INTRODUCTIONINTRODUCTIONINTRODUCTIONINTRODUCTION Tuberculosis (T.B.) has existed from the Tuberculosis (T.B.) has existed from the

very dawn of civilization.very dawn of civilization. Records of TB in mummies were found in Records of TB in mummies were found in

Egypt as far as 5000 years ago.Egypt as far as 5000 years ago.

(Cave, 1935)(Cave, 1935)

Extrapulmonary tuberculosis was Extrapulmonary tuberculosis was also known since antiquity.also known since antiquity.

Pott’s disease was described in Pott’s disease was described in paints and statues of ancient paints and statues of ancient Egyptians.Egyptians.

(Ghalioungy, 1958)(Ghalioungy, 1958)

GASTROINTESTINAL TUBERCULOSISGASTROINTESTINAL TUBERCULOSIS

Tuberculous enteritis as a complication of Tuberculous enteritis as a complication of pulmonary T.B. was appreciated by pulmonary T.B. was appreciated by HippocratesHippocrates in in the 5the 5thth century B.C. century B.C.

Diarrhea attacking a Diarrhea attacking a person with phthisis is a person with phthisis is a

mortal symptommortal symptom

(Walsh, 1909)(Walsh, 1909)

Ebn Sina Ebn Sina The Famous Arab Scientist (980-1037)The Famous Arab Scientist (980-1037)

in his book “in his book “Al-KanounAl-Kanoun” ” described tuberculosis (described tuberculosis (Al-SolAl-Sol) in details.) in details.He describedHe described Abdominal distentionAbdominal distention DiarrheaDiarrhea BorborygmiBorborygmi

In late stages of the disease.In late stages of the disease.(Hunter, 1999)(Hunter, 1999)

GASTROINTESTINAL TUBERCULOSISGASTROINTESTINAL TUBERCULOSIS

Mycobacterium tuberculosis is the pathogen in Mycobacterium tuberculosis is the pathogen in most cases.most cases.

Mycobacterium bovis in some parts of the world Mycobacterium bovis in some parts of the world with no pasteurization of milk.with no pasteurization of milk.

Mycobacterium avium intracellulare has become a Mycobacterium avium intracellulare has become a major pathogen in HIV patients.major pathogen in HIV patients.

(Nial et al., 1997)(Nial et al., 1997)

GASTROINTESTINAL TUBERCULOSISGASTROINTESTINAL TUBERCULOSIS

PATHOGENESISPATHOGENESIS

PATHOLOGYPATHOLOGY

Portis (1953)Portis (1953)

Bacill in depth of mucosal glands

Inflammatory reaction

Phagocytes carry bacilli to Peyers Patches

Formation of tubercle

Tubercles undergo necrosis

Most active inflammation in submucosa.Most active inflammation in submucosa.

PATHOLOGYPATHOLOGYSubmucosal tubercles enlarge

Endarteritis & edema

Sloughing

Ulcer formation

Accumulation of collagenous tissue

Thickening & Stenosis

(Howell & Knapton, 1964)(Howell & Knapton, 1964)

(Boyed, 1943)(Boyed, 1943)

PATHOLOGYPATHOLOGY

Lymphatic obstructionof mesentery and bowel Thick fixed mass

Regional lymph nodes• Hyperplasia• Caseation necrosis• Calcification

Bacilli via lymphatics

Inflammatory process in submucosa penetrates to serosa

Tubercles on serosal surface

Bacilli reach lymphatics

FORMS OF GI TBFORMS OF GI TBFORMS OF GI TBFORMS OF GI TB

UlceroconstrictiveUlceroconstrictive60% of patients60% of patients

Highly virulentHighly virulent

Mostly small IntestinalMostly small Intestinal

HypertrophicHypertrophic10% of patients10% of patients

ChronicChronic

Mostly IleocoecalMostly Ileocoecal

MixedMixed 30% of patients30% of patients

(Howell & Knapton, 1964)(Howell & Knapton, 1964)

T.B. Bacilli, Z.N. stainMaha Hasaballa, Cairo University

T.B. transverse girdle ulcer small intestine Makram Milad, Cairo University

T.B. stenotic surgical segment with involvement of mesenteric fat Makram Milad, Cairo University

Pathology of the previous ulcerSub mucosal muscular and subserous granulomasMakram Milad, Cairo University

T.B. LymphadenitisMakram Milad, Cairo University

GASTROINTESTINAL TUBERCULOSIS POSES A GASTROINTESTINAL TUBERCULOSIS POSES A DIAGNOSTIC PROBLEMDIAGNOSTIC PROBLEM

The disease is not common.The disease is not common. Not familiar to clinicians.Not familiar to clinicians. Involves inaccessible sites.Involves inaccessible sites. May be associated with other serious disorders, the May be associated with other serious disorders, the

manifestations of which obscure or modify those of T.B.:manifestations of which obscure or modify those of T.B.:

HIV, Chronic Renal Failure, Diabetes Mellitus, HIV, Chronic Renal Failure, Diabetes Mellitus,

Liver Cirrhosis, Neoplastic disease.Liver Cirrhosis, Neoplastic disease.

(Kramer et al., 1990)(Kramer et al., 1990)

The approach to the subject The approach to the subject was directed to these main points.was directed to these main points.

Country and continent of origin.Country and continent of origin. AgeAge GenderGender Associated HIV infectionAssociated HIV infection Associated pulmonary diseaseAssociated pulmonary disease Constitutional signs and symptomsConstitutional signs and symptoms Signs and symptoms related to the site of Signs and symptoms related to the site of

involvement in the G.I. tractinvolvement in the G.I. tract

To achieve this aimTo achieve this aimThe following was carried onThe following was carried on Search on the Pubmed was done for all abstracts since Search on the Pubmed was done for all abstracts since

1965.1965. Original articles tackling the subject and available in Original articles tackling the subject and available in

Egyptian libraries were collectedEgyptian libraries were collected Abstracts and original articles that describe symptoms Abstracts and original articles that describe symptoms

and signs related to gastrointestinal tuberculosis were and signs related to gastrointestinal tuberculosis were selected.selected.

Abstracts and articles were classified according to Abstracts and articles were classified according to organ involvement in the gastrointestinal tract.organ involvement in the gastrointestinal tract.

Retrieved data were pooled, tabulated and statistically Retrieved data were pooled, tabulated and statistically analyzed.analyzed.

Demonstration photos were kindly Demonstration photos were kindly

provided by colleagues; staff members of provided by colleagues; staff members of

Faculty of Medicine, Cairo UniversityFaculty of Medicine, Cairo University

Gastro-intestinal tuberculosis cases as Gastro-intestinal tuberculosis cases as reported by publication year (n = 2204)reported by publication year (n = 2204)

Year

1995 - 20001990 - 19951985 - 19901980 - 19851975 - 19801970 - 19751965 - 19701960 - 1965

Cou

nt

700

600

500

400

300

200

100

0

Distribution of gastrointestinal tuberculosis Distribution of gastrointestinal tuberculosis cases (n=2204) by sitecases (n=2204) by site

Site

gall bladder

pancreaticobiliary

hepatobiliary

peritonieum

colorectal

ileocolon

small intestine

stomach

esophagus

Per

cen

t50

40

30

20

10

0 3

39

2124

54

Distribution of gastrointestinal Distribution of gastrointestinal tuberculosis cases by countrytuberculosis cases by country

Malaysia6.5%

Others37.8%

S. Africa11.6%

Saudi Arabia11.7%

India23.9%

USA8.5%

Distribution of gastrointestinal Distribution of gastrointestinal tuberculosis cases by continenttuberculosis cases by continent

Europe13.9%

Australia5.0%

S. America1.1%

Africa23.0%

Asia57.0%

Adults98.0%

Children2.0%

Distribution of gastrointestinal Distribution of gastrointestinal tuberculosis cases by age grouptuberculosis cases by age group

Male41.8%

Female58.2%

Distribution of gastrointestinal Distribution of gastrointestinal tuberculosis cases by sextuberculosis cases by sex

Present55.9%

Absent44.1%

Distribution of gastrointestinal tuberculosis Distribution of gastrointestinal tuberculosis cases reporting associated HIVcases reporting associated HIV

Distribution of gastrointestinal tuberculosis Distribution of gastrointestinal tuberculosis cases reporting associated HIV by sitecases reporting associated HIV by site

0%

20%

40%

60%

80%

100%

120%

Esoph

agus

Stom

ach

Ileoc

olon

Colore

ctal

Hepat

obilia

ry

Pancr

eatic

obilia

ry

Distribution gastrointestinal tuberculosis cases Distribution gastrointestinal tuberculosis cases reporting associated pulmonary tuberculosisreporting associated pulmonary tuberculosis

Present56.5%

Absent43.5%

Distribution of gastrointestinal tuberculosis Distribution of gastrointestinal tuberculosis cases reporting associated pulmonary cases reporting associated pulmonary

tuberculosis by sitetuberculosis by site

0%

20%

40%

60%

80%

100%

120%

Esoph

agus

Stom

ach

Ileoc

olon

Colore

ctal

Perito

nium

Hepat

obilia

ry

Pancr

eatic

obilia

ry

Distribution of gastrointestinal tuberculosis cases Distribution of gastrointestinal tuberculosis cases reporting for associated general manifestationsreporting for associated general manifestations

35.6%

34.1%

35.0%

5.0%

0% 5% 10% 15% 20% 25% 30% 35% 40%

Fever

Wt. loss

Anorexia

Night sweats

Local manifestations of esophagus cases Local manifestations of esophagus cases (n= 86)(n= 86)

57.0%

32.6%

12.8%

2.3%

1.2%

1.2%

1.2%

0% 10% 20% 30% 40% 50% 60%

Dysphagia

Fistula

Haematemesis

Esophageal diverticula

Epigastric pain

Free mediastinal air

Mediastinitis

Esophageal Tuberculous NodulesAbdel Magid KasemCairo University

Caseating Granuloma of the esophagusMakram MiladCairo University

Local manifestations of gastroduedenal Local manifestations of gastroduedenal cases (n= 42)cases (n= 42)

52.4%

26.2%

19.0%

11.9%

2.4%

0% 10% 20% 30% 40% 50% 60%

Ulcer dyspepsia

Outlet obstruction

Mass

Haematemesis

Fistula

Diffuse narrowing of the body of the stomachCalcified Lymph node. Ba. Meal Yehia Aly Cairo University

Tuberculous mass in the stomachAbdel Magid KasemCairo University

Mucosal T.B. granuloma of the stomach, Endoscopic biopsy Makram MiladCairo University

Duodenal T.B. ulceration with narrow lumenMazen Naga Cairo, University

Local manifestations of small intestinal cases Local manifestations of small intestinal cases (n= 112)(n= 112)

81.3%

20.5%

11.6%

6.3%

4.5%

1.8%

0.9%

0.9%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Perforation

Ascitis

Obstruction

Abd.pain

Ulcer

Abd.mass

Hge

Fistula

Multiple tuberculous strictures small intestineBa. Meal follow-through Yehia Aly, Cairo University

Small intestinal T.B.IleoscopyWaheed Doss, Cairo University

Local manifestations of ileocoecal cases Local manifestations of ileocoecal cases (n= 520)(n= 520)

30.8%

16.7%

9.2%

8.5%

2.0%

0% 5% 10% 15% 20% 25% 30% 35%

pain

diarrhea

distention

mass

malabsorption

Tuberculous ulcerated coecal mass Colonoscopy Hunter, Cairo University

Ileocoecol T.B. Ba. Enema Yehya AlyCairo University

Local manifestations of colorectal cases Local manifestations of colorectal cases (n= 463)(n= 463)

39.1%

21.8%

12.1%

9.0%

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

pain

rectal bleeding

mass

distention

Colonic T.B. polypoid mass.ColonoscopyHunter, Cairo, University

Colonic T.B. polypoid mass.ColonoscopyMazen Naga, Cairo, University

Local manifestations of peritonitis cases Local manifestations of peritonitis cases (n= 881)(n= 881)

90.6%

59.9%

23.7%

3.4%

3.4%

2.0%

1.0%

0% 20% 40% 60% 80% 100%

ascitis

pain

mass

lymphadenopathy

jaundice

distention

diarrhoea

Peritoneal T.B. Laparoscopy Hunter, Cairo University

T.B. peritonitis granulomata with fibrosis in the omentumMakram Milad

Calcified T.B lymph nodesC.T. scanYehia Ali, Cairo, University

T.B. Peritoneal adhesionsUltrasonographyZakareya Salama Cairo University

Peritoneal T.B with adhesions LaparoscopyHunter, Cairo, University

Local manifestations of hepatobiliary cases Local manifestations of hepatobiliary cases

(n= 71)(n= 71)

94.4%

64.8%

0% 20% 40% 60% 80% 100%

jaundice

pain

T.B. Liver abscess C.T. scan Yehia Aly, Cairo University

T.B. adhesion around the gall bladder Laparoscopy, Hunter, Cairo University

Hilar stricture due to porta hepatis lymphadenopathy

Waheed Doss, Cairo University

Local manifestations of pancreaticobiliary cases Local manifestations of pancreaticobiliary cases (n= 86)(n= 86)

60.9%

17.4%

0% 10% 20% 30% 40% 50% 60% 70%

Abd.pain

jaundice

Tuberculous distal common bile duct stricture (Tuberculous Pancreatic Mass)Waheed Doss, Cairo University

SUMMARY SUMMARY

Most publications on GI tuberculosis were in Most publications on GI tuberculosis were in

the last decade.the last decade.

The publications were mainly from Asia. The publications were mainly from Asia.

In the Western hemisphere, the disease is In the Western hemisphere, the disease is

mainly in emigrants from endemic areas. mainly in emigrants from endemic areas.

Adults represent the majority of G.I. T.B. cases.Adults represent the majority of G.I. T.B. cases. The disease is slightly more prevalent in The disease is slightly more prevalent in

females.females. HIV infection is a main risk factor.HIV infection is a main risk factor. Pulmonary T.B. is a frequent but not an Pulmonary T.B. is a frequent but not an

essential association. essential association.

SUMMARY SUMMARY

Patients present with nonspecific constitutional symptoms, Patients present with nonspecific constitutional symptoms, pyrexia and weight loss are the most common. pyrexia and weight loss are the most common.

Local manifestations depend on the site of G.I. tract affection: Local manifestations depend on the site of G.I. tract affection: The esophagus: Dysphagia, fistula and haematemesis.The esophagus: Dysphagia, fistula and haematemesis. The stomach and duedenum: ulcer-dyspepsia, outlet The stomach and duedenum: ulcer-dyspepsia, outlet

obstruction and abdominal mass.obstruction and abdominal mass. The intestine: pain, diarrhea, perforation & abdominal massThe intestine: pain, diarrhea, perforation & abdominal mass The colon: pain and rectal bleeding. The colon: pain and rectal bleeding. The peritoneum: ascites and abdominal distension. The peritoneum: ascites and abdominal distension. Hepato-pancreaticobiliary: pain and jaundice. Hepato-pancreaticobiliary: pain and jaundice.

SUMMARY SUMMARY

Gastrointestinal T.B.Gastrointestinal T.B.Differential DiagnosisDifferential Diagnosis

Gastrointestinal T.B. should be considered in the Gastrointestinal T.B. should be considered in the differential diagnosis of :differential diagnosis of :

Chronic diarrheaChronic diarrhea Malabsorption syndromeMalabsorption syndrome Abdominal massesAbdominal masses AscitisAscitis Inflammatory bowel disease particularly Crohn’s disease.Inflammatory bowel disease particularly Crohn’s disease. Gastrointestinal lymphomasGastrointestinal lymphomas Other GIT malignancies.Other GIT malignancies.

CONCLUSIONCONCLUSION

Since 1980s, a resurgence of tuberculosis has Since 1980s, a resurgence of tuberculosis has occurred.occurred.

The disease is still and will remain a serious The disease is still and will remain a serious public health threat worldwide public health threat worldwide

Still the great mimicker, gastro intestinal Still the great mimicker, gastro intestinal tuberculosis.tuberculosis.

(Jadvar, 1997)(Jadvar, 1997)

Do not fear to repeat what has already been said.Do not fear to repeat what has already been said.

Men need most things dinned into Men need most things dinned into

their ears their ears many times and from all sidesmany times and from all sides

THE FIRST RUMOR

THE FIRST RUMOR

makes them prick up their ears

makes them prick up their earsTHE SECONDTHE SECOND registers registers

THE THIRDTHE THIRD enters enters

(Rene Laennec, 1781-1826(Rene Laennec, 1781-1826))

(Bouma et al., 1997)

G.I. TUBERCULOSIS, A FINAL WORD

of Abdominal Tuberculosis

Be awareBe aware