IBD, Intestinal TB and Typhoid fever.pptx

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1. IBD, Intestinal TB and Typhoid fever By: Mubarek Furo (GSR IV) Moderator: Dr. Melese ( Assistance professor of General Surgery) 5/23/2022 IBD , Intestinal TB and Typhoid fever 1

2. outlines Objective Introduction Epidemiology of IBD, Intestinal TB and Typhoid fever Clinical Manifestation and diagnosis of IBD, Intestinal TB and Typhoid fever Treatment of IBD, Intestinal TB and Typhoid fever References 5/23/2022 IBD , Intestinal TB and Typhoid fever 2

3. Objective To Define IBD To List Clinical Manifestation and diagnostic work up of IBD, Intestinal TB and Typhoid fever To outline treatment of IBD, Intestinal TB and Typhoid fever 5/23/2022 IBD , Intestinal TB and Typhoid fever 3

4. Introduction IBD is chronic inflammation of digestive tract It includes ulcerative colitis, Crohn’s disease , and indeterminate colitis Anti-TNF agents the most effective available therapy Abdominal tuberculosis usually involves intestines, peritoneum, and mesenteric lymph nodes, commonest site being ileocecal region Typhoid fever is a major health problem in third world countries most of which occurs in Asia and Africa 5/23/2022 IBD , Intestinal TB and Typhoid fever 4

5. Epidemiology of IBD Inflammatory bowel disease is increasing worldwide In the industrialised world, its prevalence is around 1%. Ulcerative colitis occurs in 8 to 15 people per 100,000 in the United States and Northern Europe. Incidence of CD 1 to 5 people per 100,000 in Northern European and Caucasian populations Has bimodal age distributions 5/23/2022 IBD , Intestinal TB and Typhoid fever 5

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7. Etiology / Risk Factors Smoking Antibiotic Use in Childhood Oral contraceptive Hormone replacement Appendicectomy Vitamin D Diet Infection Family History 5/23/2022 IBD , Intestinal TB and Typhoid fever 7

8. Clinical Manifestation UC Diarrhoea Rectal bleeding Rectal urgency Nocturnal defecation Tenesmu s Passage of mucopurulent exudates Crampy abdominal pain Systemic symptoms CD Diarrhoea Abdominal pain Weight loss Systemic symptoms Blood and/or mucus in the stool Obstruction Perianal fistula/abscess 5/23/2022 IBD , Intestinal TB and Typhoid fever 8

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11. Extraintestinal manifestation EIMs can affect any organ system, but they most commonly involve the skin, eyes, joints, mouth and liver. They are more prevalent in patients with CD than those with UC. In the 30 years after IBD diagnosis, around 50% of patients have experienced at least one EIM 5/23/2022 IBD , Intestinal TB and Typhoid fever 11

12. Diagnosis CBC OFT CRP ESR Faecal calprotectin Serological Markers pANCA ASCA Mycobacterial investigation 5/23/2022 IBD , Intestinal TB and Typhoid fever 12

13. Endoscopy 5/23/2022 IBD , Intestinal TB and Typhoid fever 13

14. Dysplasia Screening s urveillance colonoscopy is recommended eight years after disease onset T he risk of CRC is associated with: Disease duration Extension and severity Concomitant primary sclerosing cholangitis (PSC) Family history of CRC 5/23/2022 IBD , Intestinal TB and Typhoid fever 14

15. Treatment of IBD Objective of treatment Induce remission Prevent relapse Treat complication Can be Surgical or Medical: 5/23/2022 IBD , Intestinal TB and Typhoid fever 15

16. Medical management Medical therapy is used to induce and maintain disease remission . Aminosalicylates Corticosteroids Immune modulator therapies Biologic Agents Antibiotic therapy 5/23/2022 IBD , Intestinal TB and Typhoid fever 16

17. Indications for Surgery Ulcerative colitis Massive life-threatening hemorrhage Toxic megacolon fulminant colitis who fail to respond rapidly to medical therapy. Intractability Major complications of medical therapy Significant risk of developing colorectal carcinoma Crohn's disease 5/23/2022 IBD , Intestinal TB and Typhoid fever 17

18. Preoperative considerations Preoperative high-dose glucocorticoids increase the risk of postoperative infectious complications and attempts should typically be made to wean glucocorticoids before surgical intervention. Immunomodulators are not associated with increased risk of postoperative infectious complications and do not typically need to be held before surgery Preoperative nutritional support for patients with malnutrition may decrease postoperative morbidity Smoking cessation may reduce postoperative morbidity in patients with Crohn’s disease 5/23/2022 IBD , Intestinal TB and Typhoid fever 18

19. Surgery for Ulcerative Colitis Emergent Operation Total abdominal colectomy with end ileostomy Loop ileostomy Elective Operation Total proctocolectomy with end ileostomy Total proctocolectomy with continent ileostomy (Kock’s pouch) Restorative proctocolectomy with ileal pouch–anal anastomosi s Abdominal colectomy with ileorectal anastomosis 5/23/2022 IBD , Intestinal TB and Typhoid fever 19

20. Surgery for Crohn's disease Principle of surgery Midline laparotomy Limited resection of Bowel with grossly normal margins Primary anastomosis / Creation of a stoma 5/23/2022 IBD , Intestinal TB and Typhoid fever 20

21. Segmental intestinal resection and primary anastomosis Stricturoplasty Endoscopic Dilatation Percutaneous drainage of abscess 5/23/2022 IBD , Intestinal TB and Typhoid fever 21

22. Anal and perianal Crohn's disease Occur in 35% of patient with CD Isolated anal CD occur in 3 to 4 % patients Th e most common perianal lesions in Crohn’s disease are skin tags Perianal abscess and fistula Treatment: A lleviation of symptoms 5/23/2022 IBD , Intestinal TB and Typhoid fever 22

23. Outcomes Recurrence Low risk High risk 5/23/2022 IBD , Intestinal TB and Typhoid fever 23

24. Abdominal Tb Abdominal tuberculosis is prevalent in developing countries It can be commonly intestinal and peritoneal TB It commonly involves ileocecal region that presents with constitutional symptoms and features of subacute intestinal obstruction Abdominal tuberculosis accounted for 6 to 11% of extra-pulmonary tuberculosis 5/23/2022 IBD , Intestinal TB and Typhoid fever 24

25. Epidemiology Abdominal TB has been considered the sixth most common form of EPTB Intestinal TB is the commonest, accounting for 30–50% cases of abdominal TB Up to 25% cases of ITB may have concomitant pulmonary disease 5/23/2022 IBD , Intestinal TB and Typhoid fever 25

26. Classification of Abdominal TB Intestinal Ulcerative Stenotic Hyperplastic Ulcero-hyperplastic Peritoneal Acute Chronic Ascitic Encysted (loculated) Plastic (Fibrous/adhesive) Purulent Tubercular abdominal cocoon 5/23/2022 IBD , Intestinal TB and Typhoid fever 26

27. Modes of Spread of Abdominal Tuberculosis By ingestion Hematogenous spread from tuberculosis of lungs From tuberculous cervical lymphadenitis through lymphatics From fallopian tubes by retrograde spread to involve peritoneum 5/23/2022 IBD , Intestinal TB and Typhoid fever 27

28. Clinical Manifestations Abdominal pain Anaemia, loss of weight and appetite Mass in right iliac fossa Diarrhea/ constipation Bleeding per-rectum Fever and other constitutional symptoms 5/23/2022 IBD , Intestinal TB and Typhoid fever 28

29. Diagnosis History and P/E CBC ESR OFT Microbiology Gene- Xpert AFB TB-PCR Culture for MTB 5/23/2022 IBD , Intestinal TB and Typhoid fever 29

30. Imaging CXR Abdominal US Small bowel follow-through Barium enema CT/MR Enterography 5/23/2022 IBD , Intestinal TB and Typhoid fever 30

31. Case Definition of Tuberculosis Paustian’s criteria Caseating granuloma on histology Acid-fast bacilli (AFB) positivity in tissue Suggestive operative findings Consistent histology from mesenteric lymph nodes Logan’s criteria Paustian’s criteria plus Response to treatment 5/24/2022 IBD , Intestinal TB and Typhoid fever 31

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34. Complications of abdominal tuberculosis Obstruction Malabsorption, blind loop syndrome Dissemination of tuberculosis to other areas of abdomen as well as extra-abdominal sites Faecal fistula Cold abscess formation Haemorrhage Perforatio n 5/23/2022 IBD , Intestinal TB and Typhoid fever 34

35. Treatment of Intestinal TB Medical treatment : Anti TB drugs Surgical treatment: Emergent indications—obstruction, perforation, and bleeding Persistent symptoms—ileocecal mass, stricture, cocoon abdomen Fistulizing intestinal tuberculosis 5/23/2022 IBD , Intestinal TB and Typhoid fever 35

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37. Intestinal Obstruction Most commonly caused by intestinal stricture Presents usually present with recurrent subacute intestinal obstruction one-fifth of patient with stricture requires surgery Treatment Stricturoplasty Resection 5/23/2022 IBD , Intestinal TB and Typhoid fever 37

38. Perforation Incidence of ranges from 1–11% of intestinal tuberculosis Clinical presentation Free perforation with peritonitis, Contained perforation, Chronic perforation in cocoon abdomen chronic fistula Have poor outcome with mortality as high as 30% 5/23/2022 IBD , Intestinal TB and Typhoid fever 38

39. Treatment of Perforation Intestinal resection and anastomosis Ileostomy Resection of diseased segment and ileostomy 5/23/2022 IBD , Intestinal TB and Typhoid fever 39

40. Outcome Mortality rate in tubercular gut perforation is very high ranging from 25% to 100% The factors associated with high mortality include Old age Cachexia Delayed operation (36 h) Multiple perforations Multiple strictures Primary closure of the perforation Anastomotic leakage Steroid therapy 5/23/2022 IBD , Intestinal TB and Typhoid fever 40

41. 5/23/2022 IBD , Intestinal TB and Typhoid fever 41 Methods : A total of 139 patients diagnosed as having abdominal TB who received anti-TB medication from January 2005 to June 2016 were reviewed. Among them, 69 patients (49.6%) had luminal TB, 28 (20.1%) had peritoneal TB, 7 (5.0%) had nodal TB, 23 (16.5%) had visceral TB, and 12 (8.6%) had mixed TB. Results : The most frequent symptoms were abdominal pain (34.5% ) and abdominal distension (21.0%). Diagnosis of abdominal TB was confirmed using microbiologic and/or histologic methods in 76 patients (confirmed diagnosis) , while the remaining 63 patients were diagnosed based on clinical presentation and radiologic imaging (clinical diagnosis). According to diagnostic method, frequency of clinical diagnosis was highest in patients with luminal (50.7%) or peritoneal (64.3%) TB, while frequency of microscopic diagnosis was highest in patients with visceral TB (68.2%), and frequency of histologic diagnosis was highest in patients with nodal TB (85.2%). Interestingly, most patients, except those with nodal TB, showed a good response to anti-TB agents, with 84.2% showing a complete response. The mortality rate was only 1.4% in the present study.

42. Methods A prospective descriptive study of patients who presented with abdominal tuberculosis was conducted at Bugando Medical Centre (BMC) in northwestern Tanzania from January 2006 to February 2012. Ethical approval to conduct the study was obtained from relevant authorities. Statistical data analysis was performed using SPSS version 17.0. Results Out of 256 patients enrolled in the study, males outnumbered females. The median age was 28 years (range = 16–68 years). The majority of patients (77.3%) had primary abdominal tuberculosis . A total of 127 (49.6%) patients presented with intestinal obstruction, 106 (41.4%) with peritonitis, 17 (6.6%) with abdominal masses and 6 (2.3%) patients with multiple fistulae in ano. Forty-eight (18.8%) patients were HIV positive. A total of 212 (82.8%) patients underwent surgical treatment for abdominal tuberculosis. Bands /adhesions (58.5%) were the most common operative findings. Ileo-caecal region was the most common bowel involved in 122 (57.5%) patients . Release of adhesions and bands was the most frequent surgical procedure performed in 58.5% of cases . Complication and mortality rates were 29.7% and 18.8 % respectively. The overall median length of hospital stay was 32 days and was significantly longer in patients with complications ( p < 0.001). Advanced age (age ≥ 65 years), co-morbid illness, late presentation, HIV positivity and CD4+ count < 200 cells/ μl were statistically significantly associated with mortality (p < 0.0001). The follow up of patients were generally poor as only 37.5% of patients were available for follow up at twelve months after discharge. 5/25/2022 IBD , Intestinal TB and Typhoid fever 42

43. Typhoid Ileal Perforations Typhoid fever is a major health problem in third world countries Incidence varies from region to region Seen in young males in the age group of 20–30 years. Rarely seen in <5 years or >50 years of age Perforation occur during late second or early third week of illness 5/23/2022 IBD , Intestinal TB and Typhoid fever 43

44. Etiology Salmonella typhi Salmonella paratyphi Non-typhoidal infection S. Typhimurium. S. Enteritidis 5/25/2022 IBD , Intestinal TB and Typhoid fever 44 Enteric fever

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46. Clinical Features History High-grade fever for the past 2–3 weeks Headache Sudden onset central abdominal pain T yphoid fever syndrome 5/23/2022 IBD , Intestinal TB and Typhoid fever 46

47. Diagnosis CBC Widal test Blood culture stool cultures Bone marrow culture Erect chest X-ray Abdominal ultrasound 5/23/2022 IBD , Intestinal TB and Typhoid fever 47

48. Complication of Typhoid fever Meningitis. Lobar pneumonia. Osteomyelitis. Intestinal hemorrhage Intestinal perforation Myocarditis 5/23/2022 IBD , Intestinal TB and Typhoid fever 48

49. Character of ileal typhoid perforation Multiple/single Punched out Located with in 30cm of distal ileum on antimesenteric border Oval in shape 5/24/2022 IBD , Intestinal TB and Typhoid fever 49

50. Treatment intestinal perforation Aggressive preoperative resuscitation IV Antibiotics Exploration laparotomy Primary closure Wedge resection and closure Resection-anastomosis : Ileostomy 5/23/2022 IBD , Intestinal TB and Typhoid fever 50

51. Outcome Have high morbidity and mortality. Morbidity includes Wound infection Fecal fistula Burst abdomen Intra-abdominal abscess Psychosis 5/23/2022 IBD , Intestinal TB and Typhoid fever 51

52. 5/23/2022 IBD , Intestinal TB and Typhoid fever 52 Patients and Methods: The study retrospectively reviewed all patients diagnosed with typhoid perforation and managed in Damaturu and Potiskum district Hospitals North-Eastern Nigeria between January 2012 and December 2016. Results: A total of 279 patients were seen, 268 analyzed and 11 were excluded due to incomplete records. Age ranged from 3 to 50 years with male to female ration of 1.1:1 and a mean of 14.75 years. The peak age group was 11-20 years accounting for 39.93%. The clinical features were abdominal pain in 99.25 % and abdominal tenderness Perforations were single in 183 (68.28%) while 85 (31.72%) were multiple with 13 perforations in an individual being the highest in all patients. Procedures done were simple closure of perforation in 87.31% patients, resection and anastomosis in 70.84%. Post-operative complications were surgical site infection in 21.64%, and renal failure in 1.12%. The mortality was 14.18%.

53. References 5/23/2022 IBD , Intestinal TB and Typhoid fever 53

54. 5/23/2022 IBD , Intestinal TB and Typhoid fever 54 THANK YOU