Abdominal Tuberculosis

Dr.Sujith Mathew JosePG in General Surgery

Coimbatore Medical College Coimbatore

Introduction

TB can involve any part of GIT from mouth to

anus, peritoneum &

pancreatobiliary system.

• TB of GIT(peritoneal)- 6th most frequent extrapulmonary site.

• LYMPHATIC ----- 1st

• GENITOURINARY• BONE & JOINTS• MILIARY• MENINGEAL------ 5th

• Most case from reactivation of latent peritonial disease, previously established hematogenously from primary pulmonary focus

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.

• Most common site - Ileocaecal region

• Types

– Ulcerative

– Hyperplastic

– Ulcero-hyperplastic

• In ileal region commonly stricture type .

• Peritoneal involvement occurs from : – Spread from Lymph node– Intestinal lesions – Tubercular salpingitis

• Abdominal lymph node and peritoneal TB may occur without GIT involvement in ~ 1/3 cases.

Peritoneal tuberculosis occurs in 3 forms.

• Wet type - ascitis.

• Encysted (loculated) type

• Fibrotic type - masses composed of mesenteric &

omental thickening, with matted bowel loops.

Clinical Features• Mainly disease of young adults,

• 2/3 of pts are 21-40 yr with equal sex incidence• Clinical presentation

– Acute – Chronic– Acute on chronic

Abdominal swelling caused by ascitis is the most common symptom

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

• Pain abdomen (80%-95%) – Colicky (luminal stenosis) , – Continous ( LN involvement)

• Alternating constipation and diarrhoea

• POSITIVE TUBERCULIN TEST• ASCITIC FLUID SAAG less

than 1.1g/dl• Microscopic examination of

ascitic fluid – ERYTHROCYTES– Increased LEUCOCYTES

(LYMPHOCYTES)

ASCITIC FLUID ADENOSINE DEAMINASE

ACTIVITY IS HIGHLY SENSITIVE AND SPECIFIC FOR

TUBERCULOUS PERITONITIS

Tuberculosis of esophagus

• Rare ~ 0.2% of total cases

• By extension from adjacent LN

• Low grade fever/ Dysphagia/ Odynophageal/Midesophageal ulcer

• Mimics esophageal Ca

Gastro Duodenal TB

• Stomach and duodenum each ~ 1% of total cases

• Shorter history, non response to treatment

• Mimics gastric Carcinoma

• Leads to duodenal obstruction due to extrinsic compression by tuberculous LN ,Hematemesis / Perforation / Fistulae / Obstructive jaundice

• Chest X-Ray usually normal

• Endoscopic picture - non specific

Illeocaecal tuberculosis

• Colicky abdominal pain ,anaemia, weightloss , diarrhoea ,fever

• ‘Ball of wind’ rolling in abdomen

• Borborygmi

• Right iliac fossa lump – due to 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 of cases (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 lower GI bleeding

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

Rectal and Anal Tuberculosis

• Hematochezia - most common symptom, due to mucosal trauma by stool

• Constitutional symptoms

• Constipation

• Rectal stricture

• Anal fistula – usually multiple

Complications

• Obstruction

• Perforation -2nd commonest cause after typhoid ,usually single and proximal to a stricture,Pneumoperitoneum in ~ 50% cases

• Mal-absorption

• Fecal fistula

• Cold abscess

• Haemorrhage

Diagnosis and InvestigationsRaised ESR

Positive Mantoux Test

Chest X Ray Findings

Low Hb ----- anemia

Hypoalbuminemia

ELISA (90%)

SAFA (Soluble Antigen Fluroscent Antibody)

Serum IgG

USG CT

Echogenic material in Ascitic Fluid - fine mobile strands or particulate matter

Thickened Mesentery

Nodules Nodular mesentery

Caecal Thickening Mesenteric Lymphadenopathy

Lymph Nodes Omental thickening

Diagnostic LaproscopyWhitish Nodules <5mm scattered over peritoniumHPR -------------- Caseating granuloma

Multiple adhesions between organs and parietal peritonium

Gross appearance mimic Peritonial carcinomatosis, sarcoidosis and Crohn’s disease

Ascitic Fluid for microscopy to demonstrate AFB (<3%) culture (<20%)

Colonoscopy

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

Tubercular ulcers– Large (10 to 20mm) or small (3 to 5mm) – Located between the nodules – Single or multiple – Transversely oriented / circumferential contrast to Crohns

• Deformed and edematous ileocaecal valve

Barium study X-ray findings • Pulled up caecum ,

conical caecum • Obtuse ileocaecal

angle • Narrow ileum with

thickened ileocaecal valve (Fleischner sign)

• Calcifications• Ulcers and strictures

in ileum and caecum –napkin lesions

Ascitic Fluid Study

• Straw coloured Exudate

• Protein >3g/dL

• Total count of 150-4000/µl, Lymphocytes >70%

• SAAG < 1.1 g/dL

• ZN stain positive in < 3% cases

• Positive culture in < 20% cases

• ADA positive

• Glucose <30mg

Treatment

• ATT for at least 6 months -Rifampicin, INH, Pyrazinamide and Ethambutol.

• Surgery –Indications

Intestinal obstruction , severe haemorrhage , perforations , intra-abdominal abscess

• For ileocaecal TB -Limited ileocaecal resection

• Single stricture – stricturoplasty

• In perforation –resection and anastomosis

• In obstruction – ileo-transverse anastomosis

• Drainage of intra-abdominal abscess , perianal abscess

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