Abdominal tuberculosis is common in India and other developing countries. It can affect the intestines, peritoneum, mesentery and lymph nodes. Symptoms include abdominal pain, diarrhea, weight loss and fever. Diagnosis involves imaging tests like ultrasound and CT scan as well as biopsy of affected tissues. Treatment consists of a combination of anti-tuberculosis drugs for at least 6-12 months as well as possible surgery for complications like obstruction or abscess. Regular follow up is needed to monitor response to treatment.

1. TUBERCULOSIS IN SURGERY
PRESENTER-DR INDUMATHI B

2. Introduction
• A common disease in India and other developing countries
• Abdominal tuberculosis is the 6th most common type of extra-
pulmonary tuberculosis.
• 40% of Indians harbour Tb bacilli
• Incidence is high in HIV infected patients
• Commonly caused by Mycobacterium tuberculosis(gram neutral, acid
fast, alcohol fast)
• Occasionally by mycobacterium bovis, M.kanasii, M.fortium,
M.marinum, M.ulcerans

3. • The characteristic lesion is ‘tubercle’, which is an avascular granuloma
composed of central zone containing giant cells ,with or without
caseation necrosis ,surrounded by a rim of epithelioid cells,
lymphocytes and fibroblasts.

4. ABDOMINAL TUBERCULOSIS
• INTESTINAL TUBERCULOSIS
• PERITONEAL TUBERCULOSIS
• TUBERCULOSIS OF MESENTRY AND ITS LYMPH NODES
• ANO-RECTAL-SIGMOIDAL TUBERCULOSIS
• TUBERCULOSIS OF OMENTUM

5. MODE OF SPREAD OF ABDOMINAL TUBERCULOSIS
• By ingestion of food contaminated with tubercle bacilli causing
primary intestinal tuberculosis.
• Ingestion of sputum containing tuberculous bacteria from primary
pulmonary focus causing secondary intestinal tuberculosis.
• Hematogenous spread from tuberculosis of lungs.
• From neck nodes(Tuberculous cervical lymphadenitis -5-10%) through
lymphatics.
• From fallopian tubes by retrograde spread to involve peritoneum.
• Direct spread from adjacent organs.

6. INTESTINAL TUBERCULOSIS
• Intestinal tuberculosis is also called as KOENIGS SYNDROME.
• ILEOCAECAL REGION :
• A)Ulcerative
• B)Hyperplastic
• C)Ulcerohyperplastic
• ILEAL REGION:
• Stricture type

7. ILEOCAECAL TUBERCULOSIS
• It is the most common site of abdominal tuberculosis .
• Causative organism:
• Mycobacterium tuberculosis-Acid fast 20%h2so4.
• It is presently due to mycobacterium tuberculosis ,earlier used to be
due to mycobacterium bovis.
• Atypical mycobacterium can spread directly.
• Mycobacterium avium spreads through lymphatics.

8. TYPES
• ULCERATIVE:
• Most common-60%.
• Circumferential transverse often multiple ‘girdle 'ulcers with skip
lesions.
• Common in old, malnourished people.
• Ulcers-fibrosis-stricture formation.
• Stricture is common in ileal part.
• Intestinal nodes are involved with caseation, abscess formation.
• Bowel adhesions.
• Patients mainly present with diarrhea,blood in stool,loss of appetite
and reduced weight.

9. • HYPERPLASTIC :
• Fibroblast reaction in submucosa and subserosa causing thickening of
bowel wall & lymph node enlargement-nodular mass formation.
• 10%common,less virulent, with adequate host resistance.
• Young, well nourished individuals.
• Common in caecal part.
• Extensive chronic inflammation,Fibrosis,bowel adhesions, nodal
enlargement.
• Patient often presents with mass in the right iliac fossa,

10. • Caseation necrosis is not common.
• It is commonly primary intestinal tuberculosis.
• There is no primary foci in the lungs.
• ULCEROHYPERPLASTIC-30%

11. CLINICAL FEATURES
• Abdominal pain is the most common symptom. It is dull in
mesenteric type; colicky in intestinal type.
• Common in 25-50 years age group, equal in both sexes.
• Anemia, loss of weight & appetite.
• Diarrhea
• Fever
• Mass in right iliac fossa-hard,nodular,nonmobile,nontender .
• Subacute obstruction can occur
• Associated with adeno-carcinoma of caecum, or large bowel
lymphoma or HIV

12. DIFFERENTIAL DIAGNOSIS
• Carcinoma caecum
• Ameboma
• Appendicular mass
• Ectopic kidney
• Retroperitoneal tumor
• Lymph node mass
• Psoas abscess
• Crohn’s disease.

13. INVESTIGATIONS
• Chest X-ray
• Mantoux test, ELISA, Serum IgG.
• ESR-raised.
• Plain Xray abdomen
• -intestinal obstruction
• -calcified lymph nodes
• -calcified granuloma in liver
• -perforation

14. Investigations
• USG abdomen
• -Thickened bowel wall
• -Loculated ascites
• -Interloop ascites(club-sandwich appearance)
• -mesenteric thickening >15mm
• -lymph node enlargement
• -Pulled up caecum presenting with a mass in subhepatic region-
PSEUDO KIDNEY SIGN

15. INVESTIGATIONS
• BARIUM STUDY X-RAY(barium enema or barium follow through Xray)
• -pulled up caecum
• -obtuse ileocaecal angle ;straightening (Goose neck).
• Stierlin sign: Hurrying of barium due to rapid flow and lack of barium
in inflamed site.
• Fleischner sign(inverted umbrella sign): narrow ileum with thick
ileoceacal valve.
• Napkin lesions-ulcers and strictures in terminal ileum & caecum.
• Chicken intestine-Hypersegmentation
• Mega ileum-Multiple strictures with enormous dilatations of the
proximal ileum.

16. Investigations
• COLONOSCOPY
• -To rule out carcinoma.
• -shows mucosal nodules, ulcers, caecal & ileal strictures, deformed
ileocecal valve, mucosal edema & diffuse colitis.
• Biopsy can be taken to confirm the diagnosis.

17. INVESTIGATIONS
• CT ABDOMEN
• -Thickened bowel wall
• -Ileocaecal valve thickening
• -Adhesions.
•

18. INVESTIGATIONS
• DIAGNOSTIC LAPAROSCOPY:
• Direct visualization
• Collect ascitic fluid
• Take biopsy from mass, omentum or peritoneum.

19. Investigations
• PCR of biopsied tissue or ascitic fluid.
• -DNA-PCR can detect 1-2 organism,positive PCR signifies infection but
need not be active disease.
• ASCITIC TAP FLUID ANALYSIS
• Exudate fluid(protein>3.0g/dl)
• Serum ascitic albumin gradient<1.1
• Lymphocytic predominant cells >250/cu mm(up to 4000/cu mm)
• Glucose>30mg
• Specific gravity>1.016
• ADA (ADENOSINE DEAMINASE ACTIVITY) 95%specificity & 98%
sensitivity.
• LDH>90units/litre.

20. COMPLICATIONS
• Obstruction -20%
• Malabsorption ,blind loop syndrome
• Dissemination of tuberculosis
• Cold abscess formation
• Perforation
• Faecal fistula

21. TREATMENT
• DRUGS
• FIRST LINE DRUGS:
• INH
• Rifampicin
• Pyrazinamide
• Ethambutol
• SECOND LINNE DRUGS:
• Amikacin, kanamycin, PAS, Ciprofloxacin ,Clarithromycin
,Azithromycin, Rifabutin.

22. TREATMENT
• SURGICAL MANAGEMENT:
• Indications:
• Intestinal obstruction
• Severe haemorrhage
• Acute abdomen(perforation)
• Intra abdominal abscess or fistula formation.
• Uncertain diagnosis.

23. TREATMENT
• SURGICAL MANAGEMENT:
• Ileocaecal resection with 5cm margin,this may be done in initial
period depending upon the obstructive & other perforations.
• During therapeutic period ,healing with fibrosis causes stricture and
obstruction in 3-6weeks after drug therapy.
• Single ileal stricture-stricturoplasty may be done.
• Single stricture with friable and edematous bowel- Resection.
• Multiple stricture with long segment gaps-multiple stricturoplasty
• Multiple strictures: Resection and anastomosis.

24. Treatment
• SURGICAL MANAGEMENT:
• Early perforations: resection and anastomosis (due to friable bowels).
• Perforation with severe contamination: resection with colostomy
• Adhesiolysis by laproscopy
• Drainage of intra abdominal abscess,perianal abscess and treatment
for tuberculous fistula-in-ano is done when necessary.

25. ILEAL TUBERCULOSIS
• It is usually stricture type
• May be multiple
• Presents with intestinal obstruction
• Bowel adhesions ,localization, fibrosis, secondary infections are
common.
• Perforation(5%)
• Plain Xrays-multiple air fluid levels.
• Resection and anastomosis with anti-Tb drugs.

26. PERITONEAL TUBERCULOSIS
• It is post primary
• Becoming more common
• Activation of long standing latent foci
• Blood spread
• Can develop from diseased mesenteric lymph nodes , intestines or
fallopian tubes.

27. Peritoneal Tuberculosis
• Basic pathology
• Enormous thickening of the parietal peritoneum
• Multiple tiny yellowish tubercles
• Dense adhesions in peritoneum and omentum with small intestines
• May precipitate intestinal obstruction
• Thickening of bowel wall

28. Peritoneal Tuberculosis
• ABDOMINAL COCOON SYNDROME
• Dense adhesions in peritoneum and omentum with contents inside as
small bowel causing intestinal obstruction.

29. Peritoneal Tuberculosis
• TYPES
• 1.Acute –mimics acute abdomen
• Rare
• On –table diagnosis
• Features of peritonitis
• Due to perforation or rupture of mesenteric tuberculous lymph nodes
• Explorarory laparotomy reveals straw coloured fluid with tubercles in
the peritoneum,greater omentum,and bowel wall.
• Fluid evacuated and sent for culture and AFB study.
• Biopsy taken from omentum
• To be closed without drains.

30. Peritoneal Tuberculosis
• 2.CHRONIC
• Present as
• Abdominal pain
• Fever
• Ascites
• Loss of appetite and weight
• Abdominal mass
• Doughy abdomen(10%)
• TYPES
• A) Ascitic B)Encysted C) Plastic D)Purulent form

31. • ASCITIC PERITONEAL TUBERCULOSIS
• Enormous distension of abdomen with dilated veins.
• Intense exudate caused ascites
• Children and young adults
• May presents with congenital hydrocele ,umbilical hernia, shifting
dullness, fluid thrill, and mass per abdomen
• Ascitic tap reveals straw coloured fluid from which AFB can be
isolated . Fluid is pale yellow, clear, rich in lymphocytes , with high
specific gravity.
• Anti –Tb drugs for one year.
• Repeated tapping may be required.

32. Peritoneal Tuberculosis
• ENCYSTED(LOCULATED)PERITONEAL TUBERCULOSIS
• Exudation with minimal fibroblastic reaction
• Ascites gets loculated because of fibrinous deposition
• Non shifting dullness is the typical feature
• May present as intra-abdominal mass mimicking ovarian cyst .
• USG guided aspiration and anti-tubercular drugs to be given.

33. PERITONEAL TUBERCULOSIS
• PLASTIC PERITONEAL TUBERCULOSIS
• Extensive fibroblastic reaction
• Widespread adhesions
• Between the coils of intestine(ileum),abdominal wall,omentum
• Obstruction Distension of abdomen
• Colicky abdominal pain(recurrent)
• Diarrhoea ,loss of weight,,mass per abdomen,doughy abdomen
• Open /laprascopic biopsy (to rule out peritoneal carcinomatosis)
• Anti –tb drugs
• Surgery is indicated if obstruction occurs.

34. • PURULENT PERITONEAL TUBERCULOSIS
• Direct spread from tuberculous salpingitis
• Mass per abdomen containing pus,omentum,fallopian tubes, small
and large bowel
• Cold abscess may get adherent to umbilicus umbilical fistula
• Genitourinary tuberculosis is usually present
• Anti –Tb drugs with exploration of umblical fistula

35. Tuberculous mesenteric lymphadenitis
• 1.CALCIFIED LESION:
• Along the line of the mesentery a single multiple calcified lesions
• Peyer’s patches involved
• No active infection
• May be on right or left side(R>L)
• Anti-tubercular drugs

36. Tuberculous mesenteric lymphadenitis
• 2.ACUTE MESENTERIC LYMPHADENITIS
• Common in children
• Mimics acute appendicitis
• Tender mass of lymph node palpable in right iliac fossa which are
matted and non-mobile.
• Intestines adherent to caseating lymph nodes obstruction
• Surgery for appendicitis or obstruction with lymph node biopsy
• Anti –tubercular drugs.

37. Tuberculous mesenteric lymphadenitis
• 3.PSEUDO MESENTERIC CYST
• Caseating material collected between the layers of mesentery
• Forms cold abscess
• Mimicking a mesenteric cyst.
• 4.TABES MESENTERICA
• Massive enlargement of mesenteric lymph nodes due to tuberculosis
• 5.CHRONIC LYMPHADENITIS
• Children
• Failure to thrive
• Protuberant abdomen and emaciation
• Lymph node on deep palpation in right iliac fossa

38. Tuberculous mesenteric lymphadenitis
• DIFFERENTIAL DIAGNOSIS:
• Carcinoma caecum
• Lymphoma
• Retroperitoneal tumour
• Nonspecific lymphadenitis
• Acute nonspecific lymphadenitis is called as nurses’ syndrome

39. Tuberculous mesenteric lymphadenitis
• INVESTIGATIONS
• X-ray abdomen shows calcifications
• USG may confirm the diagnosis
• Mantoux test may be positive
• Diagnostic laparoscopy-TB lymphadenitis. Mesenteric cold abscess
can be drained safely laparoscopy
• TREATMENT: Anti-TB drugs; laparoscopy and proceed.

40. ANO-RECTAL-SIGMOIDAL TUBERCULOSIS
• Mimics ca rectum
• Occurs within 10cm of anal verge
• Present as tenesmus, diarrhea and multiple discharging fistula in ano
• Haematochezia is the most common symptom
• Fistula is painful ,not indurated
• Tuberculous ulcers are shallow,bluish with undermined edges.
• Investigation:
• Sigmoidoscopy
• USG
• Discharge study
• Fistulectomy and biopsy

41. ANO-RECTAL-SIGMOIDAL TUBERCULOSIS
• TREATMENT:
• Anti-TB drugs
• Fistulectomy
• Sigmoid resection

42. OMENTAL TUBERCULOSIS
• As a part of other abdominal tuberculosis
• Rolled up omentum with thickening
• Cold abscess in omentum
• Age : 25 to 50 yrs
• Equal in both sexes
• Constitutional symptoms:
• Fever
• Anorexia
• Cachexia
• Diarrhoea
• Anemia
• Laparoscopy under the cover of Anti-Tb drugs.

43. FOLLOW UP & PROGNOSIS
• Regular weight check to see for weight gain
• Improvement in appetite
• Reduction of abdominal pain and distension
• Absence of fever
• Normal bowel habits
• Normal haemoglobin
• ESR becoming normal

44. Follow up & prognosis
• Patients who are not responding in 6weeks should be reassessed
again for drug resistance; or associated with malignancy ,crohn’s
disease, eosinophilic enteritis.
• During therapy, patient who is responding for drug therapy can also
go for intestinal obstruction due to fibrosis during healing stage .
• Repeated

45. TUBERCULOUS LYMPHADENITIS
• Most common form of extra pulmonary tuberculosis.
• Scrofula
• SITES:
• Common in neck lymph nodes-80%
• Upper deep cervical(jugulodigastric-54% ;20% B/L)
• Posterior triangle(22%)

46. Tuberculous lymphadenitis
• Mode of infection : Tonsils or adenoids
• Tonsillar infection shows multiple tubercles on its surface
jugulodigastric nodes.
• Infection reach lymph node first subscapsular sinus lymph
node cortex contains plenty of lymph follicles.
• Matting is due to periadenitis
• Adenoids-posterior triangle lymph nodes are involved –
retropharyngeal lymphatics.
• Fibrosis and calcification can occur

47. Tuberculous lymphadenitis
• Gross: firm,matted,lymph node with cut section showing yellowish caseating
material.
• M/S: Epitheliod cells with caseating material are seen along with langhans
type of giant cells.
• Types ; Acute type: infants & childhood below 5 yrs
• Hyperplastic type: lymphoid hyperplasia , lymph nodes-hard & mobile.
• Caseating type: matted nodes with cold abscess, young adults
• Atrophic type: small lymph nodes but caseating type with atrophied nodes,

48. Tuberculous lymphadenitis
• STAGES

49. Tuberculous lymphadenitis
• CLINICAL FEATURES:
• Swelling-firm & matted
• Cold abscess –soft,smooth,nontender,fluctuant.(skin is free)
• Contains cheesy caseating material.
• Increase in pressure-cold abscess ruptures out of deep fascia –collar
stud abscess(adherent to skin)-bursts open –discharging
sinus.(multiple, wide open mouth ,undermined, nonmobile with
bluish colour around the edges.

50. Tuberculous lymphadenitis
• 20% of Tb lymphadenitis is associated with pulmonary tuberculosis.
• Bluish hyperpigmented involved overlying skin is called as
scrofuloderma.
• Sinus may persist due to fibrosis,calcification,secondary infection,
inadequate reach of drug to maintain optimum concentration in
caseation.

51. Tuberculous lymphadenitis
• INVESTIGATIONS:
• Hematocrit, ESR, peripheral smear.
• USG NECK-nodal size,matting,cold abscess, number of nodes
• Doppler usg –hilar vascularity
• FNAC of lymph node and smear for AFB and culture. Epitheliod cells
are diagnostic. Langhans giant cells, lymphocytes, plasma cells.
• Lowenstein-Jensen media is used for culture (6weeks)
• Selenite medium –growth in 5days.

52. Tuberculous lymphadenitis
• TREATMENT
• Antitubercular drugs
• Rifampicin 450mg OD on empty stomach, bactericidal & hepatotoxic.
• INH 300mg OD ,bactericidal, intolerance of GIT, Neuritis ,Hepatitis.
• Ethambutol 800mg OD, bacteriostatic , causes GIT intolerance,
retrobulbar neuritis
• Pyrazinamide 1500mg OD (750mg BD) ,bactericidal, hepatotoxic
,hyperuricemia and increased psychosis.
• Duration -6 to 9 months.

53. Tuberculous lymphadenitis
• TREATMENT
• Aspiration of the cold abscess with wide bore needle in
nondependent site along a ‘’z” track to prevent sinus formation.
• Drainage is done through nondependent incision ;later closure of the
wound without drain.
• Surgical removal of tuberculous lymph node-no response to drugs &
sinus persists.

54. RENAL TUBERCULOSIS
• Commonly secondary
• Primary may be in lung

55. Renal tuberculosis
• PATHOLOGICAL TYPES
• Caseating granuloma coalesce to form a papillary ulcer and other
consecutive different forms:
• Tuberculous papillary ulcer
• Cavernous form
• Hydronephrosis
• Pyonephrosis
• Tuberculous perinephric abscess
• Calcified tuberculous area(pseudo calculi)

56. Renal tuberculosis
• Caseous kidney-putty kidney or cement kidney
• Miliary tuberculosis
• Tuberculous bacilluria occurs with early lesions in renal cortex-
spreads along ureter causing tuberculous ureteritis and stricture
ureter.
• Most common site is ureterovesical junction>pelviureteric junction.

57. Renal Tuberculosis
• Tuberculous cystitis –golf hole ureter(fibrosis causing rigid withdrawn
dilated ureteric orifice) and thimble bladder(entire bladder gets
fibrosed, stiff and unable to dilate and accommodate urine).
• Associated with Tuberculous prostatitis, seminal vesiculitis ,
tuberculous epididymitis and funiculitis.
• Thickened epididymis with ulcer on the posterior aspect of the
scrotum.

58. Renal tuberculosis
• CLINICAL FEATURES
• Males
• Right side
• Frequency both day and night;polyuria.
• Sterile pyuria:pale,puscells without organisms in acid urine-
Abacterial aciduria
• Painful micturition with hematuria
• Fever
• Weight loss

59. Renal Tuberculosis
• INVESTIGATIONS
• Reduced Hb, increased ESR
• Chest Xray, USG abdomen
• Three consecutive early morning samples of urine(EMSU) are
collected and sent for microscopy.
• Plain Xray KUB-calcification
• CT SCAN of abdomen and pelvis to see hydronephrosis,shrunken
kidney, stricture,necrosis.

60. Renal Tuberculosis
• INVESTIGATIONS
• IVU-hydrocalyx , narrowing of calyx, stricture ureter (multiple with
dilatations in between.
• Cystoscopy –multiple tubercles, bladder spasm, oedema of ureteric
orifice forming “Golf hole ureter”,scarring, ulceration ,bleeding ,
stone formation.
• Voiding cystourethrography- Ureteric stricture and reflux.

61. Renal Tuberculosis
• TREATMENT
• Antitubercular therapy is started. Duration-1year.
• After 6-12 weeks of drug therapy, surgical treatment is planned.
• Hanley’s renal cavernostomy-kidney is exposed, pyocalyx is drained,
cut edge of the capsule is sutured.
• Hydronephrosis-Anderson hynes operation
• Renal tuberculous abscess not resolving for 2 weeks should be
drained.

62. Renal tuberculosis
• TREATMENT
• Ureteral stricture-stenting/ reimplantation of the ureter into
bladder/Boari’s flap/ileal conduit
• Thimble bladder-hydraulic dilatation/ileocystoplasty/ caeco
cystoplasty/ sigmoid colocystoplasty is done.
• In U/L lesion with gross impairement of renal function-
Nephroureterectomy .

63. Tuberculous Epididymitis
• Commonly due to retrograde spread from tuberculous cystitis
• It involves globus minor first-later entire epididymis-testis in later
stage.
• Blood spread from lungs involves the globus major first.
• Thickened ,craggy,firm nodular epididymis is common
• Cold abscess or sinus or undermined ulcer may be present on the
posterior aspect of the scrotum.
• Lesion will be present on the anterior aspect in anteverted testis.

64. Tuberculous Epididymitis
• Scrotal skin loses its normal rugosity with wasting of the tissue under
the skin.
• Restricted mobility of the testis.
• Thickened beaded vas( due to tubercles)
• Secondary hydrocele in 30% cases ,60% will be having renal
tuberculosis.
• P/R:tender,thickened ,palpable seminal vesicles and irregular
prostate.

65. Tuberculous Dactylitis
• Refers to phalangeal tuberculosis
• It is called as spina Ventosa,because of its appearance as “air filled
balloon”