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06 Ra Abdominal Tuberculosis PDF
06 Ra Abdominal Tuberculosis PDF
64 ■ February 2016
review article
Abdominal Tuberculosis
Pravin Rathi1, Pravir Gambhire2
Table 1: Clinical features Table 2: Case series of intestinal acid, the scarcity of lymphoid
tuberculosis tissue in the mucosa, and the
Site Type Clinical
features Symptoms Mukewar Makharia Khan rapid emptying of gastric contents.
Small Ulcerative Diarrhoea, et al et al et al Usually involves the antral region,
intestine malabsorption Abdominal 80.6% 90.5% 93% involvement of the pre pyloric
Stricturous Obstruction pain region, fundus, have been reported,
Large Ulcerative Rectal bleeding Weight loss 74.6% 83% 47% the presentation is usually of a non-
intestine Hypertrophic Lump, Loss of 62.7% 69.8% 52% healing ulcer or the hypertrophic
obstruction appetite
lesion causing the gastric outlet
Peritoneal Ascitic Pain, distension Fever 40.30% 41.5 64%
obstruction. 19
Adhesive Obstruction Diarrhoea 16.4% 37.7% 12%
Lymph - Lump, Constipation 25% 49% 31% Duodenal Tuberculosis
nodes obstruction Bleeding Per 11.9% 16.9% 14% Third part is the most commonly
rectum affected site in the duodenum.
involved, leading to incompetence
of the valve, a finding that helps Intestinal Tuberculosis Duodenal lesion may be intrinsic
distinguish tuberculosis from A recent series which highlights (ulcerative, hypertrophic or
Crohn’s disease. Other locations of the intestinal tubeculosis provides a ulcerohypertrophic) or extrinsic
involvement, in order of descending elaborate view of symptomatology (i.e. compression of duodenum
frequency, are the ascending colon, of the colonic tuberculosis (Table by enlarged periduodenal
jejunum, appendix, duodenum, 2). 13-15 lymph nodes from the outside).
stomach, oesophagus, sigmoid The largest published series of
Tuberculous Peritonitis
colon, and rectum. Multiple areas duodenal tuberculosis reported
In a series of 60 patients 3 0 c a s e s f r o m I n d i a ; 20 m o s t
of the bowel can be affected. 8
published by Chow et al the most patients (73%) had symptoms
Three types of intestinal lesions c o m m o n f e a t u r e s we r e a s c i t e s of duodenal obstruction. In a
are commonly seen - ulcerative, (93 percent), abdominal pain (73 majority of these cases obstruction
st r i ct u r o u s, a nd h y p e r t r op h ic , percent), and fever (58 percent). 16 was due to extrinsic compression
cicatricial healing of the ulcerative The classic doughy abdomen is by tuberculous lymph nodes,
l e si o n s r e su l t i n g in s tric tures . associated with the fibro-adhesive rather than by intrinsic duodenal
Occlusive arterial changes may form of tuberculous peritonitis and lesion. The remainder (27%) had
produce ischemia and contribute is rarely seen. a history of dyspepsia and were
to development of strictures.
Oesophageal Tuberculosis suspected of having duodenal
These morphological types can
It is rare, constituting about u l c e r s . Tw o o f t h e s e p a t i e n t s
coexist, e.g., ulcero-constrictive
0.3% of GI tuberculosis. In addition presented with hematemesis.
and ulcero-hypertrophic lesions.
to constitutional symptoms, Other reported complications by
Small intestinal lesions are usually
dysphagia, odynophagia and various authors are perforation, 21
ulcerative or stricturous and large
retrosternal discomfort or pain fistulae (pyeloduodenal,
intestinal lesions are ulcero-
are common. Rarely, the patient d u o d e n o c u t a n e o u s , b l i n d ) , 22
hypertrophic. Colonic lesions are
may present with life-threatening and obstructive jaundice by
usually associated with ileocaecal
complications such as broncho- compression of the common bile
or ileal involvement. 9
oesophageal fistula or hematemesis. d u c t . 23 R e c e n t l y M o h i t e e t a l 24
Peritoneal involvement may from Mumbai reported a case of
The middle third of the oesophagus
be of either an ascitic or adhesive duodenal tuberculosis presenting
is most commonly affected site
(plastic) type. The lymph nodes with choledocho-duodenal fistula
near carina due to proximity
i n t h e s m a l l b o we l m e s e n t e r y
t o m e d i a s t i n a l l y m p h n o d e s . 17 Rectal Tuberculosis
and the retro peritoneum are
Endoscopic mucosal biopsy has Haematochezia is the most
commonly involved, and these may
sensitivity of 22% as reported by common symptom (88%) followed
caseate and calcify. Disseminated
Mokoena et al. 18 by constitutional symptoms (75%)
abdominal tuberculosis involving
Stomach Tuberculosis and constipation (37%). 25 The high
the gastrointestinal tract,
peritoneum, lymph nodes and solid Stomach and duodenal frequency of rectal bleeding may be
viscera has also been described. 10 tuberculosis each constitute around because of mucosal trauma caused
1 per cent of cases of abdominal b y s c y b a l o u s s t o o l t r a ve r s i n g
Clinical Features tuberculosis. Primary and isolated the strictured segment. Digital
gastric tuberculosis without examination reveals an annular
The clinical presentation evidence of lesions elsewhere stricture. The stricture is usually
depends upon the site and type of is exceedingly rare due to the tight and of variable length with
involvement (Table 1). 11,12 bactericidal properties of gastric focal areas of deep ulceration. 26
40 Journal of The Association of Physicians of India ■ Vol. 64 ■ February 2016
Table 3: Differences between Table 4: Colonoscopic findings A few case reports have described
tuberculosis and Crohn’s capsule endoscopic features of
Colonoscopic Alvares Misra Singh Das
disease findings et al SP et V et HS et intestinal TB as multiple scattered
Tuberculosis Crohn’s Disease al al al short, oblique or transverse
Mural thickening Mural thickening Ulceration 70% 92% 83% 47% mucosal ulcers with a necrotic base
without stratification with stratification in Nodularity 56% 88% 79% 42% in the jejunum and ileum. 29 Cello
acute inflammation Deformed 40% 42% 55% NA et al 30 also found that ulcers of the
Strictures concentric Strictures eccentric caecum and IC
small bowel in intestinal TB were
Fibrofatty Fibrofatty valve
Strictures 23% 25% 27% 14%
characteristically shallow with
Proliferation of proliferation of
mesentery very rare mesentery Polypoid 14% 6% 5% 4.7%
extensive irregular “geographic”
No vascular Hypervascular lesions borders, were usually not larger
engorgement in the mesentery Segmental 19% 22% 19% 14% than 1-2 cm and were transverse
mesentery involvement rather than longitudinal. However,
Hypodense Mild Fibrous bands 7% 8% NA NA it is difficult to differentiate
lymph nodes lymphadenopathy Lesions 16% NA 20% NA
with peripheral
CD from TB based on capsule
mimicking
enhancement endoscopic features alone.
carcinoma
High dense ascites Abscesses A meta-analysis compared
being common in malignancy capsule endoscopy and double
Investigations related lymphadenopathy. balloon enteroscopy in patients
Routine laboratory tests reveal iv. Bowel wall thickening is best with suspected inflammatory
mild anaemia and increased appreciated in the ileocaecal lesions and found no statistically
sedimentation rate in 50 to 80 region. The thickening is significant difference in their
percent of patients. The white uniform and concentric as diagnostic yield 31 in a series of 106
blood count is usually normal. 27 opposed to the eccentric cases of single balloon enteroscopy.
thickening at the mesenteric Colonoscopic Findings
Ultrasonography
border found in Crohn’s
Ultrasound is useful for imaging The main differential diagnosis
disease and the variegated
peritoneal tuberculosis. The at endoscopy is Crohn’s disease
appearance of malignancy.
following features may be seen, (CD). This distinction is important
v. P s e u d o k i d n e y s i g n – since the use of steroids for a
usually in combination. 28
involvement of the ileocaecal m i s d i a g n o s i s o f C D m a y h a ve
i. Intra-abdominal fluid which region which is pulled up to a disastrous consequences in patients
may be free or loculated; subhepatic position. with TB enteritis. The TB ulcers
and clear or complex. Fluid CT Abdomen tend to be circumferential and are
collections in the pelvis may
The differential diagnosis usually surrounded by inflamed
have thick septa and can mimic
usually includes Crohn’s disease, mucosa. A patulous valve with
ovarian cyst.
lymphoma, or carcinoma. CT is surrounding heaped up folds
ii. “Club sandwich” or “sliced the most helpful imaging modality or a destroyed valve with a fish
bread” sign is due to localized to assess intraluminal and extra mouth opening is more likely to
fluid between radially oriented luminal pathology, and disease be caused by TB than CD. The
bowel loops, due to local extent. The most common CT Colonoscopic findings in various
exudation from the inflamed finding is concentric mural series in patients of GI tuberculosis
bowel (interloop ascites) thickening of the ileocecal region, are high lightened in Table 4. 32-35
iii. L y m p h a d e n o p a t h y m a y b e with or without proximal intestinal Shah et al 36 has described the
discrete or conglomerated dilatation. MDCT showed frequency of distribution of colonic
(matted). The echotexture that abdominal tuberculous TB based on the colonoscopy as
is mixed Heterogenous, in lymphadenopathy involved follows: 32% disease confined to the
contrast to the homogenously predominately the mesenteric, upper ileocaecal region, 28% ileocaecal and
hypo echoic nodes of and lower para-aortic, periportal, contiguous involvement of variable
lymphoma. Small discrete and pancreaticoduodenal regions. lengths of the ascending colon, 26%
anechoic areas representing The diagnostic dilemma between segmental colonic tuberculosis
zones of caseation may be seen the Crohn’s disease and GI with involvement of the ascending
within the nodes. Calcification tuberculosis can be dealt to an colon in 10%, transverse colon in
in healing lesions is seen as extent with differences in Table 3. 12%, and descending colon in 4%;
discrete reflective lines. Both Capsule Endoscopy and Enteroscopy 10% ileocaecal and non-confluent
caseation and calcification involvement of another part of the
There is limited data regarding
a r e h i g h l y s u g g e s t i ve o f a
capsule endoscopy in intestinal TB.
tubercular etiology, neither
Journal of The Association of Physicians of India ■ Vol. 64 ■ February 2016 41
of 21 IU/L was found to yield the intestinal tuberculosis and CD are GeneXpert Assay
best results of differential diagnosis so similar that it becomes difficult The GeneXpert MTB
between tuberculous ascites and to differentiate between these two RIF assay is an automated
peritoneal carcinomatosis with; entities. The sensitivity of ASCA nucleic acid amplification
sensitivity, specificity, positive (IgG and IgA) in CD is 60%–80%, test that can simultaneously
predictive value, and negative whereas the specificity is almost identify M. tuberculosis
predictive value were 92.0%, 85.0%, 90%. 52 ASCA IgG, a combination and rifampin resistance. Among
88.5% and 89.5%, respectively. of ASCA IgA and IgG, and either 547 patients with suspected extra
Quantiferon - TB Gold (QFT-G) A S C A I g A o r A S C A I g G we r e pulmonary TB in India and 1068
positive in a similar number of patients in Europe, the sensitivity
In May 2005, this new test was
patients with CD and intestinal and specificity of the Xpert
a p p r o ve d b y t h e F D A f o r t h e
tuberculosis and have no diagnostic assay were 81 and 99 percent,
diagnosis of latent TB. Quantiferon-
value in differentiating these two respectively. 56,57
TB gold (QFT-G) is a blood test that
diseases. 53
uses an interferon gamma release In a metanalysis of 12 studies
assay that measures the release of T-cell Based Testing for Mycobacterium (699 samples) that tested Xpert
interferon gamma after stimulation Tuberculosis (ELISPOT)
MTB/RIF using tissue samples from
in vitro by M. tuberculosis antigens. A n F D A a p p r o ve d E n z y m e - a site other than a lymph node,
Most of the studies on this test have Linked Immunospot Assay and compared the results against
been performed on pulmonary TB. (ELISPOT), measuring gamma culture as a reference standard (10
In a study looking at patients with producing T-cell responses to studies had more than 10 samples).
active pulmonary TB, compared early secreted antigenic targets of The estimates of sensitivity varied
with PPD skin test, the sensitivity mycobacterium tuberculosis, has widely and ranged from 42% to
of the QFT-G was 62 and 86%, shown promising results. Sharma 100%. The pooled estimate of
respectively. 49 In a review of meta- et al 54 evaluated the diagnostic sensitivity was calculated as 81.2%
analysis 50 the pooled sensitivity, accuracy and cost-effectiveness (95% CI, 67.7–89.9%). The pooled
specificity, positive likelihood of ascitic fluid interferon-gamma specificity was 98.1% (95% CI,
ratio, and negative likelihood ratio (IFN-gamma) and adenosine 87.0–99.8%). The condition of the
of IGRA for the diagnosis of ITB deaminase (ADA) assays in the specimen (fresh versus frozen) did
was 81% (95% CI, 75-86%), 85% diagnosis of tuberculous ascites. not appear to affect the performance
(95% CI, 81-89%), 6.02 (95% CI: IFN-gamma and ADA assays of Xpert MTB/RIF. The five studies
4.62-7.83), and 0.19 (95% CI: 0.10- showed equal sensitivity (0.97) and testing fresh specimens achieved a
0.36) The AUC was 0.92 xlix. IGRAs differed marginally in specificity pooled sensitivity of 79% (95% CI,
do not have high accuracy for the (0.97 vs. 0.94). Difference in AUCs 64–94%). A further three studies
prediction of active TB, although was not significant (0.99 vs. 0.98, used frozen specimens and had
use of IGRAs in some populations p <0.62). For differentiating TB a pooled sensitivity of 76% (95%
might reduce the number of from non-TB ascites, optimal cut CI, 58–94%). The condition of the
people considered for preventive off points were 112 pg/mL for specimen (fresh or frozen) did not
treatment. Several longitudinal IFN-gamma and 37 IU/L for ADA. affect the specificity. 58
studies show that incidence rates Nucleic Acid Amplification Diagnosing TB in LN:
of active TB, even in IGRA-positive Nucleic Acid Amplification metanalysis of fourteen studies that
individuals in high TB burden assays (NAA) are used to amplify tested the accuracy of Xpert MTB/
countries, are low, suggesting the quantity of M. tuberculosis RIF on samples from lymph node
that a vast majority (>95 percent) DNA in diagnostic specimens biopsies or fine-needle aspiration
of IGRA-positive individuals do where organisms may be present (FNA) compared against culture
not progress to TB disease during in amounts too small to be seen as a reference standard. For the 11
follow-up. 51 The latest guidelines by routine staining techniques. studies with more than 10 samples
from the United States, Canada, Two NAA tests were approved (total, 849 samples) the estimates
the European Centre for Disease by the United States Food and for sensitivity ranged from 50%
Prevention and Control (ECDC), Drug Administration as of 2012, to 100%. The pooled sensitivity
the United Kingdom, and World but only for use with sputum or across studies was 84.9% (95% CI,
Health Organization (WHO) do respiratory secretions obtained by 72.1–92.4%); the pooled specificity
not support the use of QFT-G in the bronchoscopy. 55 However in 2014 was 92.5% (95% CI, 80.3–97.4%).
setting of active TB. guidelines issued by the WHO the WHO recommendation
Anti-Saccharomyces Cerevisiae Gene Xpert has been validated for 2013: Xpert MTB/RIF may
Antibody (ASCA) the extra pulmonary TB too be used as a replacement test
The clinical, morphological, for usual practice (including
and histological features of
Journal of The Association of Physicians of India ■ Vol. 64 ■ February 2016 43
conventional microscopy, culture diagnosis between intestinal TB directly observed therapy is highly
or histopathology) for testing and CD. recommended.
specific nonrespiratory specimens Ascitic Fluid Routine Microscopy and Traditionally the 9 month AKT
(lymph nodes and other tissues) Culture was given to the patients with
from patients suspected of having Tuberculous peritonitis should abdominal Koch’s however it is
extra pulmonary TB (conditional be considered in all patients n o w p r o ve n t h a t t h e 6 - m o n t h
recommendation, very low- quality presenting with unexplained therapy is as effective as 9-month
evidence). lymphocytic ascites with a serum- therapy in patients with intestinal
Standards for TB care in INDIA ascites albumin gradient of <1.1 g/ TB and may have the additional
WHO 2014: For all patients (adults, dL. Up to one-half of patients benefits of reduced treatment cost
adolescents and children) with have underlying cirrhosis and and increased compliance. 65
presumptive extra-pulmonary TB, therefore have a SAAG ≥1.1 The In patients with newly
appropriate specimens from the protein content of the ascitic fluid diagnosed pulmonary TB, the
presumed sites of involvement is usually >3.0 g/dL. 61 “cure” rate after DOTS ranges
must be obtained for microscopy/ Examination of an Acid fast from 75%-92%. Treatment success
culture and drug sensitivity testing stained smear of ascitic fluid has a in extra pulmonary TB was 91% in
(DST)/CB-NAAT/molecular test/ disappointingly low yield. Direct one study, but this study did not
histo-pathological examination. smear for Ziehl-Neelson stain further categorize extra pulmonary
MTBDR Plus has a reported sensitivity of 0 to TB. 66 In a study by Mukewar et al xiii
It is a molecular probe 6 percent. 62 In most series, the in colonic tuberculosis Majority of
capable of detecting rifampicin frequency of a positive ascites the ulcers (87.2%), nodules (84.6%),
and isoniazid resistance mutations culture is disappointingly less than polypoid lesions (85.7%), luminal
(rpoB gene for rifampicin resistance; 20 percent. The utility of cultures narrowing (76.2%), and ileo-cecal
katG and inhA genes for isoniazid is even more questionable when valve deformities (76.5%) resolved
resistance). In an evaluation of considering the delay of four to six with anti-TB treatment after 4
5 3 6 s m e a r p o s i t i ve s p e c i m e n s weeks before a result is obtained. weeks . However, biopsies were not
from patients at risk for MDR-TB The delay can be associated with taken from these patients during
in South Africa, the molecular increased mortality. 63 follow up thereafter nor was there
probe was ≥99 percent sensitive any long term follow up of the
and specific for multidrug TB The Role of Laparoscopy treated individuals was a drawback
resistance compared with standard of the study.
B h a r g a v a e t a l 64 r e p o r t e d
DST; results were available in one Drug resistance is increasingly
laparoscopic findings in 38 proven
to two days. Since the assay does common in strains of MTB and may
cases of peritoneal tuberculosis.
not depend on culture, it yielded contribute to recurrent or persistent
The laparoscopic appearances
results even in specimens that were disease in patients correctly
can be classified into three types:
contaminated or had no growth. diagnosed as having TB but not
thickened peritoneum with miliary
Molecular testing was successful showing clinical, endoscopic or
yellowish white tubercles with or
even when the AFB smear was histological response to treatment
without adhesions (n = 25), only
negative. Use of the assay can with first line chemotherapy for TB.
thickened peritoneum with or
reduce time to initiation of therapy Multi-drug resistance (MDR) has
without adhesions (n = 8), and fibro
for MDR-TB. 59 been observed in 2.4% to 13.2% of
adhesive pattern (n = 5). Biopsies
TB PCR were avoided from fibro adhesive strains of MTB isolated from newly
Makharia et al in his series lesions due to risk of complications. diagnosed pulmonary TB patients
of 53 patients with intestinal Visual diagnosis was accurate in and in 17.4% to 25.5% of previously
tuberculosis, 36 (67.9 %) had 95% of patients. In comparison, treated patients. 15 Extensive drug
positive PCR for M. Tuberculosis. 14 in 27 (82%) of 33 patients, the resistance (XDR) is found almost
In a study by Amarapurkar et al 60 examination enabled a histological exclusively in previously treated
PCR was positive in 21.6% cases diagnosis to be made on the basis patients and accounts for about 6%
of intestinal tuberculosis and 5% of typical granuloma. of MDR TB. 67 Statistics regarding
Crohn’s disease. PCR assay showed prevalence of MDR and XDR strains
high specificity (95%) for the Management in intestinal TB are not available
diagnosis of intestinal tuberculosis. from India; however, in one series
Therapy with standard of 30 patients with colonic TB in
thus PCR assay is useful for rapid
antituberculous drugs is usually Taiwan, 13% had MDR TB. 68
and accurate diagnosis of intestinal
highly effective for intestinal TB. Monitoring During Treatment
TB, and also helpful for differential
Compliance with treatment is the
Treatment of patients with
main determinant of outcome and
44 Journal of The Association of Physicians of India ■ Vol. 64 ■ February 2016
patients received maximum doses for ileocecal TB based upon clinical, Experiences with 300 cases. Am J
of INH, RIF, PZA simultaneously, radiologic, and endoscopic findings, Gastroenterol 1977; 67:324-37.
arm II (n=59), patients received despite nondiagnostic histological 12. Tandon RK, Bansal R, Kapur BML, et al
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13. Saurabh Mukewar, Shrikant Mukewar,
all with maximum doses. In arm III i n t h e a b s e n c e o f a d e f i n i t i ve Raghvendra Ravi,et al Colon Tuberculosis:
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Book Review
Clinical Methods and Interpretation in Medicine
by Author: Dr. Ashis Kumar Saha M.D.(Cal), D.T.M and H (Cal). FICP. FACP(USA)
Associate Professor, Medicine K P C Medical College, Jadavpur, Kolkata
Publisher: Jaypee Brothers Medical Publishers (P) Ltd.
Pages: 1500, Price: 795/-
Students and Doctors learn in differing ways. Some by listening, others by reading or looking at images. Dr. Saha’s book provides
the opportunity to assimilate all three methods. We can hear the author’s voice in the text, we can read his words and the images,
figures and tables provide excellent visual prompts.
The practice of Clinical Medicine is truly as much an art as a science. It is a wise clinician who realizes their limits and the need
for constant and regular education. This book can do much to fill this requirement. It is comprehensive, clear and well structured.
One can approach it by System or Symptom and dipping into it at random leads to a progressive wish to read more.
The book will be as valuable for the student as the more experienced clinician. It will be an excellent resource to which they will
frequently return.
Colin Robertson
Hon. Professor of Emergency Medicine, University of Edinburgh, Scotland