ABDOMINAL ABDOMINAL TB:PRESENTATION, TB:PRESENTATION,

DIAGNOSIS AND TREATMENTDIAGNOSIS AND TREATMENT

Vishal Gajbhiye Vishal Gajbhiye

ABDOMINAL TB CLASSIFICATIONABDOMINAL TB CLASSIFICATION Intestinal - ulcerative - hyperplastic - perforative Peritoneal - wet - dry/plastic - fibrotic fixed - acute primary peritonitis Mesenteric involvement - mass - abscess - nodal Solid organ - liver , spleen,pancreas

ETIOPATHOGENESISETIOPATHOGENESIS Primary Secondary

Route of abdominal infection– Direct ingestion– Haematogenous spread– Direct extension from contiguous organ– Through lymph channels

 

FLOW CHART OF PATHOGENESISFLOW CHART OF PATHOGENESIS

Primary infection

Primary complex

Bacteremia

Good immunity Poor immunity

Lodging of bacillus in organs & nodes

dormant

Reactivation/ dec immunity

Secondary TB

Severe TB

INTESTINAL TUBERCULOSISINTESTINAL TUBERCULOSIS

Primary form – non-pasteurised dairy products

10 rarely seen in IndiaSecondary form – swallowing infected

sputum, haematogenous from 10 focus

CLINICAL PRESENTATIONCLINICAL PRESENTATION Intestinal obstruction

– Acute– Subacute– Chronic

Perforation Ascites

– Diffuse– Loculated– Organized

Lump– Abscess– LN Mass– Bowel mass– IC mass– Omental mass

SYSTEMIC MANIFESTATIONSSYSTEMIC MANIFESTATIONS

Weight loss Fever Night sweating Nausea & Vomiting Diarrhoea / Constipation Anorexia Amenorrhoea Pulmonary

UNCOMMON PRESENTATIONUNCOMMON PRESENTATION

Gastro-duodenal TBOesophagusSegmental colonicRectalAnal TBGenitourinary TB

IMPORTANT CLINICAL FINDINGSIMPORTANT CLINICAL FINDINGS

Doughy abdomenLump causes IC mass Omental mass Cocoon

INVESTIGATIONSINVESTIGATIONS

Basic test– TLC/DLC– ESR– Mantoux test– Chest X-ray– Plain X-ray abdomen

Diagnostic testsELISA for TB

X-RAY ABDOMEN WITH X-RAY ABDOMEN WITH CALCIFIED LYMPH NODECALCIFIED LYMPH NODE

X-RAY ABDOMEN WITH X-RAY ABDOMEN WITH INTESTINAL OBSTRUCTIONINTESTINAL OBSTRUCTION

USG IN ABDOMINAL TBUSG IN ABDOMINAL TB

FINDINGS Intra abdominal fluid Septae Peritoneal Thickening Lymphadenopathy

GUIDED PROCEDURES Ascitic tap FNAC / Biopsy

USG SEPTATE ASCITESUSG SEPTATE ASCITES

USG NECROTIC/CALCIFIED USG NECROTIC/CALCIFIED LYMPH NODE MASSLYMPH NODE MASS

USG BOWEL/MESENTERIC USG BOWEL/MESENTERIC THICKENINGTHICKENING

BARIUM CONTRAST STUDYBARIUM CONTRAST STUDY

FINDINGESFleishner signConical caecum Increased IC angleMultiple strictures

BARIUM CONTRAST STUDY BARIUM CONTRAST STUDY WITH IC-TUBERCULOSISWITH IC-TUBERCULOSIS

BARIUM CONTRAST STUDY BARIUM CONTRAST STUDY WITH STRICTURESWITH STRICTURES

CT SCAN ABDOMENCT SCAN ABDOMEN

Whenever diagnosis in doubt

FINDINGS Lymphadenopathy – m/c I C Mural thickening High density ascities Irregular soft tissue densities in omental area

CT SCAN TB LYMPHADENITISCT SCAN TB LYMPHADENITIS

CT SCAN BOWEL THICKENINGCT SCAN BOWEL THICKENING

CT-SCAN MESENTERIC AND CT-SCAN MESENTERIC AND PERITONEAL THICKENINGPERITONEAL THICKENING

ASCITES FLUIDASCITES FLUID

Routine microscopy AFB stain AFB culture TB PCR ADA

– Serum > 42 IU/L– Ascites fluid > 33 IU/L

SAAG < 1.1 LDH > 90 U/L

BACTEC FAST METHOD OF BACTEC FAST METHOD OF TB CULTURETB CULTURE

Liquid (BACTEC) – results available in 10-14 days

Solid (LJ Media) media – 4-6 wks

TB PCRTB PCR

It is genetic testSensitivity and specificityRapid & Result available in few hoursQuantitative – 1 to 2 bacilli

LAPAROSCOPYLAPAROSCOPY

Advantage– Diagnostic– Biopsy– Therapeutic– May avoid empirical use of ATT

Disadvantage– Invasive investigation– Difficult– Costly

TREATMENTTREATMENT

ATT as per dots/rntcp recommendationEmpirical ATT to be condemnedAspiration of abscessSurgery for unrelieved obstructionSurgery for perforation

Category of treatment

Type of patient Regimen

Category I New sputum smear +ve TB

Seriously ill new smear –ve TB

Seriously ill new EPTB

2 H3R3Z3E3

+

4 H3R3

Category II Sputum smear positive relapse

Sputum smear positive failure

Sputum smear +ve treatment after default

2 H3R3Z3E3S3 + 1H3R3Z3E3

+ 5H3R3E3

Category III New sputum smear –ve PTB

New EPTB, not seriously ill

2H3R3Z3 + 4 H3R3

RNTCP Classification of EPTBRNTCP Classification of EPTB

SERIOUSLY ILL TB meningitis Disseminated TB TB pericarditis TB peritonitis/intestinal

TB Bilateral pleurisy Spinal TB with

neurological complications

Genitourinary tract

NOT SERIOUSLY ILL Lymph node TB Pleural effusion

(unilateral) Bone (excluding spine) Peripheral joints

SURGERY FOR SURGERY FOR OBSTRUCTIONOBSTRUCTION

IC TBIndication of right hemicolectomySubacute obstructionCoccon abdomen

SURGERY FOR SURGERY FOR PERFORATIONPERFORATION

Resection of involved segment and primary anastomosis

Primary repair – risk of re-perforation or fistulisation

COMPLICATIONSCOMPLICATIONS

– Obstruction & perforation– Malnutrition and superinfection– Blind loop– Malabsorption– Enterocutaneous fistula– Short bowel syndrome– Infertility

ABDOMINAL TB AND HIVABDOMINAL TB AND HIV

Both incidence and severity increasedEP TB 10-15% of all cases

50% of patient with AIDSMainly MDR TBSecond line drugs can be used

CONCLUSION :Suspicion is mustDiagnosis is possibleTB PCR is a valuable testEmpirical ATT should be avoidedLaparoscopy is an important diagnostic toolSurgery for unavoidable reasons only

THANK YOU