-Ulcerative contents
-Hypertrophic  Tuberculosis of the
-Sclerotic or fibrous solid viscera
-Diffuse colitis Liver
 Peritoneal tuberculosis Pancreas
-Acute Spleen
-Chronic  Miscellaneous
1. Ascitic form Retroperitoneal lymph
2. Encysted form node tuberculosis
3. Fibrous form

5.  Constitutes 70 to80% of abdominal tuberculosis
 Any region of the gastro intestinal tract from
mouth to anus can be involved
 Ileoceacal area most commonly affected
 It can be of ulcerative, hypertrophic, diffuse
colitis, ulcerohypertrophic, and sclerotic forms
 Entero-enteric, entero-vesical and entero-
cutaneous fistula can occur
 Luminal narrowing is often caused by adjacent
lymphadenitis which results in traction
diverticula formation, narrowing and sinus tract
formation

6.  Ulcerative form
 Usually occurs in adult patients who
are malnourished
 Ulcers lie transverse “girdle ulcers”
 Areas of the normal appearing mucosa
may be found
 Healing and fibrosis results in stricture
 Hypertrophic form
 Commonly occurs in young patients who are
relatively well nourished
 Characterised by extensive inflammation and
fibrosis which often results in adherence of bowel,
mesentery and lymph nodes

7.  Clinical features
 20 to 40 yrs age group most often affected
 A slight female preponderance
 Most common symptom is abdominl pain
others include abdominal distention, wt.loss
anorexia, fever, diarrhoea or constipation
borborygmi, bleeding per rectum
 Signs include anemia, malnutrition, abdominal
tenderness, ascites, mass in the right iliac fossa
features of intestinal obstruction
 Classic doughy abdomen described only in 6 to
11% in Indian studies

8.  Oesophageal tuberculosis
 Very rare, upper part is involved more often than
lower part, commonly present with dysphagia and
odynophagia
 Gastric tuberculosis
 Rare due to the presence of gastric acid
 Ulcerative form is the commonest
 Duodenal tuberculosis (MAC infection)
 Tuberculosis of Appendix
 Anal tuberculosis
 Mostly ulcerative, may be lupoid, verrucus,
miliary lesion
 Multiple fistulae with inguinal lymphadenopathy

9.  Acute tuberculous peritonitis
 Chronic tuberculous peritonitis
 Ascitic form
Insidious in onset, abdominal pain usualy
absent, rolled up omentum infiltrated with
tubercle may felt as a transverse solid mass
 Encysted (loculated) form
 Fibrous form
Wide spread adhesions may cause coils of
intestine matted together and distended, they
may act as blind loop

11.  In a patient with PUO, marked elevation of serum
alkaline phosphatase(3 to 6 times) with mild
elevation of s.transaminases, normal PT, s.albumin
and a slight increase in bilirubin hepatic tuberculosis
should be suspected
 Clinical syndromes of Hepatobiliary tuberculosis
Congenital tuberculosis
Primary hepatic tuberculosis
Disseminated/miliary tuberculosis
Tuberculoma
Tuberculosis of biliary tract
Hepatic failure
Granulomatous hepatitis
Tuberculous pylephlebitis

12.  Malabsorption
Coeliac disease
Lymphoma
Immunoproliferative small intestinal diseae
 Mass
Appendicular mass
Actinomycosis
Crohn’s disease
Caecal carcinoma
Lymphoma
 Ascites
Cardiac disease
Renal disease
Hepatic diseae
malignacy

13.  Hematology &serum biochemistry
 Anemia, raised ESR, hypoalbumenemia, leucopenia
with relative lymphocytosis, normal serum
transminase level, raised serum ALP
 Ascitic fluid examination
 Exudative, fluid protein>3gm%, SAAG<1.1
Ascitic/blood glucose ratio<0.96, WBC count
usually 140 to 4000cells/mm³ consist of
lymphocytes predominantly, AFB(+<3%),
culture(+<20%), IFN-γ increased
ADA((98%sensitivity&95%specificity
at cut off value 32 IU/L), PCR
 Mantoux test (positive in 50 to 100%)

14.  Culture medium
Lowenstein-Jensen
Middlebrook 7H11
Liquid medium
 QuantiFERON-TB test(QFT)
 BACTEC radiometric system
 Mycobacterial Growth indicator tubes
 Animal pathogenicity
 PCR assay
 Ligase chain reaction

15.  Imaging studies
 Chest skiagram (associated PTB in 24 to 28%)
 Plain X-ray abdomen
May show calcified lymph nodes
or granulomas in the liver, spleen,
pancreas. Other features include
dilated loops with fluid levels,
dilatation of terminal ileum and
ascites . Pneumoperitoneum may
be evident in patients with
intestinal perforation

16.  Barium studies
Enteroclysis followed by barium enema is the best
protocol
Increased transit time with hypersegmentation
(chicken intestine) and flocculation is the earliest sign
Localised areas of irregular thickened folds, mucosal
ulceration, dilated segments and strictures
Thickened iliocaecal valve with a broad triangular
appearance with the base towards the caecum
(inverted umbrella sign or (Fleischner’s sign)
Rapid transit and lack of barium retension
(Sterlin’s sign)
Narrow beam of barium due to stenosis(string’s sign)
Barium oesophagogram- ulcerative oesophagitis,
stricture, pseudo tumour masses, fistula, sinus,
traction diverticulae
Duodenal tuberculosis- segmental narrowing,
widening of the “C” loop due to lymphadenopathy

17.  Group1: Highly s/o intestinal TB if one or more of
the following features are present
a. Deformed ileocaecal valve with
dilatation of terminal ileum
b. Contracted caecum with an abnormal
ileocaecal valve and/or terminal ileum
c. Stricture of the ascending colon with
shortening of and involvement of
ileocaecal region

18.  GroupII: Suggestive of intestinal tuberculosis if
one of the following features is present
a.Contracted caecum
b.Ulceration or narrowing of the
terminal ileum
c. Stricture of the ascending colon
d.Multiple areas of dilatation, narrowing
and matting of small bowel loops
 GroupIII: Non-specific changes
Features of matting, dilatation and
mucosal thickening of small bowel loops
 GroupIV: Normal study

19.  Abdominal sonography
Often reveals a mass made up of matted loops of
small bowel with thickened walls, diseased
omentum, mesentery and loculated asites
Fine septae may be seen in the ascitic fluid
Interloop ascites gives rise to charecteristic “club
sandwitch ” appearance
Mesenteric thickening is better detected in the
presence of ascites and is often seen as the “stellate
sign” of bowel loops radiating from its root
In intestinal tuberculosis bowel wall thickening is
usually uniform and concentric as opposed to the
eccentric thickening at the mesenteric border seen in
Crohn’s disease and the variegated appearance seen
in malignancy
Granulomas or absess in the liver ,pancreas or
spleen

20.  Abdominal computerised tomography
CT is better than USG in detecting high dense
ascites
Abdominal lymphadenopathy is the commonest
manifestation of tuberculosis on CT
Retroperitoneal, peripancreatic, porta hepatis,
and mesenteric/omental lymph node
enlargement may be evident
Caseous necrosing lymph node appears as low
attenuating, necrotic centers and thick, enhancing
inflammatory rim
Preferential thickening of the medial caecal wall
with an exophytic mass engulfing the terminal
ileum associated with massive lymphadenopathy
is characteristic of tuberculosis
Short segments of mural thickening with normal
intervening bowel associated with ileocaecal
involvement strongly suggest tuberculosis

21.  MRI:- has no added advantage
 Endoscopy
Colonoscopy:- Ulceration is the most
common finding. Ileocaecal valve may
edematous or deformed. Nodules, ulcers,
pseudopolyps may be seen. A combination
of histology and culture can establish
diagnosis in 80% of cases
Fine needle aspiration cytology
Peritoneal biopsy
Laparoscopy:- most effective method. 80 to
95% diagnostic accuracy. Characteristic
finding include multiple, yellowish-white
miliary nodules over peritoneum,
erythematous, thickened and hyperemic
peritoneum

22. High index of suspicion
USG of abdomen
Suggestive Suspicious Normal
Contrast CECT
Treat barium abdomen
studies
Classical Suspicious Classical Doubtful
Endoscopic Perform
Treat Treat
biopsy FNAC/biopsy

23.  Medical treatment
A six month short-course ATT is as effective as
standard 12 month regimen
Corticosteroids-role not well established
 Surgical treatment
To manage complication such as obstruction,
perforation and massive hemorrhage
Strictures by stricturoplasty or resection
Perforation by resection and anastomosis
Bypass surgery not indicated
Surgery followed by full course of ATT

24.  The treatment TB should precede the treatment
of HIV, ie. HAART
 Patient already on HAART, should continue
the same treatment with appropriate
modifications in HAART and ATT
 Patients who are not receiving HAART, the
need and time of initiation of HAART have to
be decided on individual basis after assessing
the CD4 count and type of TB
 Adverse reactions to both ATT and ART are
common so careful monitoring is needed

25.  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.

26.  API update 2007
 Tuberculosis by Sharma & Mohan
 Harrison’s principles of internal medicine 16th ed.
 American journal of gastro enterology