abdominal localisation of tuberculosis and the role of surgery
Abdominal tuberculosis
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Transcript of Abdominal tuberculosis
ABDOMINAL TUBERCULOSI
S
Dr. Minhajuddin KhurramAL-AMEEN MEDICAL COLLEGE HOSPITAL,
bIJAPUR
A common disease in India and other developing countries
It the 6th most common type of extra-pulmonary tuberculosis
40% of Indians harbour tb bacilli In 2010, Global Incidence – 9.4million In india – 2.3millionPrevalence in India is 3.1 million3,20,000 deaths… -WHO
Introduction
Introduction
24th March 1882- World Tb day
TB declared as notifiable disease by INDIAN GOVERNMENT on may9th 2012
Introduction
1. Intestinal (Koenig’s syndrome)A. Iliocaecal region
Ulcerative -60% Hyperplastic-10% Mixed-30%
B. Ileal region Stricture type
2. Peritoneal tuberculosisA. AcuteB. Chronic
Ascitic Encysted Plastic Purulent
Types
3. Tuberculous mesenteric lymphadenitisA. Calcified lesionB. Acute Meseneteric lymphadenitisC. Pseudo-mesenteric cystD. Tabes mesentericaE. Chronic Lymphadenitis
4. Ano-recto-sigmoidal5. Involvement of solid organs as a part
of milary tuberculosis6. Involvement of omentum7. Rare types
A. Oesophageal (0.2% of abdominal)B. Gastroduodenal
Types
1. By ingestion◦ Ingestion of food contaminated with
tubercle bacilli causing Primary Intestinal Tuberculosis
◦ Ingestion of sputum containing tuberculous bacteria from primary pulmonary focus - Secondary Intestinal Tuberculosis
2. Hematogenous spread from lungs3. Through lymphatics (neck)4. Fallopian tubes (retrograde
spread)
Mode Of Spread
Etiology
Etiology
Most common site of abdominal tuberculosis due to:◦ Stasis◦ Abundant payer’s patches◦ Alkaline media◦ Bacterial contact time is more◦ Minimal digestive activity◦ Maximum absorption in the area
Ileocaecal Tuberculosis
A. Ulcerative type (60%):◦ Secondary to pulmonary tuberculosis◦ Virulent organism◦ Poor body resistance◦ Multiple circumferential transverse ulcers
(Girdle ulcers) with skip leisons ◦ Commonly in ileum◦ Rarely in caecum
Ileocaecal Tuberculosis
◦ Napkin ring strictures in longstanding ulcers (common in ileum)
◦ Intestinal nodes involvement with caseation and abscess
◦ May present with blood in stools, diarrhoea, loss of appetite and reduced weight
◦ Complications: Acute: Ulcer perforation Chronic: Stricture Subacute obstruction
Ileocaecal Tuberculosis
Ileocaecal Tuberculosis
B. Hyperplastic Type -10%◦ Primary GIT tuberculosis◦ Less virulent organism◦ Good body resistance◦ Chronic granulomatous lesions in ileoceacal
region◦ Fibroblastic activity in submucosa and
subserosa causes thickening of bowel wall with lymph node enlargement
Presenting as Mass in Right Iliac Fossa (Nodular fixed and firm mass)
◦ Caseation is very rare
Ileocaecal Tuberculosis
B. Hyperplastic Type -10%◦ No primary leision in the chest◦ Complication: May cause sub-acute intestinal
obstruction due to mass
Ileocaecal Tuberculosis
Others◦ Abdominal pain (90%)
Colicky type in intestinal tuberculosis Dull aching in mesenteric lymphadenitis
◦ Mass in right iliac fossa (35%) Hard, nodular, fixed, nontender mass mimicing ca
caecum◦ Subacute intestinal obstruction (20%)◦ Can be associated with adenocarcinoma of
caecum
Clinical Features
1. Ca Caecum2. Ameboma3. Appendicular mass4. Lymph node mass5. Psoas abscess6. Crohn’s disease
Differential Diagnosis
Chest Xray – for primary focus Blood investgations: Mantoux, ELISA, serum
IgG ESR- raised Plain Xray abdomen
◦ Intestinal obstruction◦ Calcified lymph nodes◦ Hollow viscus perforation◦ Calcified Granuloma in liver
Investigations
USG abdomen◦ Thickened bowel wall◦ Loculated ascitis◦ Interloop ascitis◦ Mesenteric thickening◦ Lymph node enlargement◦ Pulled up caecum (Pseudokidney sign)
Investigations
Barium study Xray (barium enema or barium follow through)◦ Pulled up caecum◦ Obtuse ileocaecal angle; straightening (Goose
neck)◦ Steirlin sign: Hurrying of barium due to rapid flow
and lack of barium in inflamed site◦ Fleischner sign (Inverted umbrella sign):
Narrow ileum with thickened ileocaecal valve◦ Napkin leisons◦ Chicken intestine: Hypersegmentation ◦ Mega Ileum: Dilatation of proximal ileum
Investigations
Barium Study showing Mega Ileum
Colonoscopy◦ To rule out ca◦ Shows mucosal nodules, ulcers, strictures,
deformed ileocaecal valve, mucosal oedema and diffuse colitis
◦ Biopsy can be taken to eslablish the diagnosis
Investigations
CT Abdomen◦ CT scan shows thickening
of the cecum with pericecal inflammatory changes. Mesenteric lymph nodes are also evident (arrows).
Investigations
Diagnostic laproscopy◦ Direct visualization◦ Collect acsitic fluid◦ Take biopsy from mass, omentum or peritoneum
Investigations
PCR of tissue Acsitic tap fluid analysis
◦ Exudate fluid (protein >2.5gm%)◦ Lymphocyte predominant cells >250 cu mm
(upto 4000 cu mm)◦ Glucose <30mg%◦ Specefic gravity >1.016◦ ADA (Adenosine deaminase activity) 95%
specificity and 98% sensitivity◦ LDH > 90 units/litre
Investigations
1. Obstruction 20%2. Malabsoprption, blind loop syndrome3. Dissemination of tuberculosis4. Cold abscess formation5. Hemorrhage6. Perforation7. Fecal fistula
Complications
Mediacal management:◦ First line drugs:
INH Rifampicin Pyrazinamide Ethambutol
◦ Second line drugs: Amikacin, kanamycin, PAS, Ciprofloxacin, Clarithrymycin, Azythromycin, Rifabutin Drug: RNTCP 2H3R3Z3 E3 + 4H3R3
◦ Treatment to be continued for 6-9 months◦ Supportive nutrition
Treatment
Surgical Management:◦ Indications:
Intestinal obstruction Severe hemorrhage Acute abdomen (perforation) Intra-abdominal abscesses/ fistula formation Uncertain diagnosis
Treatment
Surgical Management:
1. Ileocaecal resection with 5 cm margin
2. Stricturoplasty- single stricture
3. Single strictutre with friable bowel : Resection
4. Multiple Strictures: Resection and anastomosis
5. Multiple strictures with long segment gaps:
Multiple stricturiplasty
Treatment
Surgical Management:6. Early perforation: resection and anastomosis
(due to friable bowels)7. Perforation with severe contamination: resection
with colostomy8. Adhesiolysis by laproscopy (Very difficult
procedure)9. Drainage of abscesses and treatment for fistula
in ano
Treatment
It is usually stricture type May be multiple Presents with intestinal obstruction Bowel adhesions, localization, fibrosis,
secondary infection are common Perforation (5%) Plain Xray – Multiple air fluid levels Resection and anastomosis with Anti-
tubercular drugs
Ileal 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 fallpian tubes
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 obstruction◦ Thickening of bowel wall
Peritoneal Tuberculosis
Abdominal Cocoon Syndrome◦ Dense adhesions in peritoneum and omentum
with contents inside as small bowel causing intestinal obstruction
Peritoneal Tuberculosis
A. Acute –mimics acute abdomen◦ Rare◦ On-table diagnosis◦ Features of peritonitis◦ Due to perforation or rupture of mesenteric lyph
nodes◦ Exploratory laprotomy 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
Peritoneal Tuberculosis
A. Chronic◦ Presents as
Abdominal pain Fever Ascites Loss of appetite and weight Abdominal mass Doughy abdomen (10%)
◦ Typesa) Ascitic formb) Encysted formc) Plastic formd) Purulent form
Peritoneal Tuberculosis
a) Acsitic peritoneal tuberculosis:◦ Intense exudate caused ascitis◦ Common in children and young adults◦ Enormous abdominal distension◦ May cause congenital hydrdocele, umbilical
hernia, shifting dullness, fluid thrill and mass per abdomen
◦ Rolled up omentum and nodular due to extensive fibrosis
Peritoneal Tuberculosis
a) Acsitic peritoneal tuberculosis:◦ Doughy abdomen◦ Shifting dullness◦ Asitic tap reveals straw coloured fluid from
which AFB can be isolated (<3%)◦ Anti-tubercular drugs for one year◦ Repeated tapping may be required
Peritoneal Tuberculosis
b) Encysted (Loculated) peritoneal tuberculosis
◦ Exudation with minimal fibroblastic reaction
◦ Ascites gets loculated due to fibrinous deposition
◦ Non shifting Dullness is the typical feature
◦ May present as intra-abdominal mass mimicing
ovorain cyst, mesenteric cyst
◦ USG guided aspiration and antitubercular drugs
to be given
Peritoneal Tuberculosis
c) Plastic Peritoneal Tuberculosis◦ Extensive fibroblastic reaction◦ Widespread adhesions◦ Between coils of intestine (matted intestines),
abdominal wall, omentum◦ Obstruction Distension of abdomen◦ Colicky abdominal pain (recurrent)◦ Diarrhoea, loss of weight, mass per abdomen◦ Doughy abdomen
Peritoneal Tuberculosis
c) Plastic Peritoneal Tuberculosis◦ Open or laproscopic biopsy (to rule out
peritoneal carcinomatosis)◦ Anti-tubercular drugs◦ Surgery to relieve obstruction by adhesolysis
Peritoneal Tuberculosis
d) Purulent peritoneal tuberculosis◦ Direct spread from tuberculous salpingitis◦ Mass per abdomen containing pus, omentum,
fallopian tubes, small and large bowel◦ Cold abscess may get adherant to umbilicus◦ May cause umbilical discharge◦ Genitourinary tuberculosis usually present◦ Aanti-tubercular drugs with exporation of
umbilical fistula
Peritoneal Tuberculosis
1. Calcified lesion:
◦ Along the line of the mesentery a single or
multiple calcified lesions
◦ Payer’s patches involved
◦ No active infection
◦ May be on right or left side (R>L)
◦ Antitubercular drugs
Tuberculous Mesenteric Lymphadenitis
2. Acute mesenteric lymphadenits◦ Common in children◦ Mimics acute appendicitis◦ Tender mass of lymph node palpapble in Right
iliac fossa which are matted and non-mobile◦ Intestines adherant to caseating lymph nodes
obstruction◦ Surgery for appendicitis or obstruction with
lymph node biopsy◦ Antitubercular drugs
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 Lyphadenitis◦ Children◦ Failure to thrive◦ Protuberant abdomen and emaciation◦ Lymph node on deep palpation in right iliac fossa
Tuberculous Mesenteric Lymphadenitis
Mimics ca rectum Occurs within 10 cmof anal verge Presents with tenesmus, diarrhoea and multiple
discahrging fistula in ano Fistula is painless, not indurated with undermined
edges Shallow bluish ulcers with undermined edges Investigation:
◦ Sigmoidoscopy◦ USG◦ Discharge study◦ fistulectomy and biopsy
Treatment: Drugs, fistulectomy or sigmoid resection
Ano-Recto-Sigmoidal Tuberculosis
As a part of other abdominal tuberculosis Rolled up omentum Cold abscess in omentum Anti-tubercular drugs Syrgery for cold ascess
Omental Tuberculosis
As a part of other abdominal tuberculosis Rolled up omentum Cold abscess in omentum Anti-tubercular drugs Syrgery for cold ascess
Omental Tuberculosis
Age: 25 to 50 yrs Equal in both sexes Constitutional symptoms:o Fever (50-70%)oAnorexia (80%)oCachexiaoDiarrhoea (10-20%)oAnemia
Clinical Features
Clinical Features
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