Ileocaecal tb

tuberculosis abdomen: ileocaecal involvement

1. ILEOCAECAL TB UG Class – Batch 2017 Date- 23/09/2021 Dr. Ankita Singh Assistant Professor Department of Surgery

2. Learning objectives Introduction Mode of involvement Morphologic t ypes Presentation Diagnosis Treatment

3. Introduction TB common in India Mycobacterium Tuberculosis – acid fast, alcohol fast Mycobacterium Bovis & Avium Atypical mycobacterium A bdominal tuberculosis: 6 th most common type of extrapulmonary tuberculosis Associated with immunocompromised states Intestinal tuberculosis: Koenig’s syndrome Most common ileocaecal TB (60-70%)

4. Modes of involvement of GIT By ingestion: Food contaminated with tubercle bacilli causing primary intestinal tuberculosis . Ingestion of sputum containing tuberculous bacteria from primary pulmonary focus causing secondary intestinal tuberculosis.

5. Mode of spread.. Haematogenous spread from tuberculosis of lungs. From neck lymph nodes ( tuberculous cervical lymphadenitis (5-10 %) through lymphatics. From Fallopian tubes by retrograde spread to involve peritoneum (10 %). Direct spread from adjacent organs.

6. Ileocaecal tuberculosis Commonest site in abdomen Ileocaecal valve: stasis of content; increasing contact time Liquid content Increased rate of fluid & electrolyte absorption Minimum digestive activity Abundant P eyer’s patches

7. Types of ileocaecal TB Ulcerative (60%) Hyperplastic (10%) Ulcero -hyperplastic (30%)

8. Types of ileocaecal TB.. Ulcerative type Hyperplastic type Secondary TB Primary TB High virulence Lower virulence Poor immunity Good immunity Presentation: diarrhoea , bleeding per rectum, decreased appetite, weight loss Usually lump abdomen (RIF) Usually ileum involvement- transverse ulcers ( girldle ), skip lesions Chronic granulomatous lesion in ileocaecal region ( tumour like) Compliction : napkin ring stricture, progress to bowel obstruction caseating LN, cold abscess Sub- acute or acute bowel obstruction CXR: primary lesion None seen Barium study: ileal stricture with hypermotility Pulled up caecum, obtuse ileocaecal angle, narrow (conical) caecum

9. Clinical features Endemicity M:F ::1:1 Any age; usually 2 nd -5 th decade Pain abdomen- most common Diarrhea Bleeding per rectum Constitutional symptoms: Fever, malaise, night sweats, anemia, loss of weight & appetite

10. Clinical features.. Respiratory complaints Lump RIF: Differential diagnosis Symptomatic complications: Subacute / acute bowel obstruction Perforation peritonitis Disseminated TB

11. Diagnosis Definitive: FNAC/ Biopsy/ sputum for AFB Can be done endoscopically Histology: Epitheloid granuloma Special staining/media: ZN stain LZ media Bactec MGIT media COBAS taqman PCR Diagnostic laparoscopic findings

12. Diagnosis Indirect evidences: CXR Mantoux test ELISA, S.Ig G Inflammatory markers- ESR, CRP Ascitic fluid/pus analysis: TLC,DLC; Sugar,Proteins ; Microscopy; Culture & Sensitivity Direct : Genexpert /CBNAAT/PCR , Quantiferon Gold, Bactec M ADA & gama - INF

13. Diagnosis Imaging: USG abdomen Ascites Ileocaecal thickening LN Other organs X ray abdomen Acute/ subacute bowel obstruction Calcification CECT abdomen

14. Diagnosis Imaging: Barium study: Enteroclysis or barium meal follow through Characteristic features: Earliest- increased transit time – stierlin sign , hypersegmentation (chicken bowel ), flocculation of barium String sign & Napkin lesions Mega ileum Goose neck deformity Fleischner sign/ inverted umbrella sign Pulled up caecum, conical caecum Pulled down hepatic flexure Calcifications, valve incompetence, spasm

15. Diagnosis Imaging: Colonoscopy: Visualization & biopsy Capsule endoscopy

16. Treatment DRUGS: DOTS treatment Symptomatic Supportive therapy : Building up nutrition, blood/products transfusion, steroids etc. Surgery

17. Treatment.. SURGERY Indications: Bowel obstruction Bowel perforation GI bleed- severe Abscess/ fistula Symptomatic correctable disease, Uncertain diagnosis

18. Treatment.. SURGERY Stricturoplasty Ileal resection & anastamosis Limited right hemicolectomy ( ileocaecal resection) Exteriorisation Anastamosis Right hemicolectomy Bypass surgery- ileotransverse anastamosis Not prefered

19. Treatment.. SURGERY Adhesiolysis Drainage of abscess

20. Thank you