Post on 27-May-2015
05/12/2007
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
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
Gastrointestinal tuberculosis-Ulcerative
-Hypertrophic
-Sclerotic or fibrous
-Diffuse colitis
Peritoneal tuberculosis-Acute
-Chronic
1. Ascitic form
2. Encysted form
3. Fibrous form
Tuberculosis of the mesentery and its contents
Tuberculosis of the solid viscera
Liver
Pancreas
Spleen
MiscellaneousRetroperitoneal lymph node tuberculosis
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
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
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
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
Acute tuberculous peritonitis
Chronic tuberculous peritonitis
Ascitic formInsidious in onset, abdominal pain usualyabsent, rolled up omentum infiltrated with tubercle may felt as a transverse solid mass
Encysted (loculated) form
Fibrous formWide spread adhesions may cause coils of intestine matted together and distended, they may act as blind loop
In a patient with PUO, marked elevation of serum alkaline phosphatase(3 to 6 times) with mild elevation of s.transaminases, normal PT, s.albuminand a slight increase in bilirubin hepatic tuberculosis should be suspected
Clinical syndromes of Hepatobiliary tuberculosisCongenital tuberculosisPrimary hepatic tuberculosisDisseminated/miliary tuberculosisTuberculomaTuberculosis of biliary tractHepatic failureGranulomatous hepatitisTuberculous pylephlebitis
MalabsorptionCoeliac disease
Lymphoma
Immunoproliferative small intestinal diseae
Mass Appendicular mass
Actinomycosis
Crohn’s disease
Caecal carcinoma
Lymphoma
AscitesCardiac disease
Renal disease
Hepatic diseae
malignacy
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%)
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
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
Barium studiesEnteroclysis 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
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
GroupII: Suggestive of intestinal tuberculosis ifone of the following features is present
a.Contracted caecum
b.Ulceration or narrowing of theterminal ileum
c. Stricture of the ascending colon
d.Multiple areas of dilatation, narrowingand matting of small bowel loops
GroupIII: Non-specific changes
Features of matting, dilatation andmucosal thickening of small bowel loops
GroupIV: Normal study
Abdominal sonographyOften 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 “stellatesign” 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
Abdominal computerised tomographyCT 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
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 casesFine needle aspiration cytologyPeritoneal biopsyLaparoscopy:- most effective method. 80 to
95% diagnostic accuracy. Characteristic finding include multiple, yellowish-white miliary nodules over peritoneum, erythematous, thickened and hyperemic peritoneum
High index of suspicion
USG of abdomen
Suggestive
Treat
Suspicious
Contrast barium studies
Classical
Treat
Suspicious
Endoscopic biopsy
Normal
CECT abdomen
Classical
Treat
Doubtful
Perform FNAC/biopsy
Medical treatmentA six month short-course ATT is as effective as
standard 12 month regimen
Corticosteroids-role not well established
Surgical treatmentTo 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
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
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.
API update 2007
Tuberculosis by Sharma & Mohan
Harrison’s principles of internal medicine 16th ed.
American journal of gastro enterology