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Abdominal Tbpresentation Diagnosis and Treatment New

Abdominal Tbpresentation Diagnosis and Treatment New

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Published by: rajan kumar on May 16, 2009
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04/23/2013

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ABDOMINAL TB:PRESENTATION, DIAGNOSIS AND TREATMENT Vishal Gajbhiye

ABDOMINAL TB CLASSIFICATION
Intestinal - ulcerative - hyperplastic - perforative  Peritoneal - wet - dry/plastic - fibrotic fixed - acute primary peritonitis  Mesenteric involvement - mass - abscess - nodal  Solid organ - liver , spleen,pancreas

ETIOPATHOGENESIS
 Primary  Secondary

 Route
– – – –

of abdominal infection

Direct ingestion Haematogenous spread Direct extension from contiguous organ Through lymph channels

FLOW CHART OF PATHOGENESIS
Primary infection Primary complex Bacteremia Good immunity Lodging of bacillus in organs & nodes dormant Reactivation/ dec immunity Secondary TB Poor immunity Severe TB

INTESTINAL TUBERCULOSIS
 Primary

form – non-pasteurised dairy

products  10 rarely seen in India  Secondary form – swallowing infected sputum, haematogenous from 10 focus

CLINICAL PRESENTATION

Intestinal obstruction
– Acute – Subacute – Chronic

 

Perforation Ascites
– Diffuse – Loculated – Organized

Lump
– – – – –

Abscess LN Mass Bowel mass IC mass Omental mass

SYSTEMIC MANIFESTATIONS
 Weight  Fever  Night

loss

sweating  Nausea & Vomiting  Diarrhoea / Constipation  Anorexia  Amenorrhoea  Pulmonary

UNCOMMON PRESENTATION
 Gastro-duodenal  Oesophagus  Segmental  Rectal  Anal

TB

colonic

TB  Genitourinary TB

IMPORTANT CLINICAL FINDINGS
 Doughy

abdomen  Lump causes  IC mass  Omental mass  Cocoon

INVESTIGATIONS
 Basic
– – – – –

test

TLC/DLC ESR Mantoux test Chest X-ray Plain X-ray abdomen

 Diagnostic

tests  ELISA for TB

X-RAY ABDOMEN WITH CALCIFIED LYMPH NODE

X-RAY ABDOMEN WITH INTESTINAL OBSTRUCTION

USG IN ABDOMINAL TB
FINDINGS  Intra abdominal fluid  Septae  Peritoneal Thickening  Lymphadenopathy GUIDED PROCEDURES  Ascitic tap  FNAC / Biopsy

USG SEPTATE ASCITES

USG NECROTIC/CALCIFIED LYMPH NODE MASS

USG BOWEL/MESENTERIC THICKENING

BARIUM CONTRAST STUDY
 FINDINGES  Fleishner

sign  Conical caecum  Increased IC angle  Multiple strictures

BARIUM CONTRAST STUDY WITH IC-TUBERCULOSIS

BARIUM CONTRAST STUDY WITH STRICTURES

CT SCAN ABDOMEN
 Whenever

diagnosis in doubt

 FINDINGS    

Lymphadenopathy – m/c I C Mural thickening High density ascities Irregular soft tissue densities in omental area

CT SCAN TB LYMPHADENITIS

CT SCAN BOWEL THICKENING

CT-SCAN MESENTERIC AND PERITONEAL THICKENING

ASCITES FLUID
 Routine

microscopy  AFB stain  AFB culture  TB PCR  ADA
– Serum > 42 IU/L – Ascites fluid > 33 IU/L

 SAAG

< 1.1  LDH > 90 U/L

BACTEC FAST METHOD OF TB CULTURE

 Liquid

(BACTEC) – results available in 1014 days  Solid (LJ Media) media – 4-6 wks

TB PCR

 It

is genetic test  Sensitivity and specificity  Rapid & Result available in few hours  Quantitative – 1 to 2 bacilli

LAPAROSCOPY
 Advantage
– Diagnostic – Biopsy – Therapeutic – May avoid empirical use of ATT

 Disadvantage
– Invasive investigation – Difficult – Costly

TREATMENT
 ATT

as per dots/rntcp recommendation  Empirical ATT to be condemned  Aspiration of abscess  Surgery for unrelieved obstruction  Surgery for perforation

Category of treatment Category I

Type of patient

Regimen

New sputum smear +ve TB Seriously ill new smear – ve TB Seriously ill new EPTB Sputum smear positive relapse Sputum smear positive failure Sputum smear +ve treatment after default New sputum smear –ve PTB New EPTB, not seriously ill

2 H3R3Z3E3 + 4 H3R3

Category II

2 H3R3Z3E3S3 + 1H3R3Z3E3 + 5H3R3E3

Category III

2H3R3Z3 + 4 H3R3

RNTCP Classification of EPTB
SERIOUSLY ILL  TB meningitis  Disseminated TB  TB pericarditis  TB peritonitis/intestinal TB  Bilateral pleurisy  Spinal TB with neurological complications  Genitourinary tract NOT SERIOUSLY ILL  Lymph node TB  Pleural effusion (unilateral)  Bone (excluding spine)  Peripheral joints

SURGERY FOR OBSTRUCTION
 IC

TB  Indication of right hemicolectomy  Subacute obstruction  Coccon abdomen

SURGERY FOR PERFORATION
 Resection

of involved segment and primary anastomosis  Primary repair – risk of re-perforation or fistulisation

COMPLICATIONS
– Obstruction & perforation – Malnutrition and superinfection – Blind loop – Malabsorption – Enterocutaneous fistula – Short bowel syndrome – Infertility

ABDOMINAL TB AND HIV
 Both

incidence and severity increased  EP TB 10-15% of all cases 50% of patient with AIDS  Mainly MDR TB  Second line drugs can be used

CONCLUSION :
 Suspicion

is must  Diagnosis is possible  TB PCR is a valuable test  Empirical ATT should be avoided  Laparoscopy is an important diagnostic tool  Surgery for unavoidable reasons only

THANK YOU

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