Dr.

Minhajuddin Khurram
AL-AMEEN MEDICAL COLLEGE HOSPITAL,
bIJAPUR
 A common disease in India and other developing
countries
 It the 6th most common type of extra-pulmonary
tuberculosis
 40% of Indians harbour tb bacilli
 In 2010,
Global Incidence – 9.4million
In india – 2.3million
Prevalence in India is 3.1 million
3,20,000 deaths…
-WHO
 24th March 1882- World Tb day

 TB declared as notifiable disease by

INDIAN GOVERNMENT on may9th 2012
1. Intestinal (Koenig’s syndrome)
A. Iliocaecal region
 Ulcerative -60%
 Hyperplastic-10%
 Mixed-30%
B. Ileal region
 Stricture type
2. Peritoneal tuberculosis
A. Acute
B. Chronic
 Ascitic
 Encysted
 Plastic
 Purulent
3. Tuberculous mesenteric lymphadenitis
A. Calcified lesion
B. Acute Meseneteric lymphadenitis
C. Pseudo-mesenteric cyst
D. Tabes mesenterica
E. Chronic Lymphadenitis
4. Ano-recto-sigmoidal
5. Involvement of solid organs as a part
of milary tuberculosis
6. Involvement of omentum
7. Rare types
A. Oesophageal (0.2% of abdominal)
B. Gastroduodenal
1. By ingestion
◦ Ingestion of food contaminated with
tubercle bacilli causing Primary
Intestinal Tuberculosis
◦ Ingestion of sputum containing
tuberculous bacteria from primary
pulmonary focus - Secondary
Intestinal Tuberculosis
2. Hematogenous spread from lungs
3. Through lymphatics (neck)
4. Fallopian tubes (retrograde spread)
 Most common site of abdominal tuberculosis
due to:
◦ Stasis
◦ Abundant payer’s patches
◦ Alkaline media
◦ Bacterial contact time is more
◦ Minimal digestive activity
◦ Maximum absorption in the area
A. Ulcerative type (60%):
◦ Secondary to pulmonary tuberculosis
◦ Virulent organism
◦ Poor body resistance
◦ Multiple circumferential transverse ulcers (Girdle
ulcers) with skip leisons
◦ Commonly in ileum
◦ Rarely in caecum
◦ Napkin ring strictures in longstanding ulcers
(common in ileum)
◦ Intestinal nodes involvement with caseation and
abscess
◦ May present with blood in stools, diarrhoea, loss
of appetite and reduced weight
◦ Complications:
 Acute: Ulcer perforation
 Chronic: Stricture  Subacute obstruction
B. Hyperplastic Type -10%
◦ Primary GIT tuberculosis
◦ Less virulent organism
◦ Good body resistance
◦ Chronic granulomatous lesions in ileoceacal
region
◦ Fibroblastic activity in submucosa and subserosa
causes thickening of bowel wall with lymph node
enlargement
 Presenting as Mass in Right Iliac Fossa (Nodular
fixed and firm mass)
◦ Caseation is very rare
B. Hyperplastic Type -10%
◦ No primary leision in the chest
◦ Complication: May cause sub-acute intestinal
obstruction due to mass
 Others
◦ Abdominal pain (90%)
 Colicky type in intestinal tuberculosis
 Dull aching in mesenteric lymphadenitis
◦ Mass in right iliac fossa (35%)
 Hard, nodular, fixed, nontender mass mimicing ca
caecum
◦ Subacute intestinal obstruction (20%)
◦ Can be associated with adenocarcinoma of caecum
1. Ca Caecum
2. Ameboma
3. Appendicular mass
4. Lymph node mass
5. Psoas abscess
6. Crohn’s disease
 Chest Xray – for primary focus
 Blood investgations: Mantoux, ELISA, serum
IgG
 ESR- raised
 Plain Xray abdomen
◦ Intestinal obstruction
◦ Calcified lymph nodes
◦ Hollow viscus perforation
◦ Calcified Granuloma in liver
 USG abdomen
◦ Thickened bowel wall
◦ Loculated ascitis
◦ Interloop ascitis
◦ Mesenteric thickening
◦ Lymph node enlargement
◦ Pulled up caecum (Pseudokidney sign)
 Barium study Xray (barium enema or barium
follow through)
◦ Pulled up caecum
◦ Obtuse ileocaecal angle; straightening (Goose neck)
◦ Steirlin sign: Hurrying of barium due to rapid flow
and lack of barium in inflamed site
◦ Fleischner sign (Inverted umbrella sign): Narrow
ileum with thickened ileocaecal valve
◦ Napkin leisons
◦ Chicken intestine: Hypersegmentation
◦ Mega Ileum: Dilatation of proximal ileum
 Barium
Study
showing
Mega Ileum
 Colonoscopy
◦ To rule out ca
◦ Shows mucosal nodules, ulcers, strictures,
deformed ileocaecal valve, mucosal oedema and
diffuse colitis
◦ Biopsy can be taken to eslablish the diagnosis
 CT Abdomen
◦ CT scan shows thickening
of the cecum with
pericecal inflammatory
changes. Mesenteric
lymph nodes are also
evident (arrows).
 Diagnostic laproscopy
◦ Direct visualization
◦ Collect acsitic fluid
◦ Take biopsy from mass, omentum or peritoneum
 PCR of tissue
 Acsitic tap fluid analysis
◦ Exudate fluid (protein >2.5gm%)
◦ Lymphocyte predominant cells >250 cu mm (upto
4000 cu mm)
◦ Glucose <30mg%
◦ Specefic gravity >1.016
◦ ADA (Adenosine deaminase activity) 95% specificity
and 98% sensitivity
◦ LDH > 90 units/litre
1. Obstruction 20%
2. Malabsoprption, blind loop syndrome
3. Dissemination of tuberculosis
4. Cold abscess formation
5. Hemorrhage
6. Perforation
7. Fecal fistula
 Mediacal management:
◦ First line drugs:
 INH
 Rifampicin
 Pyrazinamide
 Ethambutol
◦ Second line drugs:
 Amikacin, kanamycin, PAS, Ciprofloxacin,
 Clarithrymycin, Azythromycin, Rifabutin
 Drug: RNTCP 2H3R3Z3 E3 + 4H3R3
◦ Treatment to be continued for 6-9 months
◦ Supportive nutrition
 Surgical Management:
◦ Indications:
 Intestinal obstruction
 Severe hemorrhage
 Acute abdomen (perforation)
 Intra-abdominal abscesses/ fistula formation
 Uncertain diagnosis
 Surgical Management:
1. Ileocaecal resection with 5 cm margin
2. Stricturoplasty- single stricture
3. Single strictutre with friable bowel : Resection
4. Multiple Strictures: Resection and anastomosis
5. Multiple strictures with long segment gaps:
Multiple stricturiplasty
 Surgical Management:
6. Early perforation: resection and anastomosis (due
to friable bowels)
7. Perforation with severe contamination: resection
with colostomy
8. Adhesiolysis by laproscopy (Very difficult
procedure)
9. Drainage of abscesses and treatment for fistula in
ano
 It is usually stricture type
 May be multiple
 Presents with intestinal obstruction
 Bowel adhesions, localization, fibrosis,
secondary infection are common
 Perforation (5%)
 Plain Xray – Multiple air fluid levels
 Resection and anastomosis with Anti-
tubercular drugs
 It is post primary
 Becoming more common
 Activation of long standing latent foci
 Blood spread
 Can develop from diseased mesenteric lymph
nodes, intestines or fallpian tubes
 Basic pathology
◦ Enormous thickening of the parietal peritoneum
◦ Multiple tiny yellowish tubercles
◦ Dense adhesions in peritoneum and omentum with
small intestines
◦ May precipitate obstruction
◦ Thickening of bowel wall
 Abdominal Cocoon Syndrome
◦ Dense adhesions in peritoneum and omentum with
contents inside as small bowel causing intestinal
obstruction
A. Acute –mimics acute abdomen
◦ Rare
◦ On-table diagnosis
◦ Features of peritonitis
◦ Due to perforation or rupture of mesenteric lyph nodes
◦ Exploratory laprotomy reveals straw coloured fluid
with tubercles in the peritoneum, greater omentum
and bowel wall
◦ Fluid evacuated and sent for culture and AFB study
◦ Biopsy taken from omentum
◦ To be closed without drains
A. Chronic
◦ Presents as
 Abdominal pain
 Fever
 Ascites
 Loss of appetite and weight
 Abdominal mass
 Doughy abdomen (10%)
◦ Types
a) Ascitic form
b) Encysted form
c) Plastic form
d) Purulent form
a) Acsitic peritoneal tuberculosis:
◦ Intense exudate caused ascitis
◦ Common in children and young adults
◦ Enormous abdominal distension
◦ May cause congenital hydrdocele, umbilical
hernia, shifting dullness, fluid thrill and mass per
abdomen
◦ Rolled up omentum and nodular due to extensive
fibrosis
a) Acsitic peritoneal tuberculosis:
◦ Doughy abdomen
◦ Shifting dullness
◦ Asitic tap reveals straw coloured fluid from which
AFB can be isolated (<3%)
◦ Anti-tubercular drugs for one year
◦ Repeated tapping may be required
b) Encysted (Loculated) peritoneal tuberculosis
◦ Exudation with minimal fibroblastic reaction
◦ Ascites gets loculated due to fibrinous deposition
◦ Non shifting Dullness is the typical feature
◦ May present as intra-abdominal mass mimicing
ovorain cyst, mesenteric cyst
◦ USG guided aspiration and antitubercular drugs to
be given
c) Plastic Peritoneal Tuberculosis
◦ Extensive fibroblastic reaction
◦ Widespread adhesions
◦ Between coils of intestine (matted intestines),
abdominal wall, omentum
◦ Obstruction  Distension of abdomen
◦ Colicky abdominal pain (recurrent)
◦ Diarrhoea, loss of weight, mass per abdomen
◦ Doughy abdomen
c) Plastic Peritoneal Tuberculosis
◦ Open or laproscopic biopsy (to rule out peritoneal
carcinomatosis)
◦ Anti-tubercular drugs
◦ Surgery to relieve obstruction by adhesolysis
d) Purulent peritoneal tuberculosis
◦ Direct spread from tuberculous salpingitis
◦ Mass per abdomen containing pus, omentum,
fallopian tubes, small and large bowel
◦ Cold abscess may get adherant to umbilicus
◦ May cause umbilical discharge
◦ Genitourinary tuberculosis usually present
◦ Aanti-tubercular drugs with exporation of
umbilical fistula
1. Calcified lesion:
◦ Along the line of the mesentery a single or
multiple calcified lesions
◦ Payer’s patches involved
◦ No active infection
◦ May be on right or left side (R>L)
◦ Antitubercular drugs
2. Acute mesenteric lymphadenits
◦ Common in children
◦ Mimics acute appendicitis
◦ Tender mass of lymph node palpapble in Right
iliac fossa which are matted and non-mobile
◦ Intestines adherant to caseating lymph nodes
obstruction
◦ Surgery for appendicitis or obstruction with lymph
node biopsy
◦ Antitubercular drugs
3. Pseudo-mesenteric cyst
◦ Caseating material collected between the layers of
mesentery
◦ Forms cold abscess
◦ Mimicking a mesenteric cyst
4. Tabes mesenterica
◦ Massive enlargement of mesenteric lymph nodes due
to tuberculosis
5. Chronic Lyphadenitis
◦ Children
◦ Failure to thrive
◦ Protuberant abdomen and emaciation
◦ Lymph node on deep palpation in right iliac fossa
 Mimics ca rectum
 Occurs within 10 cmof anal verge
 Presents with tenesmus, diarrhoea and multiple
discahrging fistula in ano
 Fistula is painless, not indurated with undermined
edges
 Shallow bluish ulcers with undermined edges
 Investigation:
◦ Sigmoidoscopy
◦ USG
◦ Discharge study
◦ fistulectomy and biopsy
 Treatment: Drugs, fistulectomy or sigmoid resection
 As a part of other abdominal tuberculosis
 Rolled up omentum
 Cold abscess in omentum
 Anti-tubercular drugs
 Syrgery for cold ascess
 As a part of other abdominal tuberculosis
 Rolled up omentum
 Cold abscess in omentum
 Anti-tubercular drugs
 Syrgery for cold ascess
 Age: 25 to 50 yrs
 Equal in both sexes
 Constitutional symptoms:
o Fever (50-70%)
o Anorexia (80%)
o Cachexia
o Diarrhoea (10-20%)
o Anemia