TB of SMALL INTESTINE

BY

K. MANIEVELRAAMAN

TB

Pulmonary Extra-pulmonary

Mycobacterium tuberculosis

3

Mycobacterium tuberculosis

•Obligate aerobe

• Acid fast 20% H2SO4

• Alcohol fast

•Gram variable

• Thin rods

• SLOW growing

• Lipid laden cell wall

Modes of Spread

• Ingestion

• Haematogenous

• Lymphatics

• Retrograde spread

• Direct spread

Ileum>caecum >ascending

colon >jejunum >appendix >sigmoid

>rectum >duodenum >stomach >esophagus

In the order of frequency…

What makes ILEOCAECAL region

the most common site?

• Abundance of Peyer’s patches

• M – cells

• Stasis Prolonged contact time

• Increased Fluid and Electrolyte absorption

• Minimal digestive activity

ULCERATIVE60%

ULCEROHYPERPLASTIC

30%

HYPERPLASTIC10% 0%

ULCERATIVE TYPE

• SECONDARY

• Virulent organism & Poor body resistance (old age)

• Multiple

Transverse

Circumferential ulcers (GIRDLE ulcers)

• Caseation common

• Serosa reddened & edematous

HYPERPLASTIC TYPE

• PRIMARY

• Less virulent organisms & Good body resistance (young)

• Chronic Granulomatous lesions

• Caseation uncommon (early nodal involvement)

• Establishes in lymphoid follicles

CLINICAL PRESENTATION

• Colicky Abdominal Pain 90%

• Anaemia, Loss of weight, Loss of appetite 80%

• Fever, Malaise 50-70%

• Mass 35% ( Hard, nodular, non-tender, non-mobile)

• Intestinal obstruction, Diarrhoea 20%

• ‘Ball of wind’ rolling in abdomen, Borborygmi

• Age : 25-50 ; Both sexes

• Associated with HIV, Lymphoma, Adenocarcinoma

COMPLICATIONS

• ULCERATIVE :

• Stricture ( Napkin ring stricture)

• Intestinal Obstruction

• HYPERPLASTIC :

• Subacute Intestinal Obstruction

• Malabsorption

• Blind loop syndrome

• Dissemination

• Cold abscess formation

• Fistula

• Perforation

• Haemorrhage

Obstruction

• Most common complication

Due to :

• Hyperplastic type

• Strictures of the small intestine--- commonly multiple

• Adhesions

• Adjacent LN involvement traction, narrowing and fixation of bowel loops.

Perforation

• 2nd commonest cause after typhoid

• Usually single and proximal to a stricture

• Clue - TB Chest x-ray, h/o SAIO

• Pneumoperitoneum

Malabsorption

Due to :

• Bacterial overgrowth in stagnant loop

• Bile salt deconjugation

• Diminished absorptive surface

• Involvement of lymphatics and nodes

Less common sites

• GASTRODUODENAL TB ( Gastric – uncommon)

• Mimics Peptic ulcer disease, Gastric CA

• Duodenal obstruction external compression by lymph nodes

• JEJUNAL TB

• Stricture, obstruction, perforation

Investigation and Diagnosis

• CXR

• Blood investigations

• Hb, ESR, TC, DC, Protein, serum transaminase and ALP levels

• Mantoux test

• ELISA, SAFA

• PCR of the tissue

Ascitic fluid analysis

• Straw colored

• Protein >2.5g/dL

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

• SAAG < 1.1 g/dL

Adenosine Deaminase (ADA)

Converts adenosine to inosine

• ADA increased due to stimulation of T-cells by

mycobacterial Ag

• Serum ADA > 54U/L

• Ascitic fluid ADA > 33U/L

• Ascitic fluid to serum ADA ratio > 0.985

• Coinfection with HIV normal or low ADA

PLAIN X-RAY ABDOMEN

• Calcified lymph nodes

• Dilated loops with multiple fluid

levels

• Dilation of terminal ileum and

ascites

• Pneumoperitoneum

USG ABDOMEN

• Thickened bowel wall

• Loculated ascites

• Lymph node enlargement

• Pseudokidney sign

• Stellate sign

Colonoscopy

• Nodules & Ulcers

• Deformed Ileocecal valve

• Biopsy can be taken

CT Abdomen

• Done with CT enteroclysis

• Thickened bowel wall

• Ileocecal valve thickening

• Adhesions

• CT guided aspiration, biopsy,

FNAC can be done

Barium study X-ray• Barium follow through or CT- absent filling as a result of narrowing of the

ulcerated segment

• Barium follow through or small bowel enema– long narrow filling defect in the

terminal ileum

• Narrowed segment with proximal distension

• Pulled up caecum

• Conical caecum

• Pulled down hepatic flexure

• Steirlin sign

• Fleischner sign, goose neck deformity

• String sign, Mega ileum

Laparoscopy

• Yellowish white military nodules on the peritoneum

• Erythematous , thickened peritoneum

• Adhesions

MANAGEMENT

• Medical therapy (No int. obstruction ATT)

• ATT INH, rifampicin, pyrazinamide, ethambutal first line

drugs

• 6 to 9 months

• Supportive treatment TPN, blood transfusion

• Steroids along with ATT to prevent adhesion

Indications for Surgery

• Intestinal obstruction

• Acute abdominal presentation like perforation

• Severe haemorrhage

• Intra-abdominal abscess formation and fistula formation

Surgery

• Limited ileocaecal resection

• Stricturoplasty ( solitary or multiple )

• Resection and anastomosis

• Ileotransverse colon anastomosis (bypass)

• Adhesiolysis

• Drainage of abscess