Pictorial Essay

Sonographic Appearances in
Abdominal Tuberculosis

Arun Batra, MD, DNB, Manpreet Singh Gulati, MD, DNB, Dipanka Sarma, MD,
Shashi Bala Paul, MBBS

Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India

Received 19 October 1999; accepted 8 February 2000

A bdominal tuberculosis can be a diagnostic

challenge even for experienced physicians
because patients with the disease usually present
TABLE 1
Sonographic Findings in 100 Patients with
Abdominal Tuberculosis

with nonspecific signs and symptoms. The disease Site of Disease/Finding % of Patients
is endemic in most developing countries, and its Peritoneum 65
incidence in western countries has risen because Mesenteric disease 60
Ascites 20
of the increased incidence of the Acquired immu- Peritoneal thickening 12
nodeficiency syndrome (AIDS).1 Sonography can Omental involvement 18
detect findings in individuals with early-stage Lymph nodes 62
disease; can delineate lesions of the bowel, peri- Mesenteric node involvement 52
Retroperitoneal node involvement 4
toneum, lymph nodes, and solid organs; and can Periportal node involvement 6
help to identify targets for biopsies. Sonography is
Gastrointestinal tract 32
also inexpensive and readily available in areas of Ileocecal disease* 18
the world where abdominal tuberculosis is most Small bowel disease 12
Colonic disease 1
prevalent. Gastric disease 0
Abdominal tuberculosis can mimic conditions Duodenal disease 2
as varied as lymphoma, Crohns disease, amebia- Viscera 16
sis, and adenocarcinoma. Imaging features are Splenic disease 8
Liver disease 1
not pathognomonic but can readily suggest the Gallbladder disease 1
diagnosis when considered along with the clinical Pancreatic disease 1
presentation, immune status, and demographic Adrenal gland disease 2

background of the patient. Psoas muscle involvement 3

The purpose of this pictorial essay is to discuss
*Includes involvement of the terminal ileum, the cecum, and the
the sonographic findings in tuberculosis of the adjoining portion of the ascending colon.

gastrointestinal tract, peritoneum, lymphatic sys- Isolated transverse-colon involvement.

tem, hepatobiliary system, and spleen. A spec-

trum of sonographic appearances selected from a
retrospective review of the records of 100 immu-
nocompetent patients with tuberculosis (Table 1)
is shown. This review does not include patients
with AIDS or genitourinary tuberculosis.
Correspondence to: M. S. Gulati, B-3/185 Janak Puri, New
Delhi 110 058, India
2000 John Wiley & Sons, Inc.
VOL. 28, NO. 5, JUNE 2000
TECHNIQUE
Sonography can usually demonstrate all of the
features of abdominal tuberculosis because the
patients tend to be emaciated, which provides a
good acoustic window for a thorough examination.
The use of a 57.5-MHz linear-array transducer is
particularly effective for evaluating the perito-
neum, omentum, and mesentery. Graded com-
pression sonography is the most effective tech-
233
 BATRA ET AL

nique for evaluating the mesentery. With gradual
and varying degrees of compression by the trans-
ducer, the bowel loopsparticularly when dilated
and filled with air because of a distal obstruc-
tioncan be displaced from the region of interest.
The limited field of view provided by the high-
frequency transducers can be compensated for to
some extent by juxtaposing 2 images of adjacent
areas in the dual-screen mode and printing a hard
copy of the combined images. The recently intro-
duced extended field-of-view technology is an ef-
fective alternative.

FIGURE 1. Ileocecal tuberculosis in a 17-year-old girl. Oblique sagittal sonogram obtained using a 3.5-MHz
curvilinear-array transducer (A) and high-resolution, oblique sagittal sonograms obtained using a 7.5-MHz
linear-array transducer (B) of the right iliac fossa show circumferential wall thickening of the contracted cecum
and ascending colon (open arrows). The adjacent terminal ileum (arrows) shows mild thickening of its wall.
(A) The ileocecal junction and medial wall demonstrate greater thickening (arrowheads). (B) The high-
resolution images show small, round mesenteric lymph nodes (long arrow) around the thickened bowel and
adjacent echogenic omental thickening. The terminal ileum, which is air-filled on the low-frequency sonogram
(A), appears collapsed on the high-resolution sonograms (B) because of graded compression sonography.

234 JOURNAL OF CLINICAL ULTRASOUND

 ABDOMINAL TUBERCULOSIS
PATHOGENESIS AND PATHOLOGY
The causative organism for abdominal tuberculo-
sis is usually Mycobacterium tuberculosis or My-
cobacterium avium-intracellulare, the latter of
which is more common in immunocompromised
hosts. Abdominal tuberculosis is usually caused
by ingestion of bacilli in infected sputum or con-
taminated food. The bacilli incite formation of epi-
thelioid granulomas and caseous necrosis in the
bowel wall. The most common form of the disease
is the ulcerative type, which results from ulcer-
ation of overlying mucosa. A second form is the
hyperplastic type, which features florid bowel-
wall thickening. A combination of these 2 types
results in the ulceroproliferative type. Local
spread of abdominal tuberculous to the mesenter-
ic nodes may lead to rupture of the nodes into the
peritoneum, causing tuberculosis peritonitis. Vis-
ceral involvement usually occurs by hematoge-
nous spread of infection.
GASTROINTESTINAL TUBERCULOSIS
Gastrointestinal tuberculosis may be the ulcer-
ative type, hyperplastic type, or a combination of
the 2. The features of the combination type are
well demonstrated on sonography. Gastrointesti-
nal tuberculosis most frequently occurs in the il-
eocecal junction; other sites in which the disease
occurs are, in descending order of frequency, the
ileum, cecum, ascending colon, jejunum, other
parts of the colon, rectum, duodenum, and stom-
ach.2 Sonography shows extramucosal changes
directly and can occasionally detect mucosal
changes.
Ileocecal tuberculosis is often hyperplastic, and
the gross morphology is well evaluated with so-
nography.3 In early-stage disease, a few regional
nodes and circumferential thickening of the wall
of the cecum and terminal ileum (normal thick-
ness of wall of small and large bowel is 3 mm4)
may be sonographically visualized. In later stages
of disease, the ileocecal valve and adjacent medial
wall of the cecum are predominantly and asym-
metrically thickened (Figure 1). These changes
are, however, nonspecific and may also be seen in
cecal adenocarcinoma, Crohns disease, lym-
phoma, and amebiasis. In advanced ileocecal tu-
berculosis, gross wall thickening, adherent loops,
large regional nodes, and mesenteric thickening
may together form a complex mass of varied echo-
genicity centered on the ileocecal junction (Figure
2). These features are highly suggestive of tuber-
culosis in the appropriate clinical setting.5
Mucosal changes that occur in early stages of
VOL. 28, NO. 5, JUNE 2000
FIGURE 2. Abdominal tuberculosis in a 19-year-old woman with
symptoms of recurrent partial intestinal obstruction. Transverse
sonogram of the right iliac fossa reveals a complex heterogeneous
mass consisting of matted bowel (short black arrow), thickened echo-
genic mesentery (curved white arrow) with enlarged lymph nodes
(long arrow), and surrounding loculated ascites with septa (curved
black arrow).
tuberculous enteritis are not usually sonographi-
cally visible. However, deep ulcerations occasion-
ally can be detected and appear as radial exten-
sions of the echogenic luminal contents into the
surrounding thickened wall (Figure 3A). As the
disease progresses, wall thickening and short-
segment strictures develop in the intestine, re-
sulting in partial intestinal obstruction and occa-
sionally in intestinal perforation and abscess
formation. On transverse sonograms, areas of
narrowing representing strictures appear as seg-
ments of circumferential mural thickening and
reduced luminal content (Figure 3B). Real-time
sonography helps to assess hyperperistalsis
proximal to an obstructing lesion. Long-standing
obstruction leads to the formation of enteroliths,
which may occasionally be sonographically de-
tected (Figure 4). Enteroliths are rare in the pre-
sent era, probably because of early management.
Intussusception induced by mural lesions can
also be sonographically detected, especially in
children (Figure 5).
Colonic tuberculosis may also be sonographi-
cally evaluated. Although it can occur indepen-
dently, colonic tuberculosis is usually contiguous
with ileocecal tuberculosis. The extent of involve-
ment (ie, whether the disease involves a long or
short colonic segment) is better evaluated on real-
time sonography and may be difficult to docu-
ment. Short-segment involvement is seen more
often around the hepatic flexure than in other ar-
eas of the colon.
235
 BATRA ET AL

FIGURE 3. Subacute intestinal obstruction due to tuberculous small-bowel stricture in a 25-year-old woman.
(A) Oblique sonograms of the left lower quadrant obtained using a 7.5-MHz linear-array transducer reveal a
long, circumferential thickening of the jejunum with adjacent involved nodes (arrowhead). Radial extension of
the echogenic luminal contents into the thickened wall (arrow) represent ulcerations, confirmed on a barium
x-ray study. (B) Transverse sonogram through the stricture shows the thickened wall with a narrow lumen and
an adjacent mesenteric lymph node (arrowhead).

Duodenal tuberculosis is uncommon.2 Tuber- nopathy. Sonography shows concentric mural

culous duodenal obstruction usually results from
extrinsic compression of the third part of the du-
odenum by lymph nodes in the superior mesen-
teric region. Sonograms of the third part of the
duodenum may show hypoechoic centers and help
establish a diagnosis. Intrinsic involvement of the
duodenum (Figure 6) is less common than is duo-
denal obstruction by extrinsic nodes and may be
ulcerative or hyperplastic.
Gastric tuberculosis is very rare and usually
difficult to diagnose. Antral narrowing occurs
usually secondary to ulceration and fibrosis but is
sometimes due to surrounding caseous lymphade-
236
thickening [normal thickness of stomach is 5 1
mm (standard deviation) 6 ] with surrounding
lymph nodes, both of which are visualized best
when the patient has a fluid-filled stomach. Mu-
cosal involvement may also be sonographically
detected when the patients stomach is fluid-
filled.
PERITONEAL TUBERCULOSIS
Peritoneal tuberculosis is the most common form
of abdominal tuberculosis and involvesalone or
in combinationthe peritoneal cavity, mesen-
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FIGURE 4. Long-standing recurrent partial intestinal obstruction due
to tuberculosis in a 48-year-old woman. Oblique sagittal sonogram of
the lower abdomen reveals a markedly dilated ileal loop (arrowheads)
containing a large intraluminal structure (curved arrows) with distal
shadowing. At surgery, a 3-cm, oval enterolith was found proximal to
a tight ileal stricture.
FIGURE 5. Intussusception in a 9-year-old child with intestinal tuber-
culosis. Transverse sonogram through the right lower abdomen
shows the intussusception with the echogenic mesenteric fat inter-
posed between the concentric bowel loops.
FIGURE 6. Duodenal tuberculosis in a 22-year-old woman presenting
with recurrent episodes of abdominal pain, vomiting, and weight loss
for 5 months. Transverse sonogram of the epigastric region reveals
gross thickening of the duodenal wall (arrows), seen anterolateral to
the head of the pancreas (arrowheads).
FIGURE 7. Tuberculous ascites in a 45-year-old man with weight loss,
fever, and abdominal distention. High-resolution sagittal sonogram
of the pelvic region using a 7.5-MHz linear-array transducer demon-
strates multiple thin, incomplete septa and low-level internal echoes.
The debris and fine septa appeared on real-time sonography to be
floating. These features are best seen on sonograms and are not seen
on CT scans.
 BATRA ET AL

FIGURE 8. Peritoneal tuberculosis in an 18-year-old woman. (A) Sagittal sonogram of the pelvis reveals
exudative ascites in the pouch of Douglas seen as a fluid collection (COLL) with internal echoes and associated
peritoneal thickening (arrow) best appreciated along the outer surface of the urinary bladder (UB). (B) Trans-
verse sonograms obtained with a 7.5-MHz linear-array transducer reveal diffuse thickening of the peritoneum
(arrowheads) with focal areas of nodularity (thick arrow) beneath the anterior abdominal wall. The underlying
greater omentum is thickened and is predominantly echogenic with a hypoechoic nodule (long thin arrow)
within it.

tery, and omentum. Classically, 3 types of perito-
neal tuberculosis are described: wet, dry, and fi-
brotic-fixed.7 The wet type manifests as free or
loculated ascites; the dry type with mesenteric
thickening, lymphadenopathy, and fibrous adhe-
sions creating a plastic abdomen; and the fi-
brotic-fixed type with omental thickening and
matted bowel loops, which may be clinically in-
terpreted as a mass.
Sonography may demonstrate free, loculated,
238
or focal ascites.5 Free ascitic fluid is commonly
seen; on sonograms, it may be anechoic or contain
debris. Lacy strands or fine septa and low-level
internal echoes within the ascitic fluid are char-
acteristic of exudative ascites (Figure 7). Locu-
lated ascites appears on sonograms as an en-
cysted collection of fluid with thin, interlacing
septations. Focal ascites is an interloop fluid col-
lection that appears on sonograms as the club-
sandwich sign.8 This results from alternating
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 ABDOMINAL TUBERCULOSIS

hyperechoic and hypoechoic layers of the serosa
and bowel wall of 2 adjacent loops with the inter-
vening layer of anechoic fluid. Peritoneal thicken-
ing appears as an irregular, sheet-like, hy-
poechoic layer (Figure 8A). Thickening of the
peritoneum just beneath the abdominal wall can
best be appreciated with a high-frequency linear-
array transducer (Figure 8B).
Mesenteric disease is an important and com-
mon manifestation of early-stage abdominal tu-
berculosis.9 The mesentery is initially thickened
and echogenic9 with a few discrete lymph nodes
interspersed within it. In later-stage mesenteric
tuberculosis, irregular hypoechoic areas repre-
senting a conglomerate of caseating lymph nodes
may be sonographically visualized (Figure 9A).
Focal, irregular echogenic areas of calcification
with distal shadowing may be identified (Figure
9B). Matted and fixed bowel loops arranged
around the thickened mesentery stand out as
spokes radiating from a center and form the sono-
graphic stellate sign.5
Omental thickening associated with peritoneal
tuberculosis is well demonstrated on sonography.
In cases of peritoneal tuberculosis, the greater
omentum is thickened, has a heterogeneous echo-
texture, and sometimes contains hypoechoic nod-
ules (Figure 8B).
TUBERCULOSIS OF THE LYMPH NODES
Lymphadenopathy is commonly visualized sono-
graphically in abdominal tuberculosis. A diagno-
sis of tuberculosis can be suspected based on dis-
tribution and morphology of the lymph nodes. The
mesenteric (Figures 1, 2, 3, and 9), celiac, porta
hepatis, and peripancreatic lymph nodes are
characteristically involved, reflecting the lym-
phatic drainage of the small bowel. The retroper-
itoneal lymph nodes are relatively spared, 9
and, unlike in cases of lymphoma, their involve-
ment rarely occurs in isolation. In disseminated

FIGURE 9. Peritoneal tuberculosis in a 25-year-old woman who presented with abdominal pain and swelling, vomiting, and a palpable, ill-defined
mass in the central abdomen. (A) Transverse sonograms of the umbilical region reveal extensive hypoechoic mesenteric thickening (curved white
arrow) with multiple conglomerate lymph nodes (straight white arrow). A few discrete lymph nodes (black arrow) are also seen. (B) A transverse
sonogram through an adjacent region reveals an irregular focus of central calcification (arrow) with distal shadowing within the conglomerate
lymph nodal mass. The mesentery is best evaluated with graded compression sonography and a high-frequency linear-array transducer.

VOL. 28, NO. 5, JUNE 2000 239

 FIGURE 10. Disseminated tuberculosis in an 18-year-old woman presenting with prolonged fever and weight
loss. (A) Transverse sonogram of the central abdomen shows multiple conglomerate, hypoechoic mesenteric
lymph nodes adjacent to the bowel. (B) Transverse sonogram of the suprarenal regions reveals bilateral
hypoechoic adrenal masses (curved arrow, calipers indicate mass on right side) and multiple retroperitoneal
(paracaval) nodes on the right side. A lymph node at the porta hepatis region shows calcification (long arrow).
A sonographically guided biopsy of the right adrenal mass confirmed tuberculosis.

240 JOURNAL OF CLINICAL ULTRASOUND

 ABDOMINAL TUBERCULOSIS

tuberculosis, however, diffuse lymphadenopathy mesenteric thickening and lymphadenopathy

without a predilection for any site may be seen
(Figure 10). The involved lymph nodes are usu-
ally matted together with hypoechoic centers and
occasionally contain calcification.
HEPATOBILIARY AND
SPLENIC TUBERCULOSIS
Tuberculosis of the liver or spleen is rarely seen in
isolation and is more frequently part of multifocal
or disseminated disease. Involvement of the liver
or spleen can occur in the form of microabscesses
in a miliary tuberculosis pattern represented
sonographically by a coarsened echotexture (Fig-
ure 11) or in the form of larger abscesses10 or
granulomas (Figure 12). The hypoechoic rim
sometimes seen surrounding the abscesses (Fig-
ure 12B) may represent compressed splenic pa-
renchyma. Often the only feature of visceral in-
volvement is organomegaly, with calcified
granulomas (Figure 13) occasionally visible in
late-stage disease or after healing.
Tuberculosis of the gallbladder is very rare. So-
nography may show thickening of the gallbladder
wall; irregular, shaggy septa within the gallblad-
der; and regional lymphadenopathy. Sonographic
features in tuberculosis of the gallbladder usually
cannot be differentiated from those in carcinoma
(Figure 14). However, sonographic features of
along with the clinical presentation may preop-
eratively suggest the diagnosis of tuberculosis of
the gallbladder.
Pancreatic tuberculosis is rare but should be
considered in cases in which the patient presents
with fever, abdominal pain, and sonographically
detected focal pancreatic lesions. Pancreatic in-
volvement may result from either hematogenous
dissemination or direct spread of the disease from
adjacent nodes. Imaging features are largely non-
specific. Sonography may demonstrate focal pan-
creatic enlargement mimicking pancreatic carci-
noma or the formation of 1 or more pancreatic
abscesses (Figure 15) suggestive of an infected
pseudocyst.
CONCLUSIONS
Manifestations of abdominal tuberculosis are pro-
tean, and sonography can reliably demonstrate a
range of findings. Conventional barium-contrast
studies detect mucosal changes better than do
nonbarium-contrast studies but cannot provide
a direct image of extramucosal disease. Therefore,
sonography is ideal in defining the true extent of
disease, assessing complications, and performing
follow-up examinations. The technique of graded
compression and the use of high-frequency trans-
ducers can help detect early and subtle features of
abdominal tuberculosis. Sonography is an inex-

FIGURE 11. Splenic involvement in a 33-year-old man who had disseminated tuberculosis and presented with
unexplained fever and weight loss of recent onset. High-resolution oblique coronal sonogram of the spleen
using a 7.5-MHz linear-array transducer reveals a coarse echotexture representing miliary involvement of the
parenchyma. There was no corresponding correlative finding on CT (not shown).

VOL. 28, NO. 5, JUNE 2000 241

 BATRA ET AL

FIGURE 12. Multifocal abdominal tuberculosis in a 24-year-old man who for 6 weeks had fever, anorexia, and weight loss. Physical examination
revealed pallor, hepatosplenomegaly, and an epigastric mass. (A) Oblique coronal sonogram of the spleen reveals multiple irregular, hypoechoic
focal lesions (arrowheads) representing abscesses scattered in the parenchyma. (B) High-resolution oblique coronal sonograms of the spleen show
a thin, hypoechoic halo (arrowheads) surrounding an abscess and occasional specks of marginal calcification (arrow). (C) Oblique sagittal
sonogram of the liver reveals a hypoechoic focal lesion with irregular echogenic margins in the left lobe (arrows). (D) Oblique coronal sonogram
of the epigastric region shows multiple hypoechoic and necrotic celiac and lesser-omental lymph nodes. Echogenic debris is seen in the dependent
part of the individual nodes (arrows).

242 JOURNAL OF CLINICAL ULTRASOUND

 ABDOMINAL TUBERCULOSIS

FIGURE 12. Continued.

VOL. 28, NO. 5, JUNE 2000 243

 BATRA ET AL
FIGURE 13. Longitudinal sonogram of the spleen of a 56-year-old
woman shows a superficially located, calcified focal lesion (arrow)
suggestive of an old granuloma. These lesions are sometimes inci-
dentally detected in patients who previously had tuberculosis, as in
this case.
FIGURE 14. Tuberculosis of the gallbladder in a 29-year-old man who
presented with mild pain and a palpable mass in the right upper
quadrant. Oblique sagittal sonogram shows a contracted gallbladder
(arrowheads) with gallstones and ill-defined, associated wall thicken-
ing of the fundus of the gallbladder (open arrow). Results of a sono-
graphically guided fine-needle aspiration biopsy of the fundus were
consistent with tuberculosis.
pensive and readily available imaging modality.
Sonography is especially useful in developing na-
tions, where it may be the only radiologic study
available and may help to ensure an early diag-
nosis of abdominal tuberculosis. Because tubercu-
losis may involve the genitourinary organs, the
adrenal glands (Figure 10B), the psoas muscles
(Figure 16), and the spine, these sites should also
be carefully evaluated in cases in which abdomi-
nal tuberculosis is suspected.
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FIGURE 15. Pancreatic tuberculous abscess in an 8-year-old child.
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