Abdominal Tuberculosis Evaluation and management pptx

Abdominal Tuberculosis is one of the common extrapulmonary TB. Tuberculosis prevelance about 25% in worldwide. But extrapulmonary TB also rising day by day. Various reason for this includes more diagnostic improvement, immunosuppressive drugs, HIV etc. wHO different action plan on pulmonary tuberculosis decrease tuberculosis prevelance. Many developing countries provided with anti TB drug. Extrapulmonary TB burden raise mostly subcontinent country like India , Bangladesh, Pakistan etc. Abdominal Tuberculosis is common form of extrapulmonary tuberculosis. Abdominal Tuberculosis involve different parts of intestine, solid organ like liver spleen and lymph nodes, peritoneum. Gastrointestinal manifestations are abdominal pain, vomiting , constipation and abdominal distension, also present as chronic diarrhea, malabsorption. Solid organ involvement manifestation depends on involve organ. Hepatic TB present as right upper abdomen pain, hepatomegaly, splenic TB present as abdominal lump and mechanical pain. Also pr sent with constitutional symptoms like fever, anorexia weight loss. Almost 25-40% cases abdominal Tuberculosis have previous pulmonary tuberculosis. Peritoneum involvement present with ascites. Lymph nodes TB present with abdominal lump. Diagnosis of abdominal Tuberculosis is difficult because organism isolation required. Many cases caseous necrosis not possible. So, diagnosis required other investigation techniques. Now molecular testing including PCR, multiplex PCR, gene xpert help diagnosis easy. Management of abdominal Tuberculosis including medical supportive and surgical. Anti TB drugs treatment is main key of management. Duration 6months to 1 year. Depending upon response. Surgical treatment indicated in intestinal obstruction, abdominal mass, stricture, abscess and intestinal hemorrhage. Management is multidisciplinary. Good nutritional support required in malabsorption.

1. Dr. Md. Ashiqur Rahman Resident Department of Gastroenterology, BSMMU Welcome to Journal Presentation

2. Authors : Adnan B. Al‑ Zanbagi , M. K. Shariff Published : Saudi Journal of Gastroenterology Year : 2021 Type : Review article

3. Introduction TB is 18 th century disease is still relevant in 21 st century. About ¼ of world population is infected with TB. Incidence is highest in the Asian and African countries. Increasing incidence also in developed nations, mainly LTB due to: Immunocompromising disease Biologic use Migration

4. TB has huge impact on healthcare system and economy. Pulmonary TB is the focus of WHO to control this disease. Abdominal TB in the form of: Gastrointestinal tract Peritoneum Lymph nodes Solid organs The clinical presentation of GITB is variable and non specific. Diagnosis is challenging and delayed with serious morbidity.

5. Epidemiology In 2018, 10 million people were developed TB disease and more than 1 million died. About 8 to 24% TB cases were extra pulmonary. EXPTB is about 28% in HIV patient. Country or Region Prevalence of EXPTB India 20% China 31% Pakistan 30% USA 20% Europe 17%

6. In general, TB is dropping across the world but EXPTB is rising. In 2018, proportion has risen from 16.4% to 22.4% in Europe and 15.7% to 20.4% in USA within a decade The rising trend of EXPTB may be due to: Increasing awareness Better diagnostic tools Increasing HIV

7. Risk Factors Extreme age Female ESRD Latent TB Reactivation of latent TB more in EXPTB including abdominal TB. Solid organ transplantation- 37% to 67% Anti- TNF medication Concomitant HIV

8. Pathogenesis T ransmission of mycobacterium in GITB by following routes. Lymphatic system Hematogenous Ingestion of infected sputum Spread from adjacent organ

9. Clinical Features Presentation is chronic or acute on chronic with non specific symptom and insidious onset Duration of illness weeks to months up to 4 years with average around 8 weeks.

10. Gastrointestinal TB GITB involves upper, middle and lower GIT from esophagus to anus including perianal. It occurs as primary infection or secondary infection. Pathological type Ulcerative Hypertrophic Ulcero - hypertropic Fibrotic

11. Mycobacterium invade into submucosa Granulomas, vasculitis, hypertrophy Ulcer Perforation, Fistulas Abscess Strictures Obstruction

12. Ileocecal region is the most common site, which account 44% to 84% of all GITB. Anatomic and physiological factor Constricted ileocecal region Long contact time Abundant lymphoid tissue Increased absorption Alkaline PH Age between 32 to 40 years. Patient present over months, sometimes as late as 8 years. Family history of TB is 5% to 19%.

13. Clinical Features Frequency (%) Systemic Fever (37.5-38.5^c) Up to 73 Weight Loss 50-80 Abdominal Pain (chronic, generalized or localized) 74 Vomiting 31-44 Altered bowel habit (Diarrhoea or constipation) Blood mixed < 15 Signs Abdominal distention& tenderness > 50 Abdominal lump 6-19 Complication Intestinal Obstruction (stricture or adhesion) Up to 50 Perforation 15-30

14. Esophageal TB Esophageal TB is uncommon and present mainly with dysphagia Predominantly spread from contagious intrathoracic viscera Usually involve middle 1 /3 of esophagus in the form of ulcer, rarely as growth Complication in the form of Abscesses Stricture Perforation Bleeding and fistulas to adjacent structures

15. Gastroduodenal TB Around 1‑6% of all GITB Commonly presented with GOO due to stricturing lesion Stricture in duodenum(52%), pylorus(9%) Other findings are Ulcer – gastric, duodenal, periampullary Submucosal growth Rarely fistula to adjacent viscera

16. Diagnosis Diagnosing of GITB is challenging. Single test is rarely sufficient. It requires biochemical and combination of Microbiological, Radiological Endoscopic investigations Diagnostic laparoscopy

17. Biochemistry Findings Frequency (%) High ESR 69-87 Anemia ( mild to moderate) 22-90 Leukocytosis 16-26 Hypoalbuminemia 44 Tuberculin test 52-88 IGRA 86 Ascitic fluid study Values WBC counts 500-1500/ cmm ( lymp > 60%) Protein > 2.5 g/dl SAAG < 1.1 g/dl ADA >30 U/L ( sensitivity 94%) >40 U/L ( sensitivity 100%)

18. Radiology Small bowel follow‑through or barium enema shows Fleischner sign - wide open ileocecal valve Conical caecum - pulled up view of caecum Purse string sign - short stricture IC valve with proximal dilatation Sensitivity-63%, specificity-68% CT scan of abdomen Intestine appears as Homogenous thickening-usually circumferential Segmental stricture Heterogenous mass- thickened IC valve, terminal ileum, part of cecam and LN

19. Peritoneum Thickening – smooth or nodular Ascites – loculated or free with fibrin strands Lymph node Enlarged, necrotic with peripheral enhancement, discrete or matted, rarely calcification Mesenteric, periportal and peripancreatic Complications Intestinal obstruction, Perforations, Fistulae and Abscess collection MRI is rarely used as a diagnostic tool.

20. Endoscopy Lesions seen on endoscopy, both in upper and lower GIT, include Erythema or erosions, ulcers, Nodules, Pseudopolyps , Strictures and rarely fistulae or mass‑like lesions Colonoscopy findings Frequency (%) Transverse or ring-shaped ulcers 73 Aphthous ulcers 10-21 Longitudinal ulcers 2-8 Widely open IC valve 26-78 Nodular mucosa 22 Pseudopolyps 16 Strictures, cobblestone appearance and skip lesions Less frequent

21. Diagnostic laparoscopy Confirmatory for the diagnosis peritoneal disease Typical findings Thickened peritoneum with erythema Whitish nodules and adhesions Sensitivity/Specificity 96 to 100% Histology of biopsy specimens high S/S.

22. Histopathology Granulomas are found in around 62% to 72% Alteration of architecture like crypt distortion and cryptitis. Intestinal biopsy Sensitivity Specificity PPV NPV Granuloma 28-58% 69-100% 64-100% 41-65%

23. Microbiology Microbiological analysis of ascitic fluid or biopsy specimen for AFB on smear, PCR AFB on culture Ascitic fluid for AFB stain and AFB cultures is low. Positive test is very helpful, but, a negative test can not exclude GITB Sensitivity Specificity PPV NPV AFB on biopsy smear 9-30% 100% 100% 57%

24. Intestinal TB Peritoneal TB Caseating Granuloma 30-80% - AFB + ve on microscopy 6-20% 2% AFB culture 6-54% 35% PCR 48% 48-76% Gene- xpert 8% 18-20% ADA >30 - 94% Laparoscopy visualization and histology - 92 and 93%

25. Differential diagnosis Peritoneal carcinomatosis including ovarian cancer Combined CA‑125 and CEA may be helpful Ascitic fluid for cytology, histopathology and culture of biopsy Intra‑abdominal malignancies including lymphoma CECT or MRI with specific enhancement pattern Anatomical distribution of lymph nodes Histopathology Granulomatous inflammatory including Crohn's disease AFB on smear, + ve culture for M.TB Histopathology - granuloma with central caseation Radiology - lymph node with necrosis

26. Others - Histoplasmosis, cryptococcus, sarcoidosis Highly suspicious and indistinguishable condition, empirical course of ATT is a valid diagnostic and therapeutic option

27. Treatment Anti-TB therapy Endoscopic Rx Surgery Duration of ATT : No difference in 9months or 6months regime. Response to ATT : Majority improvement ~ 2months. General well-being or global symptoms 70% at 2m and 99% at 6m Fever or CRP/ESR 50% at 2m and 94% at 6m

28. Complete mucosal healing of lesions on colonoscopy 80% at 2 months 100% at 6months No adequate response by 6 months May require surgery or Alternative diagnosis Intestinal stricture cause poor response (length, number) Endoscopic dilatation feasible for short and single stricture. Use of steroid is not recommended.

29. Principle form of surgery Ileocecal resection Right hemicolectomy Small bowel resection Adhesiolysis Stricteroplasty Indication: Obstruction (adhesion, stricture) Perforation Peritonitis Ileocecal mass Failed ATT

30. Globally, MDR‑TB increase 16% in 2018 Testing done in 50% case for drug resistance Prevalence of drug resistance about 4 to 25% Appropriate treatment regimens Avoid unnecessary delay in the therapy Avoid empiric anti‑TB therapy

31. Summery Abdominal TB increasing with increasing incidence of immunosuppressive condition. Intestinal and peritoneal TB is common. Diagnosis is challenging, require combined investigations. Abdominal TB should exclude in acute or chronic abdominal disease. Treatment is standard ATT, surgery may require in complicated case.

32. Thank You