Abdominal Tuberculosis

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Definition Abdominal Tuberculosis is a condition in

which there is tuberculous infection of the peritoneum or other organs in the abdomen.

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

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Gram negative bacillus – Mycobacterium tuberculosis

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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.

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•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.

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Distribution of tuberculous lesionsIleum > caecum > ascending colon >

jejunum

>appendix > sigmoid > rectum > duodenum

> stomach > oesophagus

•More than one site may be involved

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•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.

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Ways of presentation:

•Acute tuberculous peritonitis•Chronic tuberculous peritonitis•Tuberculous stricture of the intestine

(small) causing subacute intestinal obstruction

•Ileo caecal tuberculosis presenting with a mass in the right iliac fossa.

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•The most common site of involvement of the GI tuberculosis is the ileocaecal region.

•Ileocaecal and small bowel tuberculosis presents with a palpable mass in the right lower quadrant and/or complications of obstruction, perforation or malabsorption especially in the presence of stricture.

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Tuberculous ulcers in the intestine

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Symptoms and Presentations

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

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Chronic tuberculous peritonitis

•The condition presents with abdominal pain

•Fever•Loss of weight•Ascites•Night sweats•Abdominal mass

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Gastrointestinal TB: Any site along the GI tract may become infected. Symptoms are referable to the site infected, including the following:

•abdominal pain mimicking peptic ulcer disease with stomach or duodenal infection;

• malabsorption with infection of the small intestine;

•and pain, diarrhea, or hematochezia with infection of the colon.

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Rare clinical presentations include :• dysphagia• odynophagia •mid oesophageal ulcer due to esophageal

tuberculosis, •dyspepsia and gastric outlet obstruction due to

gastro-duodenal tuberculosis

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Origin of infection

•Tuberculous mesenteric lymph nodes.•Tuberculosis of the ileocaecal region.•Tuberculous pyosalpinx(pus in uterine

tube).•Blood borne infection from pulmonary

tuber-culosis, usually the ‘miliary’ but occasionally the cavitating form.

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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 formRare – usually secondary to tuberculous salpingitis – pockets of adherent intestines and omentum containing tuberculous pus. – cold abscesses

•Encysted formInflammation and ascites are confined to one part of the abdominal cavity

•Fibrous formWide spread adhesions adhesive obstruction

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Circumferential ulceration is characteristic of intestinal tuberculosis.　　

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Gastrointestinal Tuberculosis•This is uncommon today because routine

pasteuriz-ation of milk has eliminated Mycobacterium bovis infections. However,

•Abdominal tuberculosis is usually secondary to pulm-onary tuberculosis, radiologic evaluation often shows no evidence of lung disease

•Ileocecum and Colon,The 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 ulcerative,hypertrophic or ulcerohypertrophic.

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Gastrointestinal Tuberculosis

•Barium 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•A narrowed terminal ileum with rapid

emptying of the diseased segment through a gaping ileocecal valve into a shortened, rigid, obliterated cecum

•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)

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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 within the meso-colon, Ileocecal valve becomes fixed, irregular, gaping, and incompetent

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Tuberculosis of esophagus•Rare ~ 0.2% of total cases

•By extension from adjacent LN

•Low grade fever / Dysphagia / Odynophagia / Midesophageal ulcer

•Mimics esophageal Ca

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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

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Ileocaecal tuberculosis•Colicky abdominal pain

• ‘Ball of wind’ rolling in abdomen

•Borborygmi

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

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Obstruction• Most common complication

Pathogenesis▫ Hyperplastic caecal TB ▫ Strictures of the small intestine--- commonly

multiple▫ Adhesions▫ Adjacent LN involvement traction, narrowing and

fixation of bowel loops.

• In India ~ 3% to 20% of bowel obstruction

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Perforation •5%-9% of SI perforations in India

•2nd commonest cause after typhoid

•Usually single and proximal to a stricture

•Clue - TB Chest x-ray, h/o SAIO

•Pneumoperitoneum in ~ 50% cases

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Malabsorption• Common • 2nd only to tropical sprue in India• Clue----h/o of pain / SAIO• Pathogenesis

▫ bacterial overgrowth in stagnant loop ▫ bile salt deconjugation ▫ diminished absorptive surface due to ulceration▫ involvement of lymphatics and LN

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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

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Investigations•Blood routine•Urine routine - to detect diabetes

mellitus•Plain X-ray of the abdomen•Laparoscopy•Laparoscopic biopsy of tubercles foun in

the peritoneum or other parts

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Immunological Tests• ELISA • SAFA •Competitive ELISA

Response to mycobacteria variable & reproducibility poor

Value of immunological tests remain undefined

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Ascitic fluid examination•Straw coloured

•Protein >3g/dL

•TLC of 150-4000/µl, Lymphocytes >70%

•SAAG < 1.1 g/dL

•ZN stain + in < 3% cases

•+ culture in < 20% cases

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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

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ColonoscopyColonoscopy - mucosal nodules & ulcers• Nodules

▫ Variable sizes (2 to 6mm)▫ Non friable▫ Most common in caecum especially near IC valve.

• Tubercular ulcers▫ Large (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

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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)

Caseating granulomas + in 85%-90% of Bx

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Tuberculous peritonitis – USGM – Intestines floating in peritoneal fluid - ascites

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Treatment Antituberculous treatment drugs : Akurit –

4 Ripe Kit

• isoniazid•rifampicin•pyrazinamide•ethambutol•Surgical intervention as and when

needed

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Drugs used to treat TB disease. From left to right isoniazid, rifampin, pyrazinamide, and ethambutol. Streptomycin (not shown) is given by injection

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