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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 Poor immunity

Lodging of bacillus in organs & nodes Severe TB

dormant

Reactivation/ dec immunity

Secondary 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 loss
 Fever
 Night sweating
 Nausea & Vomiting
 Diarrhoea / Constipation
 Anorexia
 Amenorrhoea
 Pulmonary
UNCOMMON PRESENTATION
 Gastro-duodenal TB
 Oesophagus
 Segmental colonic
 Rectal
 Anal 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
 Diagnostictests
 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
 Routinemicroscopy
 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 10-


14 days
 Solid (LJ Media) media – 4-6 wks
TB PCR

 Itis 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 Type of patient Regimen
treatment

New sputum smear +ve 2 H3R3Z3E3


Category I TB +
Seriously ill new smear – 4 H3R3
ve TB
Seriously ill new EPTB
Sputum smear positive 2 H3R3Z3E3S3 +
Category II relapse 1H3R3Z3E3
Sputum smear positive + 5H3R3E3
failure
Sputum smear +ve
treatment after default
New sputum smear –ve 2H3R3Z3 + 4 H3R3
Category III PTB
New EPTB, not seriously
ill
RNTCP Classification of EPTB
SERIOUSLY ILL NOT SERIOUSLY ILL
 TB meningitis  Lymph node TB
 Disseminated TB  Pleural effusion
 TB pericarditis (unilateral)
 TB peritonitis/intestinal  Bone (excluding spine)
TB  Peripheral joints
 Bilateral pleurisy
 Spinal TB with
neurological
complications
 Genitourinary tract
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

 Bothincidence 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