ABDOMINAL TUBERCULOSIS

DR. MUHAMMAD TAIMUR

ASSISTANT PROFESSOR SURGERY
FUSH/FFH RAWALPINDI.
LEARNING OBJECTIVES
• The final year MBBS students at the end of this lecture will be able
to:
1. know etiology, classification and clinical features
of abdominal tuberculosis.
2. Know the investigation and treatment of Abdominal
TB patients.
INTRODUCTION

• 30%-50% of world population has TB (3 billion)

• 8-10 Mill /yr
• >3 Mill in Sub-Saharan Africa
• 5,000 people die/d = 2.3 million/ yr
• TB kills more young women than any other disease
INTRODUCTION
•Defined - Mycobacterium Tuberculous infection of abdomen : may involve
GIT, Peritoneum , Omentum , Mesenteric nodes and Other solid organs.
•Sixth most common form of Extra pulmonary TB.
•Incidence & severity increasing in HIV patients.
•Clinical features depends upon site of involvement.
•Cervical node involvement in 3-10%.
•Genital tract in 10% of women.
CAUSES OF RESURGENCE IN INCIDENCE
OF TB
• Worsening economic situations
• Multidrug resistance
• HIV pandemic
• Decline of national tuberculosis control programs
• Large number of displaced persons living in poor conditions as a result of
conflicts and wars
AETIO-PATHOGENESIS
•Primary (non pasteurized milk)
•Secondary (sputum)
Route of abdominal infection
•Direct ingestion
•Hematogenous spread
•Direct extension from contiguous organ
•Through lymph channels
ABDOMINAL TB CLASSIFICATION
• GIT:- Ulcerative
Hyperplastic
Ulcerohyperplastic
Diffuse

• Peritoneal: Acute & Chronic: Ascitic

Loculated form
Fibrous form
Purulent form
ABDOMINAL TB CLASSIFICATION
•Mesentry: Adenitis, Abscess/cyst, Bowel adhesion and Rolled up
omentum

•Solid organ: Liver, Spleen, Pancreas and Gall bladder.

•Rare entities: Retroperitoneal nodes, Esophageal TB,

Gastroduodenal TB.
CLINICAL PRESENTATION
• Intestinal obstruction: Acute, Subacute and Chronic.
• Perforation
• Ascites: Diffuse, Loculated and Organized.
• Lump/Mass: Abscess, LN Mass, Bowel mass, Ileo-Caecal
mass and Omental mass.
DIFFERENTIAL DIAGNOSIS
Malignancy
• Hodgkin’s lymphoma
• Acute lymphocytic leukemia
Infection
• Pyogenic lymphadenitis
• Fungal infection of lymph nodes
• Infection with atypical mycobacteria
• HIV/AIDS
MOST COMMON SITE - ILEOCAECAL REGION

• Ileum >caecum> ascending colon > jejunum>appendix > sigmoid

> rectum > duodenum> stomach >oesophagus
• Increased physiological stasis
• Increased rate of fluid and electrolyte absorption
• Minimal digestive activity
• Abundance of lymphoid tissue
UNCOMMON PRESENTATION
• Gastro-duodenal TB
• Oesophagus
• Segmental colonic
• Rectal
• Anal TB
• Genitourinary TB
INVESTIGATION
• Imaging: X-RAY ABD, USG, CECT.
• Lab-tests: Sputum bacteriology (gram stain, culture),
Tuberculin test, Ascites ADA.
• FNAC or Biopsy.
X-RAY ABDOMEN WITH CALCIFIED LYMPH
NODE
X-RAY ABD WITH INTESTINAL OBSTRUCTION
USG IN ABDOMINAL TB

• Intra abdominal fluid

• Septae
• Peritoneal Thickening
• Lymphadenopathy
GUIDED PROCEDURES
• Ascitic tap
• FNAC / Biopsy
BARIUM CONTRAST STUDY WITH IC-
TUBERCULOSIS

• Fleishner sign
• Conical caecum
• Increased IC angle
STRICTURES/ FISTULAE
CT SCAN ABDOMEN

• Whenever diagnosis in doubt

• Lymphadenopathy
• Ileo-Caecal Mural thickening
• High density ascites
• Irregular soft tissue densities in omental area
CT SCAN BOWEL THICKENING
TUBERCULOUS PERITONITIS
Axial contrast-enhanced CT
• ascites paracolic gutter
• thickened peritoneum (white

arrow)
• omental thickening (open arrow)
• multiple rim-enhancing lymph nodes
(black arrows)
MESENTERIC TB
• Ultrasound demonstrates multiple
enlarged hypoechoic lymph nodes within
the mesentery (arrows)
• Contrast-enhanced CT scan reveals
extensive infiltration of the mesentery,
with presence of loculated ascites,
thickening and enhancing of the
peritoneum (curved arrow), low
attenuation mesenteric & retroperitoneal
lymph nodes (black arrows) and omental
thickening (white arrow)
ASCITES FLUID
• Routine microscopy
• AFB stain
• AFB culture
• TB PCR
• ADA: In Serum and Ascites fluid
• LDH > 90 U/L
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 >40 U/L
• Ascitic fluid to serum ADA ratio > 0.985 ( Bhargava et al)
• Coinfection with HIV  normal or low ADA
TB PCR
• It is genetic test
• Sensitive and specific
• Rapid & Result available in few hours
• Quantitative – 1 to 2 bacilli
LAPAROSCOPY
Advantages: 1. Diagnostic
2. Biopsy
3. Therapeutic
4. May avoid empirical use of ATT

Disadvantage: 1. Invasive investigation

2. Costly
3. Expertise
4. Complications
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
• Caseating granulomas + in 85%-90% of Bx
TREATMENT OF ABDOMINAL TUBERCULOSIS
Primarily medical
WHO – ATT schedule for 6 months
Uncomplicated TB:
HRZE – 2 months
HR – 4 months
Complicated TB:
HRZE – 2 months
HR – 7 months
TREATMENT OF ABDOMINAL TUBERCULOSIS
• SECOND LINE DRUGS
• FIRST LINE DRUGS
• Amikacin
• Isoniazid – 5 mg/kg
• Kanamycin
• Rifampicin – 10 mg/kg • PAS
• Ethambutol – 15 mg/kg • Ciprofloxacin
• Pyrazinamide – 25 mg/kg • Ofloxacin
• Clarithromycin
• Azithromycin
• rifabutin
TREATMENT OF ABDOMINAL TUBERCULOSIS
DOTS
•Improved compliance
•Adequate treatment
Prognosis assessed by
•Weight gain
•Good appetite
•No fever
•No abdominal pain
•ESR / Hb returning to normal
NON RESPONDERS – RULE OUT
•DRUG RESISTANCE
•MALIGNANCY, CROHNS DISEASE AND EOSINOPHILIC ENTERITIS
TREATMENT OF ABDOMINAL TUBERCULOSIS
INDICATIONS OF SURGERY:
• MECHANICAL COMPLICATIONS
• SEVERE INTESTINAL HAEMORRHAGE
• ACUTE ABDOMEN
• DOUBTFUL DIAGNOSIS
SURGICAL OPTIONS
• Single Stricture – Stricturoplasty
• Multiple Stricture – Resection
• Perforation – Biopsy & resection
• Obstructed ICTB – Limited resection
with 5 cm margin
• Plastered abdomen – Biopsy, closure
& ATT
• Fistula & Perianal abscess – Surgery
followed by ATT
CONCLUSION
• Diagnosis of GI tuberculosis is challenging – as presentations are variable
• Ileocecal region – commonest site in abdomen
• Ingestion of sputum – most common route
• Rapid & specific diagnosis is possible with genetic tests
• CT enteroclysis & capsule Endoscopy – Newer Advances
• ATT – Main stay in treatment
• Non-responders with ATT warrants revaluation to rule out Malignancy,
Crohn’s disease & Eosinophilic enteritis
• Surgery – limited to diagnosis & management of complications