Tuberculous Abdomen

Dr. JIAN ANGThe 2nd Affiliated Hospital of ZJU

Circumferential ulceration is characteristic of intestinal tuberculosis.　　

Epidemiology of GI TB

Extrapulmonary TB represented 28.2% of all reported TB cases.

Gastrointestinal TB was the 2nd most common type of TB.

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.

Introduction

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

Varied presentations.

PREVALENCEIsolated abdominal tuberculosis:

Unselected autopsy series- 0.02 - 5.1%

Higher prevalence in females

Despite increased Pul TB in males

Secondary to Pul. TB

HIV & TB

Before era of HIV infection > 80% TB confined to lung

Extrapulmonary TB increases with HIV

40 –60% TB in HIV+ pt - extrapulmonary

Incidence severity of

abdominal TB will increase with

the HIV epidemic

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

Robert Koch, a German Scientist who found out the causative organism and revealed his invention in1882

Gram negative bacillus – Mycobacterium tuberculosis

Tuberculous abdomen is a condition in which there is tuberculous infection of the peritoneum or other organs in the abdomen

Tuberculous peritonitis

Acute tuberculous peritonitis

Chronic tuberculous peritonitis

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

Chronic tuberculous peritonitis

The condition presents with abdominal pain

Fever

Loss of weight

Ascites

Night sweats

Abdominal mass

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

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

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.

GI TB

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

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.

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.

Distribution of tuberculous lesions

Ileum > caecum > ascending colon > jejunum

>appendix > sigmoid > rectum > duodenum

> stomach > oesophagus

More than one site may be involved

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.

Constitutional symptoms Fever (40%-70%) Weight loss (40%-90%) Anorexia Malaise

Pain (80%-95%) Colicky Continous

Diarrhoea (11%-20%)ConstipationAlternating constipation and diarrhoea

Tuberculosis of esophagus

Rare ~ 0.2% of total cases

By extension from adjacent LN

Low grade fever / Dysphagia / Odynophagia / Midesophageal ulcer

Mimics esophageal Ca

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

Ileocaecal tuberculosis

Colicky abdominal pain

‘Ball of wind’ rolling in abdomen

Right iliac fossa lump - ileocaecal region, mesenteric fat and LN

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 <1 year

Colonic tuberculosis

Pain --- predominant symptom ( 78%-90% )

Hematochezia in < 1/3 - usually minor

Overall, TB accounts for ~ 4% of LGI bleeding

Other features--- fever / anorexia / weight loss / change in bowel habits

Rectal and Anal Tuberculosis

Hematochezia - most common symp. Due to mucosal trauma by stool

Constitutional symptoms

Constipation

Rectal stricture

Anal fistula – usually multiple

Complications

GIT bleeding

Obstruction

Perforation

Malabsorption

ObstructionMost 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).

Perforation

Usually single and proximal to a stricture

Clue - TB Chest x-ray

Pneumoperitoneum ?

Malabsorption

Common

Decreased absorption

Increased Consumption

Emaciation due to TB

Overall prevalence of malabsorption:

75% pt with intestinal obstruction

40% of those without

(Tandon et al)

Investigations

Blood routine

PPD test

Ascitic fluid examination

X-ray s

Endoscope

Laparoscopy

Blood tests

Non specific findings---

Raised ESR

Positive PPD test

Anemia

ADA

Hypoalbuminaemia

Co HIV infection ?

PPD Test

PPD test – positive

Measuring the induration – PPD test

Ascitic fluid examination

Straw coloured

Protein >3g/dL

Lymphocytes >70%

SAAG < 1.1 g/dL

+ culture in < 20% cases

Adenosine Deaminase (ADA)

Aminohydrolase that converts adenosine inosine

ADA increased due to stimulation of T-cells by mycobacterial Ag

Serum ADA > 54 U/L

Ascitic fluid ADA > 36 U/L

Ascitic fluid to serum ADA ratio > 0.985 ( Bhargava et al)

Coinfection with HIV normal or low ADA

X-rays

Gastrointestinal TuberculosisBarium 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)

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

Colonoscopy

Colonoscopy - mucosal nodules & ulcers

NodulesVariable sizes (2 to 6mm)Most common in caecum especially near IC valve.

Tubercular ulcersLarge (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

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%

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)

Differential diagnosis

CD

Cancer

Lymphoma

Chronic colitis

Management

isoniazid

rifampicin

pyrazinamide

ethambutol

Surgical intervention when needed

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

Tx duration

Newly diagnosed: 2HRZE/4HR 、 2SHRZ/4HR

Relapsed: 2HRZSE/4~6HRE

CD or TB???

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.

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?

? 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??

Multiple attempts!!

Endoscopic findings?

Laproscopic findings?

Histological findings?

PCR?

Empirical TB?

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 Jun;38(6):592-7.

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 Jun;38(6):592-7.

Endoscopic findings: TB

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

Am J Gastroenterol 1998;93: 606–609.Gastrointest Endosc 2004;59:362-8.

Typical transverse ulcer

Gastrointest Endosc 2004;59:362-8.

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.

At surgery: TBReduced 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.

HistologicallyIntestinal TB: granulomas are

Large, multiple, confluent with caseation Ulcers lined by epitheliod histiocytes

CDFissuring ulcer, lymphoid aggregates, transmural inflammation, and Infrequent, small, noncaseating granulomas.

Am J Gastroenterol 2002;97:1446 –1451.

Pulimood et al. Gut 1999

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

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

Thank you!