ascites

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ABDOMINAL TUBERCULOSIS

• Prof. M.P. Sharma
• Department of Gastroenterology
• All India Institute of Medical Sciences

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Introduction

• TB can involve any part of GIT from mouth to
  anus, peritoneum pancreatobiliary system.
• Very varied presentation possible ?
• Great mimicker.
• TB of GIT- 6th most frequent extrapulmonary
  site.

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PREVALENCE

• Isolated abdominal tuberculosis
• Unselected autopsy series- 0.02 - 5.1
• Higher prevalence in females in India
  (3141)
• Despite increased Pul TB in males
• ? contamination of food and hands
• Secondary to Pul. TB

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• Chuttani 0.8 hospital admissions due to
  intestinal TB
• Autopsies of pt of pulmonary TB before ATT era ?
  intestinal involvement in 55-90
• Pimparker - abdo TB in 3.72 of 11,746
  unselected autopsies in Bombay

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HIV TB

• Before era of HIV infection gt 80 TB confined to
  lung
• Extrapulmonary TB increases with HIV
• 40 60 TB in HIV pt - extrapulmonary
• Globally, propotion of coinfected pt gt 8
• 0.4 million people in India coinfected.
• 16.6 abdominal TB pt in Bombay HIV .

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Incidence ? severity of abdominal TB will
increase with the HIV epidemic
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Pathogenesis

• Mechanisms by which M. tuberculosis reach the
  GIT
• Hematogenous spread from primary lung focus
• Ingestion of bacilli in sputum from active
  pulmonary focus.
• Direct spread from adjacent organs.
• Via lymph channels from infected LN
• In India, organism from all intestinal lesions
  M. tuberculosis and not M. bovis.

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• Most common site - ileocaecal region
• Increased physiological stasis
• Increased rate of fluid and electrolyte
  absorption
• Minimal digestive activity
• Abundance of lymphoid tissue at this site.
• Bhansali - ileum involved in 102 and caecum in
  100 of 196 pt.
• Prakash - ileocaecal involvement in 162 of 300
  pt.

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Distribution of tuberculous lesions

• Ileum gt caecum gt ascending colon gt jejunum
• gtappendix gt sigmoid gt rectum gt duodenum
• gt stomach gt oesophagus
• More than one site may be involved

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• Peritoneal involvement occurs from
• Spread from LN
• Intestinal lesions or
• Tubercular salpingitis
• Abdominal LN and peritoneal TB may occur without
  GIT involvement in 1/3 cases.

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• Peritoneal tuberculosis occurs in 3 forms.
• Wet type - ascitis.
• Encysted (loculated) type - localized swelling.
• Fibrotic type - masses composed of mesenteric
  
• omental thickening, with matted bowel
  loops.

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Clinical Features

• Mainly disease of young adults
• 2/3 of pt. are 21-40 yr old
• Sex incidence equal.
• Indian studies ? slight female
  predominance
• Clinical presentation ? Acute / Chronic / Acute
  on Chronic.

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• Constitutional symptoms
• Fever (40-70)
• Weight loss (40-90)
• Anorexia
• Malaise
• Pain (80-95)
• Colicky (luminal stenosis)
• Continous ( LN involvement)
• Diarrhoea (11-20)
• Constipation
• Alternating constipation and diarrhoea

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Tuberculosis of esophagus

• Rare 0.2 of total cases
• By extension from adjacent LN
• Low grade fever / Dysphagia / Odynophagia /
  Midesophageal ulcer
• Mimics esophageal Ca

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Gastroduodenal TB

• Stomach and duodenum each 1 of total cases
• Mimics PUD - shorter history, non response to
  t/t
• Mimics gastric Ca.
• Duodenal obstruction - extrinsic compression by
  tuberculous LN
• Hematemesis / Perforation / Fistulae /
  Obstructive jaundice
• Cx-Ray usually normal
• Endoscopic picture - non specific

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Ileocaecal tuberculosis

• Colicky abdominal pain
• Ball of wind rolling in abdomen
• Borborygmi
• Right iliac fossa lump - ileocaecal region,
  mesenteric fat and LN

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Obstruction

• Most common complication
• Pathogenesis
• Hyperplastic caecal TB
• Strictures of the small intestine--- commonly
  multiple
• Adhesions
• Adjacent LN involvement ? traction, narrowing and
  fixation of bowel loops.
• In India 3 to 20 of bowel obstruction
• Series of 348 cases of intestinal obstruction -
  TB in 54 (15.5) (Bhansali and Sethna).

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Perforation

• 5-9 of SI perforations in India
• 2nd commonest cause after typhoid
• Usually single and proximal to a stricture
• Clue - TB Chest x-ray, h/o SAIO
• Pneumoperitoneum in 50 cases

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Malabsorption

• Common
• 2nd only to tropical sprue in India
• Clue----h/o of pain / SAIO
• Pathogenesis
• bacterial overgrowth in stagnant loop
• bile salt deconjugation
• diminished absorptive surface due to ulceration
• involvement of lymphatics and LN

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Malabsorption in Intestinal TB
Glucose tolerance Lactose tolerance D-Xylose Fecal fat Schillings test
Stricture 28 22 57 60 63
No Stricture 0 0 8 25 30
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Overall prevalence of malabsorption

• 75 pt with intestinal obstruction
• 40 of those without
• (Tandon et al)

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Segmental / Isolated colonic tuberculosis

• Involvement of the colon without involvement of
  the ileocaecal region
• 9.2 of all cases
• Multifocal involvement in 1/3 (28 to 44)
• Median symptom duration lt1 year

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Colonic tuberculosis

• Pain --- predominant symptom ( 78-90 )
• Hematochezia in lt 1/3 - usually minor
• Overall, TB accounts for 4 of LGI bleeding
• Other features--- fever / anorexia / weight loss
  / change in bowel habits

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Rectal and Anal Tuberculosis

• Hematochezia - most common symp. Due to mucosal
  trauma by stool
• Constitutional symptoms
• Constipation
• Rectal stricture
• Anal fistula usually multiple

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Diagnosis and Investigations

• Non specific findings---
• Raised ESR
• Positive Mantoux test
• Anemia
• Hypoalbuminaemia

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Immunological Tests

• ELISA
• SAFA
• Competitive ELISA
• Response to mycobacteria variable
  reproducibility poor
• Value of immunological tests remain undefined

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Ascitic fluid examination

• Straw coloured
• Protein gt3g/dL
• TLC of 150-4000/µl, Lymphocytes gt70
• SAAG lt 1.1 g/dL
• ZN stain in lt 3 cases
• culture in lt 20 cases

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Adenosine Deaminase (ADA)

• Aminohydrolase that converts adenosine à inosine
• ADA increased due to stimulation of T-cells by
  mycobacterial Ag
• Serum ADA gt 54 U/L
• Ascitic fluid ADA gt 36 U/L
• Ascitic fluid to serum ADA ratio gt 0.985 (
  Bhargava et al)
• Coinfection with HIV ? normal or low ADA

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Colonoscopy

• Colonoscopy - mucosal nodules ulcers
• Nodules
• Variable sizes (2 to 6mm)
• Non friable
• Most common in caecum especially near IC valve.
• Tubercular ulcers
• Large (10 to 20mm) or small (3 to 5mm)
• Located between the nodules
• Single or multiple
• Transversely oriented / circumferential contrast
  to Crohns
• Healing of these girdle ulcers? strictures
• Deformed and edematous ileocaecal valve

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Colonoscopic Diagnosis

• 8 10 Bx from ulcer edge
• Low yield on histopath as mainly submucosal
  disease
• Granulomas in 8-48
• Caseation in 1/3 (33-38) of cases
• AFB stains - variable
• Culture positivity in 40
• Combination of histology culture ? diagnosis
  in 60

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Laparoscopic Findings

• Thickened peritoneum with tubercles-
• Multiple, yellowish white, uniform ( 4-5mm)
  tubercles
  
• Peritoneum is thickened hyperemic
• Omentum, liver, spleen also studded with
  tubercles.
• Thickened peritoneum without tubercles
• Fibro adhesive peritonitis
• Markedly thickened peritoneum and multiple thick
  adhesions (Bhargava et al)
• Caseating granulomas in 85-90 of Bx

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Management

• ATT for at least 6 months including 2 months of
  Rif, INH, Pzide and Etham
• Balasubramanium et al ( TB research center,
  Chetput, Madras) ? Randomized comparison of a 6
  month vs 12 month course of ATT in 193 pt
• Cure rate - 99 94
• However in practice t/t often given for 12 to 18
  months
• 2 recent reports ? obstructing lesions may
  relieve with ATT alone
• However most will need surgery