Tuberculous Abdomen

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Tuberculous Abdomen
Dr. JIAN ANG The 2nd Affiliated Hospital of ZJU
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Circumferential ulceration is characteristic of
intestinal tuberculosis.
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Epidemiology of GI TB

• Extrapulmonary TB represented 28.2 of all
  reported TB cases.
• Gastrointestinal TB was the 2nd most common type
  of TB.

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Extrapulmonary TB difficult to diagnose??

• Several forms of extrapulmonary TB lack any of
  the localizing symptoms or signs.
• Cutaneous anergy to PPD was noted in 35-50 of
  patients.
• No clinical or radiological evidence of pulmonary
  TB could be found in up to one 3rd of these
  patients.

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Introduction

• TB can involve any part of GIT from mouth to
  anus, peritoneum pancreatobiliary system.
• Varied presentations.

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PREVALENCE

• Isolated abdominal tuberculosis
• Unselected autopsy series- 0.02 - 5.1
• Higher prevalence in females
  
• Despite increased Pul TB in males
• Secondary to Pul. TB

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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

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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

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Robert Koch, a German Scientist who found out the
causative organism and revealed his invention
in1882
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Gram negative bacillus Mycobacterium
tuberculosis
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• Tuberculous abdomen is a condition in which there
  is tuberculous infection of the peritoneum or
  other organs in the abdomen

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Tuberculous peritonitis

• Acute tuberculous peritonitis
• Chronic tuberculous peritonitis

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• Acute tuberculous peritonitis
• Acute abdomen with severe pain
• Acute inflammation of the peritoneum
• Straw coloured fluid
• Tubercles in the greater omentum and peritoneum
• Tubercles may casseate
• Anti tuberculous treatment

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• Chronic tuberculous peritonitis
• The condition presents with abdominal pain
• Fever
• Loss of weight
• Ascites
• Night sweats
• Abdominal mass

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• Origin of infection
• Tuberculous mesenteric lymph nodes
• Tuberculosis of the ileocaecal region
• Tuberculous pyosalpinx
• Blood borne infection from pulmonary
  tuberculosis, usually the miliary but
  occasionally the cavitating form

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• Varieties of tuberculous peritonitis
• Ascitic form peritoneal fluid ? distension of
  abdomen. Patient comes with the complaint of
  swelling of the abdomen. increased abdominal
  pressure ? umbilical hernia, inguinal hernia
• Purulent form
• Rare usually secondary to tuberculous
  salpingitis pockets of adherent intestines and
  omentum containing tuberculous pus. cold
  abscesses
• Encysted form
• Inflammation and ascites are confined to one
  part of the abdominal cavity
• Fibrous form
• Wide spread adhesions ? adhesive obstruction

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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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GI TB

• GI tuberculosis is usually secondary to pulmonary
  tuberculosis, radiologic evaluation often shows
  no evidence of lung disease

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GI Tuberculosis

• Ileocecum and ColonThe ileocecal region is the
  most common area of involvement in the
  gastrointestinal tract due to the abundance of
  lymphoid tissue.
• The natural course of gastrointestinal
  tuberculosis may be ulcerativehypertrophic or
  ulcerohypertrophic.

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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.

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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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Clinical Features

• Mainly disease of young adults
• 2/3 of pt. are 21-40 yr old
• Sex incidence equal.
• 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
• Continous
• 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
• Right iliac fossa lump - ileocaecal region,
  mesenteric fat and LN

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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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Complications

• GIT bleeding
• Obstruction
• Perforation
• Malabsorption

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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.
• Series of 348 cases of intestinal obstruction -
  TB in 54 (15.5) (Bhansali and Sethna).

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Perforation

• Usually single and proximal to a stricture
• Clue - TB Chest x-ray
• Pneumoperitoneum ?

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Malabsorption

• Common
• Decreased absorption
• Increased Consumption

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Emaciation due to TB
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Overall prevalence of malabsorption

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

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• Investigations
• Blood routine
• PPD test
• Ascitic fluid examination
• X-ray s
• Endoscope
• Laparoscopy

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Blood tests

• Non specific findings---
• Raised ESR
• Positive PPD test
• Anemia
• ADA
• Hypoalbuminaemia
• Co HIV infection ?

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PPD Test
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PPD test positive
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Measuring the induration PPD test
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Ascitic fluid examination

• Straw coloured
• Protein gt3g/dL
• Lymphocytes gt70
• SAAG lt 1.1 g/dL
• 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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X-rays

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Gastrointestinal Tuberculosis

• Barium studies demonstrate spasm and
  hypermotility with edema of the ileocecal valve
  in the early stages
• Later thickening of the ileocecal valve.
• A widely gaping ileocecal valve with narrowing of
  the terminal ileum (Fleischner sign)
• A narrowed terminal ileum with rapid emptying of
  the diseased segment through a gaping ileocecal
  valve into a shortened, rigid, obliterated cecum
  (Stierlin sign)
• Focal or diffuse aphthous ulcers tend to be
  linear or stellate, following the orientation of
  lymphoid follicles (ie, longitudinal in the
  terminal ileum and transverse in the colon)

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Gastrointestinal Tuberculosis

• In advanced cases, symmetric annular stenosis and
  obstruction associated with shortening,
  retraction, and pouch formation may be seen. The
  cecum becomes conical, shrunken, and retracted
  out of the iliac fossa due to fibrosis,
  ileoceacal valve becomes fixed, irregular,
  gaping, and incompetent .

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Tuberculous peritonitis USGM Intestines
floating in peritoneal fluid - ascites
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Colonoscopy

• Colonoscopy - mucosal nodules ulcers
• Nodules
• Variable sizes (2 to 6mm)
• 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
• 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)

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Differential diagnosis

• CD
• Cancer
• Lymphoma
• Chronic colitis

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Management

• isoniazid
• rifampicin
• pyrazinamide
• ethambutol
• Surgical intervention when needed

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• at least 6 months including 2 months of Rif,
  INH, Pzide and Etham
• However in practice t/t often given for 12 to 18
  months
• obstructing lesions may relieve with Med alone
• However most will need surgery

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Tx duration

• Newly diagnosed 2HRZE/4HR?2SHRZ/4HR
• Relapsed 2HRZSE/46HRE

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• CD or TB???

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• The ultimate course of these two disorders is
  different.
• Intestinal TB is entirely curable, provided that
  the diagnosis is made early enough and
  appropriate treatment is instituted.
• In contrast, CD is a progressive relapsing
  illness.
• Unfortunately, it is difficult to differentiate
  intestinal TB from CD because of similar
  clinical, pathological, radiological, and
  endoscopic findings.

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Diagnosis intestinal TB or CD

• They can present exactly with same clinical
  pictures (same age group, symptoms and signs)
• Same radiological findings and same endoscopic
  findings
• Mostly with same pathological findings
• So how can we make the diagnosis?

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? Other features

• History of previous TB
• CXR findings of TB
• The tuberculin skin test is less helpful, because
  a positive test does not necessarily mean active
  disease.
• Perianal fistulae and extraintesitnal
  manifestations of CD
• If all negative any other clues??

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Multiple attempts!!

• Endoscopic findings?
• Laproscopic findings?
• Histological findings?
• PCR?
• Empirical TB?

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Endoscopic diagnosis?

• CD (4 parameters)
• Anorectal lesions,
• longitudinal ulcers,
• aphthous ulcers, and
• cobblestone appearance
• Intestinal TB (4 parameters)
• involvement of fewer than four segments,
• a patulous ileocecal valve,
• transverse ulcers, and
• scars or pseudopolyps

Endoscopy. 2006 Jun38(6)592-7.
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Endoscopic diagnosis?

• Lee et al hypothesized that a diagnosis of
  Crohn's disease could be made when the number of
  parameters characteristic of Crohn's disease was
  higher than the number of parameters
  characteristic of intestinal tuberculosis, and
  vice versa.

Endoscopy. 2006 Jun38(6)592-7.
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Endoscopic findings TB

• In tuberculosis patients, transverse ulcers with
  surrounding hypertrophic mucosa and multiple
  erosions were usual colonoscopic findings.

Am J Gastroenterol 199893 606609. Gastrointest
Endosc 200459362-8.
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Typical transverse ulcer
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Gastrointest Endosc 200459362-8.
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Radiology

• thickened bowel wall with distortion of the
  mucosal folds and ulcerations.
• CT may show preferential thickening of the
  ileocecal valve and medial wall of the cecum and
  massive lymphadenopathy with central necrosis.
• Calcified mesenteric lymph nodes and an abnormal
  chest film are other findings that aid in the
  diagnosis of intestinal tuberculosis.

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At surgery TB

• Reduced largely since introduction of colonoscopy
• Indications
• Mass lesions associated with the hypertrophic
  form, because they can lead to luminal compromise
  with complete obstruction.
• Surgery also may be necessary when free
  perforation, confined perforation with abscess
  formation, or massive hemorrhage occur.
• Findings
• The bowel wall appears thickened with an
  inflammatory mass surrounding the ileocecal
  region.
• The serosal surface is covered with multiple
  tubercles.
• The mesenteric lymph nodes frequently are
  enlarged and thickened.

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Histologically

• Intestinal TB granulomas are
• Large,
• multiple,
• confluent with
• caseation
• Ulcers lined by epitheliod histiocytes
• CD
• Fissuring ulcer,
• lymphoid aggregates,
• transmural inflammation, and
• Infrequent, small, noncaseating granulomas.

Am J Gastroenterol 2002971446 1451. Pulimood
et al. Gut 1999
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Empirical anti-TB

• If intestinal TB still possibility, give 4-6
  weeks of anti-TB
• 30 of CD patietns at China receives anti-TB
  before final diagnosis

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Presumptive diagnosis

• can be established in
• A patient with active pulmonary tuberculosis and
  radiologic and clinical findings that suggest
  intestinal involvement.
• Response to anti-TB

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Thank you!