Abdominal tuberculosis

Abdominal Tuberculosis

Dr. Sudhir. K. Jain

Professor of Surgery

7/7/2015 Dr.S.K.Jain, Prof Surgery, MAMC, N.Delhi

Abdominal Tuberculosis:

Presented By:

Dr. Sudhir. K. Jain, M.S, MBA(HCA), FRCS, FICS, FIAS.

Professor of Surgery,

Maulana Azad Medical College and Associated Lok Nayak Hospital,

New Delhi.

With Credits to:

Dr. R.Vishnuraja, PG2, Dept of Surgery, MAMC.

Dr. Maneesh Kumar Jain, PG3, Dept of Surgery, MAMC.


Known Disease, Unknown Facts!!!


1


Disease of the Artisans…

If u die…die of TB


Disease of the Artisans:

• It is being suggested that Beethovan died of TB and many other famous personalities of his time.

• People of the 17th and 18th century wanted to die of tuberculosis.

• Because, death due to other diseases like typhoid fever, plague or War were very painful, sudden and unpleasant.

• Where as tuberculosis gave a slow and a relatively painless death.

British poet Lord Byron wrote, "I should like to die from consumption," helping to popularize the disease as the disease of artists.


https://en.wikipedia.org/wiki/Lord_Byron

2


The King’s Evil


Fashion Designer – Tuberculosis:

• The picture shows the pictures of French and British royals.

• The picture was shown as the effect of Tuberculosis on Fashion.

• Mycobacterium scrofulaceum causes scrofula in the neck.

• In order to cover the scrofula, people wore dresses in such a way, it is covered their necks.

• It was also called as ‘The Kings Evil’ as it was thought that, scrofula can be cured by the touch of the King.


3


Anemia-The Fashion Symbol


History of Talcum powder:

• People with Tuberculosis had anemia and pallor.

• Tuberculosis was considered as the status symbol.

• So, people who actually did not have tuberculosis, started mimicking as if they have tuberculosis.

• In order to appear pale, they applied white powders to their face, which led to the arrival of talcum powders.


4•Benedick: Come, I will have thee, but by this

light I take thee for pity.•Beatrice: I would not deny you, but by this

good day I yield upon great persuasion, and partly to save your life, for I was told you were in a consumption. (V.IV.96-101).


Consumption @ TuberculosisThe Disease of Love


The Disease of Love:

• In this scene, from Shakespeare’s, ‘Play Much ado about Nothing’ Beatrice accepts Benedick’s love since she was told that Benedicks was in consumption (Tuberculosis).

• CONSUMPTION @ tuberculosis was considered at that time as a ‘Disease arising out of LOVE or BURNING DESIRE’.


Definition:

Mycobacterium tuberculosis infection of:

• Peritoneum

• Hollow viscus (Bowel- From mouth to anus)

• Solid abdominal organs – Liver, spleen, pancreas, adrenals, kidneys


How M.tuberculosis reach GIT?

6 Routes.

1. Hematogenous spread from the primary lung focus in childhood, with later reactivation.

2. Ingestion of bacilli in sputum from active pulmonary focus

3. From Ingestion of unpasteurized milk (Mycobacerium bovis)

4. Direct spread from adjacent organs

5. Through lymph channels from infected nodes.

6. Retrograde spread from female genital tuberculosis.


Common Clinical Presentation:

• Young adults (21-40 yrs)

With complaints of :

• Abdominal pain Colicky- With luminal narrowingDull aching- With mesenteric lymphnode involvement

• Diarrhea or Constipation

• Alternating constipation and diarrhea

• Weight loss, anorexia and malaise

• Fever


Complications

• Subacute Intermittent Obstruction (SAIO)

• Intestinal obstruction

• Intestinal perforation

• Intestinal bleeding (Uncommon)


Key Words: A small revision

• Granuloma

• Caseating necrosis



• Granuloma


Granuloma:

Focus of chronic inflammation.

Microscopic aggregation of Macrophages-transformed into epithelium-like cells

Surrounded by a collar of lymphocytes and occasional plasma cells.



• Granuloma




• Granuloma


Caseous necrosis:

Caseous- Cheesy:

Type of Coagulative necrosis. But tissue architecture not maintained.

Central necrosis surrounded by amorphous cells and granular material with clear inflammatory border known as Granulomatous reaction.


Peritoneal Tuberculosis

• 3 Types and their combinations.

1. Wet type with ascites

2. Encysted (Loculated) type with localized abdominal swelling

3. Dry - Fibrotic type with abdominal masses composed of mesenteric and omental thickening and caking, with matted bowel loops leading to abdominal cocoon.

4. A combination of the above.


Intestinal tuberculosis

• Can involve any portion of the GIT from mouth to anus.

• Common in ileo caecal region.

• 4 Types1. Ulcerative type2. Ulcerohyperplastic type3. Hyperplastic type4. Stricturing type

Immunocompromised and Malnourished with high virulence of the bacteria: Ulcerative form

Immunocompetent with low virulent bacteria: Hyperplastic form


Common site-Ileo caecal region-Why?

4 Reasons

• Abdundance of abdundant lymphoid tissue at this site (PeyersPatches)M Cells of Peyers Patches phagocytose BCG bacillus.

• Increased physiological stasis (Ileocaecal valve competence) with prolonged contact with the mucosa.

• Increased rate of fluid and electrolyte absorption (Alkaline Environment)

• Minimal digestive activity


TB- Oesophagus (0.2%)

• Mimics oesophageal carcinoma

• Mid oesophageal ulcer, dysphagia and odynophagia

• Low grade fever

Pathology: Extension from nearby tubercular lymph nodes into esophagus.


Barium Swallow

• Patient with mediastinal lymphadenopathies that produced a fistula demonstrated by endoscopy. Extensive esofageal ulceration (black arrows).

• Extrinsic compression due to lymphadenopathies is appraised (white arrow).


TB- Gastroduodenum (1%)

• Gastric TB- May mimic Peptic ulcer not relieving to anti-secretory therapy or gastric carcinoma.

• Duodenal TB- Obstruction due to extrinsic compression by lymph nodes.

• Other presentations:Perforation

Fistula

Ulcer excavation into pancreas

Obstructive jaundice due to CBD compression.


Why Gastric tuberculosis is Uncommon?

• Acidic environment which prevents the growth of the mycobacterium.

• Rapid gastric emptying

• Paucity of Peyer’s patches in stomach.


Ileocaecal TB

• Colicky abdominal pain, borborygmi and vomiting.

• Palpation: No abnormality or Doughy RIF lump

• Common complications:

Intestinal obstruction- Hyperplastic TB, Strictures and adhesions

Malabsorption- Bacterial overgrowth in stagnant loop, bile salt deconjugation, ulceration and involvement of lymphatics and lymph nodes.


Ileocaecal tuberculosis-Presentations

• Recurrent abdominal pain due to SAIO

• Acute intestinal obstruction

• Ileocaecal mass which can mimic malignancy

• Intestinal perforation


Jejunal TB

Presents with

Single or multiple strictures

Intestinal obstruction

Perforation (proximal to the stricture)


Segmental Colonic TB (9.2%)

• It is involvement of colon without ileocaecal region.

• Involves sigmoid, ascending and transverse colon.

• Pain and hematochezia is common.


Anal TB

Multiple anal fistula with pouting granulation tissue with discolouration of the surrounding skin- Anal TB should be suspected.


Diagnostic Crieria: Paustian 1964

Rule: One or more of the following 4 criteria should be positive.

1. Histological evidence of tubercles with caseation necrosis

2. A good typical gross description of operative findings with biopsy of mesenteric nodes showing histologic evidence of tuberculosis

3. Animal inoculation or culture of suspected tissue resulting in growth of M. tuberculosis

4. Histological demonstration of acid fast bacilli in a lesion


Investigations:Suggestive but not diagnostic of TB• Anemia

• Elevated ESR

• Positive Mantoux


Ascitic fluid-Typical Characteristics:• Straw colour

• Protein > 3 g/dl

• TLC 150-4000/mic litre

• Cytology- Predominantly lymphocytes

• Ascites to blood glucose ratio: <0.96

• SAAG <1.1g/dl

• Adenosine deaminase Positive

• Interferon gamma Positive

• TB PCR Positive


Radiological Investigations


Chest X ray

Evidence of tuberculosis in a chest X ray supports the diagnosis. But not always present.


X ray Abdomen

May show features of obstruction, perforation or intussusception. Calcified lymphnodes, calcified granulomas.


X ray Abdomen:

A. Dilated bowel loops

B. Multiple air fluid levels


Small Bowel Barium Meal

Chicken intestine

Multiple strictures of bowel loops.


Barium enteroclysis


Barium Enema

Fleischner or

Inverted umbrella sign

Conical caecum

Strictures

Pulled up/subhepaticcaecum


Fleischner or Inverted Umbrella Sign


Conical Caecum


Stricture


Barium Studies- In current age:

• Very rarely used

• Complication – Complete intestinal obstruction


Current Investigations of Choice:

• Ultrasonography

• CECT abdomen

• Colonoscopy

• Capsule endoscopy


Ultrasonography:

Can be used to visualize:

• Matted lymphnode enlargement, bowel wall thickenings and

• fluid collection in the abdomen


CECT abdomen:

Can visualize:

• Lymphnode enlargements

• Bowel wall thickening

• Luminal narrowing

• Solid organ involvement

• Ascitic collection

• Bowel perforation


Colonoscopy:


Capsule endoscopy:

Should be used with caution,

As it can cause obstruction at the stricture site.


Management of Complications

Intestinal Obstruction:

1. Strictures- Stricturoplasty

2. Adhesions- Adhesiolysis

3. Hyperplastic TB- Limited resection with end ileostomy and mucous fistula followed by ATT; followed by ileostomy closure later.


Management of Complications

Subacute Intermittent Obstruction:

• Conservative Management

• ATT


Management of Complications:

Intestinal perforation:

• Primary Repair- High chances of leak in active tuberculosis

• Resection anastomoses or Resection with ileostomy

- Preferred techniques


Thank You


Health & Medicine

Abdominal tuberculosis