Abdominal Tuberculosis

Abdominal Tuberculosis

1. Abdominal Tuberculosis Dr. Lalit K Shah Resident, 1 st Year Department of Surgery, KISMCTH Moderator- Dr Mahipendra Tiwari

2. Introduction Tuberculosis was first recognized in the fourth century BC Hippocrates described a condition resembling tuberculosis in a patient with pulmonary lesions and intestinal disease 1882-identification of the causative organism, Mycobacterium tuberculosis by Robert Koch

3. 1998-the complete genetic sequence of M. tuberculosis was identified (24th March- World TB Day) Common ailment in developing countries High prevalence in HIV infected individuals Renewed interest in developed countries

4. Bacterial agent Mycobacterium tuberculosis Mycobacterium bovis Mycobacterium avium : Lymphatics Direct or hematogeous

5. In Nepal, majorityof people are infected with Mycobacterium tuberculosis if good immunity--infection cleared in few cases--infection is in dormant state if immunity is low--reactivation of infection takes place

6. Types Intestinal Ileocecal: i . Ulcerative (55-60%); ii. Hyperplastic(10%); iii. Ulcero -hyperplastic(30%) Ileal: Stricture 2. Peritoneal Acute Chronic: i . Ascitic; ii. Encysted (Loculated); iii. Plastic (fibrous/adhesive); iv. Purulent

7. 3. Mesentery and Lymph nodes (5%) 4. Ano -rectal/sigmoidal : Fissure, fistula, abscess 5. Liver/spleen/pancreas as a part of miliary TB 6. Omentum 7. Rare types: Esophageal, Gastric, duodenal

8. Mode of spread Ingestion Primary intestinal TB: Ingestion of Mycobacterium from contaminated food Secondary intestinal TB: Ingestion of sputum containing mycobacterium from primary pulmonary focus 2. Hematogenous spread from lungs

9. 3. From neck LN (tuberculous cervical lymphadenitis) from the lymphatics 4. Direct spread from adjacent organs

10. Intestinal tuberculosis

11. Ileocecal TB Most common site of abdominal TB

12. Histology

13. Histology

14. Types - Ulcerative Most common (60%) Mostly malnourished, old individuals. Decreased immunity and increased virulence Transverse ulcer in ileum ( Multiple, circumferential (transverse) ulcers known as Girdle ulcers )

15. Presentation: Non specific symptoms: Evening rise of temperature, low grade fever, night sweats, anorexia, weight loss Specific symptoms: Diarrhea (due to formation of transverse ulcers), abdominal pain (due to sub-acute intestinal obstruction

16. Types - Hyperplastic Less common type : 10% Mostly well nourished, young Mostly primary Common in cecum Increased immunity and decreased virulence-->strong inflammatory response-->mesentric lymphadenpathy--> casesous necrosis-->formation of matted bowel loops (bowel wall thickened)

17. Fibroblasts infiltration in submucosa  Connective tissue hyperplasia  Bowel wall thickening and lymph node enlargement Presentation: Mass in RIF , SAIO

18. Types – Ulcero -hyperplastic 30%

19. Clinical features M=F Abdominal pain : Colicky Anemia , loss of appetite, weight loss Diarrhea Fever RIF mass: Hard, non tender Intestinal obstruction

20. Investigations Chest Xray: To look for primary focus in lungs Mantoux test ELISA – 90% sensitivity, SAFA (Soluble Antigen Fluorescent Antibody) – 80% sensitivity ESR : Raised

21. USG ( Abd+Pelvis ): Ascites, ileo-cecal thickening, lymphadenopathy, club sandwich appearance X-ray of abdomen: If presentation is with Intestinal obstruction. Can show gas under diaphragm in case of perforation

22. Investigations Colonoscopy: Provides direct evidence of pathology Rules out carcinoma Mucosal ulcers Cecal and ileal strictures Deformed ileocecal valve Mucosal edema and pseudopolyps Biopsy can be taken

23. Investigations Barium study X-ray Pulled up cecum giving Obtuse ileocecal angle Narrow ileum and thickened IC valve – Fleischner sign or inverted umbrella sign Terminal ileum appears to empty directly into ascending colon. ( Stierlin’s sign) Hypersegmentation (Chicken intestine) Persistent narrow stream (String sign)

24. Pulled up cecum (due to contraction of mesocolon Obtuse IC angle (Goose neck deformity)

25. Investigations Abdominal CT Ascitic tap fluid analysis Protein >3g/dL (Exudative) SAAG <1.1 (Exudative) Lymphocytes predominant LDH > 90U/L (Exudative) ADA 95-98% sensitive and specific >33IU/L in ascitic fluid is significant. In Serum, >42IU/L is significant Gamma Interleukins High sensitivity and specificity More expensive without significant advantage over ADA Diagnostic laparoscopy

26. Method AFB/mL Time taken Sensitivity Specificity ZN stain 5000-10000 1-2 hours 75% 85% LJ media culture 100 4-8 weeks 80% 90% BACTEC broth culture 10 2-6 weeks 94% 92% PCR <10 24-48 hours 97% 99%

27. Complications Obstruction Hemorrhage Malabsorption Blind loop syndrome Dissemination Cold abscess Fistula Perforation

28. Peritoneal tuberculosis

29. Acute type On table diagnosis Presents with abdominal pain Straw colored fluid with tubercles in peritoneum, greater omentum and bowel wall 2. Chronic type Fever, ascites, loss of appetite, loss of weight, doughy abdomen Omentum is thick, fibrosed

30. Chronic type Ascitic form Distension of abdomen Shifting dullness Ascitic tap: Pale yellow, clear, rich in lymphocytes, high specific gravity 2. Encysted (Loculated) form Ascites gets loculated due to fibrinous deposition Dullness which doesn’t shift

31. Chronic type 3. Plastic type Adhesions between coils of intestine (mostly ileum), abdominal wall, omentum 4. Purulent form Associated with genitourinary TB Commonly due to tubercular salpingitis Mass in lower abdomen containing pus, omentum , small and large bowel

32. Tuberculous mesenteric lymphadenitis More common in children Usually several lymph nodes Commonly right sided lymph nodes are involved Present with fever, malaise, weight loss Pain in umbilical region and RIF, mass in RIF which is matted, non mobile

33. Can mimic acute appendicitis Caseous material can accumulate between layers of mesentery, forming cold abscess. Known as Pseudomesenteric cyst Massive enlargement of mesenteric lymph nodes due to tuberculosis is known as Tables Mesenterica .

34. Ano -rectal-sigmoidal TB Hematochezia (90%), Constipation (40%) Tenesmus, diarrhea Multiple fistula Fistulas are painful and characteristically not indurated Ulcers are shallow with undermined edge

35. Treatment

36. 12-18 months course of HRZE For MDR TB, second line drugs : Amikacin, Kanamycin, PAS( Para-amino Sulphuric Acid), Ciprofloxacin, Ofloxacin, Azithromycin, Clarithromycin, Rifabutin Nutrition Steroids to prevent adhesions

37. Surgery Indications Intestinal obstruction Severe hemorrhage Acute abdomen presentation like perforation Intra-abdominal abscess or fistula

38. Surgery Types Limited ileocecal resection with 5 cm margin Single ileal stricture : Stricturoplasty Multiple ileal stricture: Resection and anastomosis Stricture within 10cm of IC valve: Resection and anastomosis Long segment bowel stricture (>12cm): Resection and anastomosis Adhesive obstruction : Adhesiolysis

39. References Bailey & Love 26th edition Sabiston Textbook of surgery 21st edition SRB’s manual of surgery 5th edition Shwartz’s principles of surgery 11th edition

40. THANK YOU