ABDOMINAL TB -ILEOCAECAL and gastrointestinal.pptx

abdominal tb radiology
Imaging findings:
symmetrical or asymmetrical parietal thickening ,
extrinsic compression by enlarged lymphnodes - may be seen as heterogenous masses associated with adherrent loops and mesentric thickening
USG
Non specific
Bowel wall thickening
Hyperemia
Stricture
Mesenteric lymphadenitis
Ileocecal tuberculosis and associated mesenteric lymphadenitis
 Transverse sonogram of ileocecal region shows thickening of the wall of the cecum (short arrow) and terminal part of the ileum (long arrow). Note enlarged mesenteric lymph nodes (N) and thickened mesentery around lymph nodes.
 b Longitudinal sonogram shows thickening of the cecum (solid arrows) and terminal part of the ileum (open arrows) and enlarged lymph nodes (N). 
Ileocecal tuberculosis and associated mesenteric lymphadenitis
 Transverse sonogram of ileocecal region shows thickening of the wall of the cecum (short arrow) and terminal part of the ileum (long arrow). Note enlarged mesenteric lymph nodes (N) and thickened mesentery around lymph nodes.
 b Longitudinal sonogram shows thickening of the cecum (solid arrows) and terminal part of the ileum (open arrows) and enlarged lymph nodes (N). 
Ileocecal tuberculosis and associated mesenteric lymphadenitis
 Transverse sonogram of ileocecal region shows thickening of the wall of the cecum (short arrow) and terminal part of the ileum (long arrow). Note enlarged mesenteric lymph nodes (N) and thickened mesentery around lymph nodes.
 b Longitudinal sonogram shows thickening of the cecum (solid arrows) and terminal part of the ileum (open arrows) and enlarged lymph nodes (N). 
Ileocecal tuberculosis and associated mesenteric lymphadenitis
 Transverse sonogram of ileocecal region shows thickening of the wall of the cecum (short arrow) and terminal part of the ileum (long arrow). Note enlarged mesenteric lymph nodes (N) and thickened mesentery around lymph nodes.
 b Longitudinal sonogram shows thickening of the cecum (solid arrows) and terminal part of the ileum (open arrows) and enlarged lymph nodes (N). 
Ileocecal tuberculosis and associated mesenteric lymphadenitis
 Transverse sonogram of ileocecal region shows thickening of the wall of the cecum (short arrow) and terminal part of the ileum (long arrow). Note enlarged mesenteric lymph nodes (N) and thickened mesentery around lymph nodes.
 b Longitudinal sonogram shows thickening of the cecum (solid arrows) and terminal part of the ileum (open arrows) and enlarged lymph nodes (N). 
Ileocecal tuberculosis and associated mesenteric lymphadenitis
 Transverse sonogram of ileocecal region shows thickening of the wall of the cecum (short arrow) and terminal part of the ileum (long arrow). Note enlarged mesenteric lymph nodes (N) and thickened mesentery around lymph nodes.
 b Longitudinal sonogram shows thickening of the cecum (solid arrows) and terminal part of the ileum (open arrows) and enlarged lymph nodes (N). 
Ileocecal tuberculosis and associated mesenteric lymphaden

1. ABDOMINAL TUBERCULOSIS

2. TYPES 1. Intestinal lleocaecal region Ulcerative-60%. Hyperplastic. Ulcero -hyperplastic. lleal region, commonly: Stricture type. 2. Peritoneal tuberculosis a. Acute. b. Chronic. i . Ascitic type. ii. Encysted (loculated) type. ili . Plastic (fibrous/adhesive) type. iv. Purulent type. 3. Tuberculosis of mesentery and its lymph nodes 4. Ano-recto-sigmoidal-present as fistula, fissure, abscess, mass. 5. Involvement of liver, spleen and other organs as a part of miliary tuberculosis. 6. Tuberculosis of the omentum . 7. Rare types: esophageal (0.2% of abdominal tuberculosis gastroduodenal (1% of abdominal tuberculosis) retroperitoneal tuberculosis.

3. INTESTINAL TB MC sites: ileocacal valve, terminal ileum and cecum

4. ILEOCAECAL TB Imaging findings: symmetrical or asymmetrical parietal thickening , extrinsic compression by enlarged lymphnodes - may be seen as heterogenous masses associated with adherrent loops and mesentric thickening

5. USG Non specific Bowel wall thickening Hyperemia Stricture Mesenteric lymphadenitis

6. Ileal tuberculosis. Transverse sonogram of the right lower quadrant abdomen discloses eccentric thickening of the posterior wall of the terminal ileum

7. Ileocecal tuberculosis and associated mesenteric lymphadenitis  Transverse sonogram of ileocecal region shows thickening of the wall of the cecum ( short arrow ) and terminal part of the ileum ( long arrow ). Note enlarged mesenteric lymph nodes ( N ) and thickened mesentery around lymph nodes.   b  Longitudinal sonogram shows thickening of the cecum ( solid arrows ) and terminal part of the ileum ( open arrows ) and enlarged lymph nodes ( N ). 

8. Ileal tuberculosis.  a  Transverse sonogram of right low quadrant abdomen shows diffuse mural thickening of the terminal ileum. The terminal ileum shows concentric thickening ( arrows ). The thickness of the anterior and posterior walls is the same.  b Transverse color Doppler sonogram of the terminal ileum shows numerous color signals

9. Transverse sonogram of the right upper abdomen shows a short segmental wall thickening of the jejunum ( arrows ). 

10. Small bowel follow-through examination shows a segmental stricture of the jejunum ( arrow ). Note thickening of the mucosal folds at the proximal loop

11. Tuberculous lymphadenitis.

12. FLUOROSCOPY Barium study: earliest-increased transit time. acute-to-subacute stage Fleischner sign: narrowing of the terminal ileum thickening and gaping of the  ileocaecal valve thickening and hypermotility of the caecum Stierlin sign: acute-on-chronic repeated emptying of the caecum, seen radiographically as barium remaining in the terminal part of the ileum and in the transverse colon - due to irritation of the caecum caused by M. tuberculosis. It is not specific for tuberculosis and can also be seen in Crohn disease 

13. The  Fleischner sign (also known as the inverted umbrella sign), refers to a widely gaping, thickened , patulous ileocaecal valve and a narrowed , ulcerated terminal ileum Fleischner sign or Inverted umbrella sign Narrow ileum with thickened ileocaecal valve

14. Stierlin’s sign Conical and shrunken cecum, widely open ileocecal valves, narrowing terminal ileum, rapid emptying of diseased segment Represents acute inflammation superimposed on a chronically involved segment of the ileum, caecum or ascending colon

15. chronic stage ileocaecal valve appears fixed, rigid and incompetent caecum appears conical in shape and shrunken in size pulled-up caecum (away from the right iliac fossa) due to fibrotic changes in the mesocolon

16. Pulled-up caecum, multiple strictures with enormous dilatation of proximal ileum (mega ileum)

17. Gooseneck deformity Loss of normal ileocaecal angle and dilated terminal ileum appears as suspended and hanging from a retracted, shortened caecum

18. string sign- persistent narrow stream

19. Barium enema shows thickened folds, spasticity, and irregularly contoured cecum (solid arrow). Significant narrowing of short segment of terminal ileum adjacent to ileocecal valve (open arrow) and proximal ileal dilatation are present.

20. hypersegmentation -chicken intestine

21. Barium studies may reveal perpendicular, stellate, or longitudinal ulcers of varying size with heaped-up margins in the colon or ileum (usually the terminal ileum). Short or long strictures may be associated with nodular mucosa. A narrow, contracted cecum associated with a gaping ileocecal valve and disproportionate inflammation of the ascending colon are findings that help distinguish ileocecal tuberculosis from Crohn’s disease

22. Longitudinal ulceration, sinus tracts, and fistulas in the terminal ileum may be indistinguishable from those in Crohn’s disease on barium studies.

23. Barium examination shows irregular narrowing of the terminal part of the ileum and cecum. Note longitudinal ulcer ( curved arrow ) at the terminal part of the ileum. Mucosal folds are markedly thickened and irregular

24. The three classic forms of GI tuberculosis are the ulcerative,Hypertrophic & ulcerohypertrophic . Sloughing of mucosa overlying submucosal tubercles results in ulceration. These ulcers usually appear as short (3-6 mm in length) collections perpendicular to the longitudinal axis of the bowel. The ulcers may be stellate or longitudinal

25. Extensive inflammation and fibrosis of the bowel wall result in the hypertrophic form of tuberculosis associated with extensive mesenteric lymphadenopathy and adhesions. Bacilli are found primarily in necrotic mesenteric lymph nodes rather than the intestinal wall.

26. COMPLICATIONS Perforation and fistulas are the most frequent gastrointestinal complications Other complications include vascular complications, intussusception and obstruction of the small bowel . strictures and obstruction Fistulas Enteroliths chronic appendicitis.

27. Tuberculosis of the cecum and ascending colon. Note the marked, irregular parietal thickening, decreased luminal diameter and densification of adjacent fat planes at the level of the cecum, segment most frequently affected by tuberculosis, adjacent to the region of the ileocecal valve and ascending colon.

28. CT assymetrical thickening of the ileocecal valve. circumferential wall thickening of terminal ileum and caecum-The medial wall of the cecum is disproportionately thickened and is often associated with a soft tissue mass that engulfs the terminal ileum. Lymphadenopathy predominates in the pericecal region but may extend into the mesentery. involvement of other organs (e.g. lung)

29. Contrast enhanced abdominal CT of a 21 yr old female patient demonstrates multiple mesenteric lymphadenopathy forming a conglomerate mass (arrows) Contrast enhanced abdominal CT of a 19 year-old female patient demonstrates large volume of high density ascitic fluid (*). It is also visible pronounced peritoneal and mesenteric thickening and enhancement (arrows).

30. TB V/S CROHNS predominance of the tuberculous inflammatory process in the cecum and ascending colon, with a patulous ileocecal valve lumen and thickened ileocecal valve lips in patients with tuberculosis. Barium studies showing disease predominantly in the cecum and ascending colon with caecal contraction and CT showing low-attenuation lymph nodes indicative of caseous necrosis should suggest tuberculosis rather than Crohn’s disease as the diagnosis in these patients.

31. However, tuberculosis and Crohn’s disease may have a similar lymphatic distribution and overlapping radiographic findings. The clinical history and patient demographics should therefore be considered before suggesting the diagnosis of Crohn’s disease.

32. COLON Barium studies may reveal abnormalities in the ascending and proximal transverse colon that are indistinguishable from those of Crohn’s disease. oval or circumferential transverse ulcers loss of anatomic demarcation between the ileum and the right colon ( Stierlin sign) right-angle intersection between the ileum and cecum, with marked hyper- trophy of the ileocecal valve ( Fleischner’s sign). These findings result from the exuberant mural thickening, which tends to be greater than that in Crohn’s disease.

33. extremely short segments of involvement of the ileum or cecum markedly enlarged lymph nodes-particularly with low density on CT ascites.

34. However, the most frequent findings include some combination of narrowing, deep ulceration, and mucosal granulation with nodularity and inflammatory polyps. Less common findings include aphthous ulcers, diffuse colitis, segmental colitis distal to the hepatic flexure, and short strictures, simulating carcinoma. Fistulas and sinus tracts are also rare.

35. DD caecal carcinoma ( colorectal carcinoma ) eccentric caecal wall thickening evidence of metastatic disease small bowel lymphoma very thick (>2 cm thickness) bowel wall lack of stricturing associated lymphadenopathy +/-  hepatosplenomegaly amoebic colitis

36. ABDOMINAL TB Peritoneal Tb Includes involvement of peritoneal cavity,mesentry and omentum Origin:hematogenous but may be secondary to lymphnode rupture , GI dissemination or tubal involvement

37. Macroscopic classification of peritoneal tb Wet type :primarily present either as free or loculated ascites ,associated or not with diffuse and smooth peritoneal thickening dry type : predominance of peritoneal and mesentric thickening with caseous nodules , lymphnode enlargement and fibrinous adhesion fibrous type :remarkable omental thickening and entanglement of bowel loops clinically resembling a mass ocassionally with loculated ascites and that may be similar to peritoneal carcinomatosis

38. Wet peritonitis Wet peritonitis in a 27-year-old, female patient. Axial MRI T2-weighted sequence ( A ) demonstrates large ascites with multiple fine septa. Gadoliniumenhanced MRI T1-weighted image ( ( B ) shows diffuse, smooth and regular peritoneal thickening (arrows).

39. Fibrinous peritonitis

40. Radiographic features CT imaging features seen with tuberculous peritonitis include: nodular or symmetrical thickening of the peritoneum and mesentery abnormal peritoneal or mesenteric enhancement ascites enlarged hypodense lymph nodes: low attenuation lymphadenopathy

41. wet type: exudative high attenuation ascites (20-45 HU), which may be free or loculated; high attenuation of the ascites is thought to be due to high protein and cellular content dry type: caseous mesenteric lymphadenopathy and fibrous adhesions; thickened, "cake-like" omentum fibrotic type: omental "cake-like" mass with fixed bowel loops; matted loops and mesentery with loculated ascites

42. free or loculated ascites may be present in 30-100% of cases- density 20-45HU presence of fat fluid level in association with necrotic lymph node is highly specific for tuberculous ascites Omental changes : altered in 80% cases, as diffuse infiltreation , nodule and omental cake(less frequently seen in tb but typicaly found in peritoneal carcinomatosis)

43. mesentric changes: ranges from a mild involvement (linear striations,vascular engorgement,star shaped appearance,fat densification )to a more extensive involvement(diffuse infiltration of mesentric leaves) mesentric abscesses result from extension of a caseous process of large lymph node masses Thick striations with vascular engorgement constitute the most common finding followed by nodular pattern

44. TB Peritonitis in 62/F-CECT shows thin lines (arrows) along course of mesenteric vessels,representing thickened mesenteric leaves

45. MC CT FINDINGS IN PERITONEAL TB Ascites(70-90%) cases smooth peritoneal thickening with marked post contrast enhancement densification of mesentric root fat planes(70%) cases lymphnode enlargement with areas of central necrosis or calcification

46. t TB peritonitis in 24/f: cect -macronodular type of masses with low density centres and thickened peripheral wall. Tiny calcifications+

47. the most frequent findings in peritoneal carcinomatosis include: a) multinodular and irregular peritoneal thickening; b) homogeneous retroperitoneal lymph nodes enlargement; c) omental cake Tube rculous peritonitis in 30-year-old woman. Contrast-enhanced CT scan shows omental cake (arrows) and diffuse mesentenc infiltration with nodules and thickened leaves. Also note loculated intraperitoneal fluid collection (A) and diffuse peritoneal thickening.

48. Tuberculous peritonitis in 19-year-old worn- an. Contrast-enhanced CT scan shows thin densely enhancing peripheral rim (omental line) (arrowheads) that covers omental infiltration. Ornentum also ap- pears to be uniform in thickness.

49. Tuberculous peritonitis in 50-year-old man. Contrast-enhanced CT scan shows high-density ascites (A) in peritoneal cavity.

50. DD-peritoneal carcinomatosis omental nodularity, caking, and ascites. Centrally low attenuation, enlarged nodes may help narrow the differential diagnosis. Hepatosplenomegaly is an associated finding seen in tuberculosis.

51. USG diffuse peritoneal thickening regular and hypoechoic enlargement of the parietal peritoneum is common, and may also demonstrate an irregular/nodular pattern  often hypervascular with  colour flow Doppler interrogation ascites  often with interwoven thin fibrinous septations

52. adhesions omental/mesenteric thickening the greater omentum may range in appearance from striated, with bands of alternating echogenicity, to nodular and hypoechoic  increased bowel wall thickness

53. LYMPH NODE Mainly in GI TB less commonly with peritoneal and solid organ presentatioin can be the only sign of disease particularly in periportal region most commonly involved chains include mesentric,celiac,portahepatis,and peripancreatic lymphnodes

54. involvement pattern 1.lymphnode enlargement with hypoattenuating in centre and hyperattenuating in periphery(typical of caseous necrosis): most common 2.increase in number but not volume 3.large,localised lymphnodes clusters and conglomerates

55. Esophagus Esophageal involvement by tuberculosis is extremely uncommon. When it occurs, these patients usually have advanced tuberculosis in the lungs or mediastinum. Both Mycobacterium tuberculosis and Mycobacterium avium- intracellulare have been implicated as causes of infectious esophagitis in patients with AIDS.

56. Esophageal involvement is usually caused by adjacent tuberculous nodes in the mediastinum that compress or erode into the esophagus , causing narrowing, ulceration, or fistula formation. In patients with active pulmonary tuberculosis, esophageal infection may also be caused by swallowed sputum containing the tubercle bacilli, particularly if there is a preexisting mucosal lesion or stricture in the esophagus . Rarely, hematogenous seeding of the esophagus may occur in patients with disseminated miliary tuberculosis.

57. RADIOGRAPHIC FINDINGS Extrinsic esophageal involvement by tuberculous nodes in the mediastinum is usually manifested on esophagography by compression, displacement, or narrowing of the esophagus by an adjacent mediastinal mass. These patients may also develop strictures or traction diverticula, usually at the level of the carina.

58. TB esophagitis There is an irregular sinus tract from proximal esophagus (arrow). Chest radiograph shows enlarged lymph nodes widening mediastinum due to primary tuberculosis.

59. C aseating nodes in the mediastinum may erode into the upper or midesophagus , producing superficial or deep areas of ulceration, longitudinal or transverse sinus tracks, or fistulas into the mediastinum or tracheobron - chial tree Sinus tracks and fistulas have been recognized as particularly prominent features of tuberculous esophagitis in patients with AIDS

60. GASTRODUODENAL The stomach and duodenum are rarely involved because of the paucity of lymphoid tissue in the upper GI tract, high acidity of peptic secretions, and rapid passage of ingested organisms into the small bowel. Patients with gastroduodenal tuberculosis may present with epigastric pain or signs of upper GI bleeding. Subsequently, they may develop nausea and vomiting because of progressive scarring and gastric outlet obstruction

61. Gastric tuberculosis may be manifested on barium studies by one or more areas of ulceration, usually on the lesser curvature of the antrum or in the region of the pylorus. Subsequent scarring may cause marked antral narrowing, eventually leading to the development of gastric outlet obstruction. Occasionally, the narrowed antrum may have an irregular contour, simulating the linitis plastica appearance of a primary scirrhous carcinoma of the stomach. As in the ileocecal region, advanced gastric tuberculosis may be associated with the development of multiple tracks and fistulas

62. Duodenal tuberculosis may also be manifested on barium studies by ulcers, thickened folds, narrowing, or fistulas. As in Crohn’s disease, duodenal tuberculosis is often associated with contiguous involvement of the distal antrum. Enlarged tuberculous lymph nodes adjacent to the duodenum may cause widening, narrowing, or obstruction of the duodenal sweep

63. Smooth stricture in D2 and non opacification of D3 CECT Axial- diffuse marked circumferential mural thickening(arrow) involving D2 and D3.

64. Stricture of D3 with extrinsic LN impression necrotic nodes in peripancreatic and paraaortic locn .

65. Sharp cut off of D3 –DD: SMA s/d Extensive necrotic peripancreatic lnpathy causing marked compression of D3.

66. Double contrast barium meal showing multiple superficial ulcers in duodenal loop.

67. Liver Tuberculosis is an infectious disease in which different ways of liver involvement may be seen. Being one of the most common infectious diseases, tuberculosis has two forms of presentation, miliary and local. The local form has two subdivisions as nodular tuberculosis (tuberculoma or abscess) and hepatobiliary tuberculosis

68. Imaging techniques are most frequently not adequate to detect miliary tuberculosis, in which hepatomegaly is usually the only radiologic finding. Tuberculomas may be manifested as hypoechoic round masses at ultrasound nonenhancing hypodense lesions at CT Calcifications in chronic stage hypointense lesions on T1-weighted images and hypointense to isointense lesions on T2-weighted images at MRI.

69. nonenhancing hypodense lesions at CT

70. Spleen Splenic tuberculosis usually occurs in the setting of disseminated, miliary infection and is manifested as multiple splenic nodules between 0.2 and 1 cm in diameter. Macronodular presentation is rare. Associated findings include lymphadenopathy hypoechoic pattern on ultrasound central low attenuation on CT

71. presence of multiple, ill-defined, hypoechoic,  splenic abscesses  with the absence of splenomegaly. Multiple, small, low attenuating splenic lesions

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