Abdominal tuberculosis dr syed obaid

Abdominal tuberculosis

1. DR.SYED UBAID ABDOMINAL TUBERCULOSIS

2. TUBERCULOSIS Major health problem 7-10 million new cases annually 6% of deaths world wide Abdominal tuberculosis is a common extrapulmonary manifestation of tuberculosis. Of non HIV patients 10 – 15 % have extrapulmonary manifestations of tuberculosis . HIV infected patients > 50% have extra pulmonary manifestations of tuberculosis There is a resurgence of abdominal tuberculosis due to multidrug resistance and co existence of HIV – AIDS.

3. In India, around 3 – 20 % of all cases of bowel obstruction are due to tuberculosis. Tuberculosis accounts for 5 – 9 % of all small intestinal perforations in India, second commonest cause after typhoid fever. Abdominal tuberculosis is an important cause of Malabsorption syndrome in India.

4. 4 Epidemiology: Both gender: equally affected Most common age: 35-45 years Risk factors: Alcoholic liver disease HIV infection 9% of all new TB cases are related to HIV Advanced age Low socioeconomic status

5. Etiology Mycobacterium tuberculosis Pathogen for most cases of abdominal tuberculosis Mycobacterium bovis Cause in small percentage of cases, in developing countries. Transmitted by unpasteurized diary products. Mycobacterium Avium complex more likely in HIV infected patients

6. Agent

7. Mode of infection Swallowing of infected sputum Hematogenous spread from pulmonary focus Ingestion of contaminated milk products Direct spread from adjacent organs Pathogenesis of abdominal TB

8. Potential fates.. The bacilli have 4 potential fates: 1. They may be killed by the immune system, 2. T hey may multiply and cause primary TB, 3. They may become dormant and remain asymptomatic, or 4. They may proliferate after a latency period (reactivation disease). 9

9. Intestinal 49% Peritoneal 42% Nodal 4% Solid visceral 5% Abdominal tuberculosis Others 1.3%

10. 1. Intestinal tuberculosis Ileocaecal region Small bowel & colon

11. Order of Frequency Ileum > caecum > ascending colon > jejunum >appendix > sigmoid > rectum > duodenum > stomach > oesophagus More than one site may be involved

12. 1. Intestinal tuberculosis Ileocaecal region Ileal region Ulcerative 60% Hypertrophic 10% Ulcerohypertrophic 30% Stricture type

13. 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 Ileocaecal Tuberculosis

14. Ulcerative type (60%) Secondary to pulmonary tuberculosis Old malnutritioned people Virulent organism Poor body resistance Multiple circumferential transverse ulcers ( Girdle ulcers ) with skip leisons C ommonly in ileum Rarely in caecum Ileocaecal tuberculosis

15. 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 Ileocaecal Tuberculosis

16. Ileocaecal Tuberculosis

17. 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 No primary lesion in the chest Ileocaecal Tuberculosis

18. Hyperplastic Type -10% Ileocaecal Tuberculosis

19. 20 30% of patients Inflammatory mass with thickened and ulcerated mucosa Commonly in ileocaecal region Cone shaped deformity of caecum Shortening of ascending colon Thickening of ileocaecal valve C. Ulcerohypertrophic type-30%

20. PATHOLOGY Bacilli in depth of mucosal glands Inflammatory reaction Phagocytes carry bacilli to Peyers Patches Formation of tubercle Tubercles undergo necrosis Most active inflammation in submucosa .

21. PATHOLOGY Submucosal tubercles enlarge Endarteritis & edema Sloughing Ulcer formation Accumulation of collagenous tissue Thickening & Stenosis

22. PATHOLOGY Lymphatic obstruction of mesentery and bowel  Thick fixed mass Regional lymph nodes Hyperplasia Caseation necrosis Calcification Bacilli via lymphatics Inflammatory process in submucosa penetrates to serosa Tubercles on serosal surface Bacilli reach lymphatics

23. Clinical Features Mainly disease of young adults ~ 2/3 of pt. are 21-40 yr old Sex incidence equal. Indian studies  slight female predominance Clinical presentation  Acute / Chronic / Acute on Chronic.

24. Constitutional symptoms fever, night sweats, anorexia, weight loss, failure to thrive(in children), malaise, anaemia, lethargy, lassitude Observed in 30% patients Atypical symptoms Lower GI bleed, fistulas, PID like pain, dysphagia Pain (80%-95%) Colicky (luminal stenosis) Continous ( LN involvement)

25. Diarrhoea (11%-20%) Constipation Alternating constipation and diarrhoea Abdominal mass in right iliac fossa (35%) Hard, nodular, fixed, nontender mass mimicing ca caecum Subacute intestinal obstruction (20%) 26

26. Ca Caecum Appendicular mass Lymph node mass Psoas abscess Crohn’s disease Differential Diagnosis

27. Diagnosis: intestinal TB or CD They can present exactly with same clinical pictures (same age group, symptoms and signs) Same radiological findings and same endoscopic findings Mostly with same pathological findings So how can we make the diagnosis?

28. Blood tests No specific diagnostic blood tests available Common blood parameters: Elevated ESR Almost always raised but not exceed 60 mm/hr Mild anemia normochromic/ normocytic Mild leukocytosis Raised CRP Hypoproteinemia Hypoalbuminemia

29. Tuberculin skin test A + ve tuberculin skin test has been reported in 55 to 100 % pts. with abdominal tuberculosis. However in areas where TB is highly endemic , + ve tst neither confirms the diagnosis of abdominal TB nor excludes it 30

30. QUANTI-FERON TB TEST Whole blood cytokine assay Approved by U.S. food and drug administration as an aid in the diagnosis of latent TB infection Recommended for screening for latent TB infection in population at low risk of TB. The test‘s performance will probably be enhanced by use of antigen such as ESAT-6 and CPF-10 that are present in M. tuberculosis but absent in others. 31

31. Concomitant PTB Concomitant PTB Present in 15-25% only Sputum smear and culture for AFB: Low diagnostic yield Abnormal CXR: 19-83% Average = 38%

32. 33 Thickened bowel wall Loculated ascites Interloop ascites-club sandwitch sign Mesenteric thickening hyperechoic >15mm Lymph node enlargement Pulled up caecum ( Pseudokidney sign) USG abdomen

33. USG abdomen Ascites Right lower quadrant mass consisting of matted bowel

34. COMPUTED TOMOGRAPHY Abdominal lymphadenopathy -commonest manifestation Enlarged lymph nodes mesenteric, peri-portal, peri-pancreatic, and upper para-aortic groups of nodes.

35. CECT The CECT have been described as – peripheral rim enhancement, non-homogenous enhancement, homogenous enhancement and homogenous non-enhancement , in that order of frequency. Different patterns are seen same nodal group, possibly related to the different stages of the pathological process.

36. CECT Conglomerate mass of 6cm. Enlarged nodes with hypo enhancing areas are seen.

37. CECT presence of nodal calcification in the absence of a known primary tumour in patients from endemic areas suggests a tubercular aetiology . CECT imaging criteria differentiating abdominal lymph node enlargement due to tuberculosis or lymphoma suggested some differences in the anatomic distribution and the CT enhancement patterns

38. CECT CECT FINDINGS Tuberculosis lymphoma Lymph nodes lesser omental , mesenteric, and upper para -aortic lower para -aortic lymph nodes Lymphadenopathy features peripheral rim enhancement, frequently with a multilocular appearance homogenous attenuation.

39. CECT Ascites can be free or loculated . Characteristically, it is a high density ascites which could be because of high protein and cellular contents of the fluid. Mesenteric involvement and presence of macronodules (> 5mm in diameter), a thin omental line (fibrous wall covering the infiltrated omentum ), peritoneal or extraperitoneal masses with low density centres and calcification, and splenomegaly or splenic calcification have been more commonly seen with tuberculous peritonitis.

40. CECT High density ascitic fluid Peritonial and mesenteric thickening and enhancement are seen.

41. CECT The diagnosis of tuberculosis is suggestive when loculated fluid collections are detected in the presence of omental infiltration, peritoneal enhancement, transperitoneal reaction, and mesenteric or bowel involvement. mural thickening affecting the ileocaecal region.

42. CECT Multiple small hypoenhancing focci in liver parenchyma.

43. Computer tomography scan Gross ascites

44. 45 Thickened omentum Computer tomography scan

45. 46 Loculated ascites Computer tomography scan

46. 47 Thickened ileocaecal bowel Computer tomography scan

47. 48 Enlarged paraaortic LN Computer tomography scan

48. 49 Tubercles in spleen & liver Computer tomography scan

49. Barium study Xray (barium enema or barium follow through x-ray) Pulled up caecum, conical caecum, pulled down hepatic flexure 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 - ulcers and strictures in the terminal ileum Increased transient time:Hypersegmentation (chicken intestine) Mega Ileum: Dilatation of proximal ileum

50. Contrast study Stricture in ileocaecal region Stricture in descending colon Good for intestinal tuberculosis affecting small or large bowel

51. Barium enema : increased ( obtuse ) ileocaecal angle retracted, fibrosed caecum (“ goose neck deformity ”) ;

52. Barium Study showing Mega Ileum

53. Endoscopy Colonoscopy is of value to rule out malignancy. It is easiest and most direct method in establishing the diagnosis. Shows mucosal nodules or ulcers , deformed ileo caecal valve, mucosal oedema and pseudopolyps and occasionally diffuse colitis. Biopsy can be taken to confirm diagnosis. Capsule endoscopy is also useful to see small intestine pathology in difficult cases . 56

54. Nodules Variable sizes (2 to 6mm) Non friable Most common in caecum especially near IC valve. Tubercular ulcers Large (10 to 20mm) or small (3 to 5mm) Located between the nodules Single or multiple Transversely oriented / circumferential contrast to Crohns Healing of these ‘girdle ulcers’  strictures Deformed and edematous ileocaecal valve 57

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59. Microbiology and histology exam Definitive diagnosis: Ziehl-Neelsen stain for AFB Tissue culture for mycobacteria Caseating granulomas on histology

60. Tissue Biopsy Peritoneal tapping Endoscopic biopsy Laparoscopy Laparotomy Histological exam Microbiological Smear & culture

61. Molecular Methods Polymerase chain reaction (PCR) PCR analysis for Mycobacterium tuberculosis complex in tissues Reported as 100% sensitivity in some series

62. Peritoneal tapping Ziehl-Neelsen stain: 3% positive At least 5000 bacteria/ ml is required Culture for AFB: 35% positive At least 10 bacteria is required 66-83% positive if 1L of ascitic fluid is cultured after centrifugation

63. Diagnostic laproscopy Direct visualization Collect acsitic fluid Take biopsy from mass, omentum or peritoneum is very useful method of investigation . Transabdominal peritoneoscopy is visualization of the peritoneal cavity using endoscope through small incision in the abdomen. It aids in visualization ,to collect ascitic fluid for analysis and to biopsy. Diagnostic laproscopy

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65. Obstruction 20% Malabsoprption , blind loop syndrome Dissemination of tuberculosis Cold abscess formation Hemorrhage Perforation Fecal fistula Complications

66. TREATMENT THERE ARE TWO MODILATIES OF TREATMENT: Medical treatment Surgical treatment 70

67. 71 The cornerstone of antituberculous therapy is multidrug treatment to decrease the duration of therapy and diminish the likelihood that drug-resistant organisms will develop Medical treatment

68. 72  Antituberculosis Drugs Drug/Formulation Adult Dosage (Daily) Main Adverse Effects First-Line Drugs Isoniazid (INH) [*] 5 mg/kg (max 300 mg) PO, IM, IV Hepatic toxicity, peripheral neuropathy   100, 300 mg tabs       50 mg/5 mL syrup       100 mg/mL injection Rifampin ( Rifadin , Rimactane ) 10 mg/kg (max 600 mg) PO, IV Hepatic toxicity, flulike syndrome, pruritus   150, 300 mg caps       600 mg injection powder

69. 73 Pyrazinamide 500 mg tabs 20-25 mg/kg PO Arthralgias, hepatic toxicity, hyperuricemia, gastrointestinal upset Ethambutol [‡] (Myambutol ) 100, 400 mg tabs 15-25 mg/kg PO Decreased red-green color discrimination, decreased visual acuity Drug/formulation Dosage Adverse effect

70. 74 Drug Dosage Adverse effect streptomycin 15mg/kg IM Vestibular and auditory toxicity, renal damage

71. 75 Second-Line Drugs Capreomycin (Capastat) 15 mg/kg IM (max 1 g) Auditory and vestibular toxicity, renal damage Kanamycin (Kantrex and others) 15 mg/kg IM, IV (max 1 g) Auditory toxicity, renal damage Amikacin (Amikin) 15 mg/kg IM, IV (max 1 g) Auditory toxicity, renal damage Cycloserine [¶] (Seromycin and others) 10-15 mg/kg in two doses (max 500 mg bid) PO Psychiatric symptoms, seizures Ethionamide (Trecator-SC) 15-20 mg/kg in two doses (max 500 mg bid) PO Gastrointestinal and hepatic toxicity, hypothyroidism Ciprofloxacin (Cipro and others) 750-1500 mg PO, IV Nausea, abdominal pain, restlessness, confusion Ofloxacin (Floxin) 600-800 mg PO, IV Nausea, abdominal pain, restlessness, confusion Drug Dosage Adverse effect

72. 76 Levofloxacin ( Levaquin ) 500-1000 mg PO, IV Nausea, abdominal pain, restlessness, confusion Gatifloxacin [¶] (Tequin) 400 mg PO, IV Nausea, abdominal pain, restlessness, confusion Moxifloxacin [¶¶] (Avelox) 400 mg PO, IV Nausea, abdominal pain, restlessness, confusion Aminosalicylic acid (PAS; Paser) 8-12 g in 2-3 doses PO Gastrointestinal disturbance Drug Dosage Adverse effect

73. Treatment categories according to DOTS strategy: 77 Category of treatment Type of patient Regimen Category I New sputum smear- positive - sputum smear negative - extra-pulmonary 2(HRZE)3 4(HR)3 Category II - Relapse - Failure - Defaulters 2(HRZES)3 1(HRZE)3 5(HRE)3

74. Surgical Management: Indications: Intestinal obstruction Severe hemorrhage Acute abdomen (perforation) Intra-abdominal abscesses/ fistula formation Uncertain diagnosis Treatment

75. Surgical Management: Limited Ileocaecal resection with 5 cm margin Stricturoplasty - single stricture Single strictutre with friable bowel : Resection Multiple Strictures: Resection and anastomosis Multiple strictures with long segment gaps: Multiple stricturiplasty Treatment

76. Surgical Management: Early perforation: resection and anastomosis (due to friable bowels) Perforation with severe contamination: resection with colostomy Adhesiolysis by laproscopy (Very difficult procedure ) Drainage of abscesses and treatment for fistula in ano Treatment

77. 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/stricturoplasty with Anti-tubercular drugs Ileal Tuberculosis

78. 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 Ano -Recto-Sigmoidal Tuberculosis

79. 2. Peritoneal Tuberculosis Acute form Chronic form Ascitic Clear straw-coloured ascitic fluid Fibrous Intestines and viscera matted together causing obstruction Encysted Matted intestines enclosing a loculation of serous fluid Purulent Purulent ascitic fluid Tuberculous peritonitis Acute abdomen Exploratory laparotomy ascitic fluid thickened omentum scattered tubercles

80. It is post primary Becoming more common Activation of long standing latent foci Blood spread Can develop from diseased mesenteric lymph nodes, intestines or fallopian tubes Peritoneal Tuberculosis

81. Pathogenesis Peritoneal seeding by tuberculosis bacilli Granulomatous multiple whitish nodules(<5 mm) over visceral and parietal peritoneum >95% of patients develop exudative free/ loculated ascitis Small group of patients … dry fibroadhesive (plastic) Adhesions/ matting of bowel loops Adenopathy, mesenteric omental thickening (omental cake) Purulent peritonitis Secondary to tuberculous salpingitis Abscess formation … lymph node, mesentery , omentum Fistula formation…. Cutaneous/ enteric

82. 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 Peritoneal Tuberculosis

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84. Abdominal Cocoon Syndrome Dense adhesions in peritoneum and omentum with contents inside as small bowel causing intestinal obstruction Peritoneal Tuberculosis

85. 89 Ascitic fluid analysis - exudate with protein level >3gm/dl -SAAG <1.1 -lymphocyte predominant cells with cell count as high as 4000 / mm3 -AFB +ve seen only < 3% -specific gravity > 1.016 -glucose < 30mg -LDH > 90 units/lit -ADA activity>33U/L in ascitic fluid

86. Acute type – mimics acute abdomen Rare On-table diagnosis Features of peritonitis Due to perforation or rupture of mesenteric lymph nodes Exploratory laparotomy 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 ATD is started Peritoneal Tuberculosis

87. Chronic Presents as Abdominal pain Fever Ascites Loss of appetite and weight Abdominal mass Doughy abdomen (10%) Types Ascitic form Encysted form Plastic form Purulent form Peritoneal Tuberculosis

88. Ascitic 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 Peritoneal Tuberculosis

89. Ascitic peritoneal tuberculosis: Asitic tap reveals straw coloured fluid from which AFB can be isolated (<3%). Fluid is pale yellow, clear, rich in lymphocytes with high specific gravity Anti-tubercular drugs for one year Repeated tapping may be required initially as a part of treatment Peritoneal Tuberculosis

90. 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 Peritoneal Tuberculosis

91. 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 Peritoneal Tuberculosis

92. Plastic Peritoneal Tuberculosis Open or laproscopic biopsy (to rule out peritoneal carcinomatosis) Anti-tubercular drugs Surgery to relieve obstruction by adhesolysis Peritoneal Tuberculosis

93. 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 Anti-tubercular drugs with exporation of umbilical fistula Peritoneal Tuberculosis

94. 3. Nodal/ Glandular tuberculosis Calcified lesion Acute Mesenteric lymphadenitis Pseudo-mesenteric cyst Tabes mesenterica Chronic Lymphadenitis Complications Abscess formation

95. 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 Tuberculous Mesenteric Lymphadenitis

96. 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 Tuberculous Mesenteric Lymphadenitis

97. Pseudo-mesenteric cyst Caseating material collected between the layers of mesentery Forms cold abscess Mimicking a mesenteric cyst Tabes mesenterica Massive enlargement of mesenteric lymph nodes due to tuberculosis Chronic Lyphadenitis Children Failure to thrive Protuberant abdomen and emaciation Lymph node on deep palpation in right iliac fossa Tuberculous Mesenteric Lymphadenitis

98. 4. Solid visceral tuberculosis Intraabdominal viscera: Liver‘ Spleen Pancreas

99. the portal of entry :hematogenous dissemination miliary tuberculosis :hepatic artery focal liver tuberculosis :portal vein. HEPATIC TB

100. three forms diffuse hepatic involvement- most common granulomatous hepatitis focal/local tuberculoma or abscess- rare

101. INVESTIGATIONS Percutaneous liver biopsy. laparoscopy liver biopsy- cheesy white irregular nodules. CT SCAN.

102. CT abdomen miliary micronodular with miliary calcifications Multiloculated cystic mass(cluster sign)

103. MILIARY TB lesions are small 1 to 2 mm epitheloid granulomas. TUBERCULOMA Masses larger than 2mm in diameter

104. It can occur due to disseminated or miliary form of the disease Most commonly encountered in HIV pt (developed countries) Fever , weight loss , diarrhea, left upper abdominal pain , splenomegaly Investigations Image-guided percutaneous needle biopsy  is the gold standard for diagnosis. CECT-abdomen-multiple hypo echoic foci(<2cm) SPLENIC TUBERCULOSIS

105. Gross pathology of resected spleen showing innumerable caseating granulomas consistent with splenic tuberculosis. Mackowiak P A et al. Clin Infect Dis. 2011;52:418-420 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected].

106. Computed tomograph scan of the abdomen showing a spleen diffusely infiltrated by small, hypodense lesions consistent with splenic granulomas. Mackowiak P A et al. Clin Infect Dis. 2011;52:418-420 The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected].

107. It is rare Often associated with miliary TB & immunocompromised pt Result from lymphohaematogenous dissemimation after pulmonary exposure Anorexia,malaise fever,weight loss,mass Investication: FNAC & BIOPSY (CT guided) PANCREATIC TB

108. Oesophageal (0.2% of abdominal) Gastroduodenal (1%) Retroperitoneal tuberculosis 5. Rare types

109. Esophageal Tuberculosis Extension of the disease from mediastinal lymph nodes or from pulmonary focus. Rarely without a primary contiguous focus. Ulceration, nodularity, stricture, sinus track formation, and fistulae with trachea or bronchus. Dysphagia, odynophagia, choking, and aspiration due to tracheoesophageal or bronchoesophageal fistula and upper GI bleeding. Massive bleed from aortoesophageal fistula has been reported. CXR and CT scan …. Active pulmonary lesions and mediastinal masses. Barium swallow …. Ulcerations, strictures, pseudotomor masses, fistulae, sinuses, and traction diverticula. Upper GI Endoscopy with biopsy is the diagnostic procedure of choice.

110. THANK YOU