Abdominal

Tuberculosis

Professor Zahidul Haq

FCPS, FRCS, MS, FICS
Fellow colorectal surgery (NUH, Singapore)
Professor
Department of Surgery
BSMMU
Abdominal tuberculosis
Difficult to recognize wide spectrum
presentation
Advances in recent past: Increased detection
Genetic test
Better imaging modalities
Endoscopy
Laparoscopy
Abdominal tuberculosis
Common extra pulmonary manifestation
Incidence increasing
Incomplete treatment
multidrug resistant strain
HIV prevelance

6% death world wide annually

 Abdominal tuberculosis

Sources of abdominal infection:

Direct ingestion
Infected sputum. tuberculosis)
Dairy products( M.Bovis)
Haematogenous spread: secondary to P.TB
Direct extension from contiguous spread
Through fallopian tube
 Contd.
Usually primary lesion
Heals + calcify
Infection in lymph node
May heal incompletely & viable tuber bacilli
spread by blood stream.
Neck
Only one group of lymph nodes
involved/usually deep jugular chain.
 Abdominal TB
Gross Pathological Type

1. Intestinal
ulcerative
Hyperplastic: whole intestine plastered
Strictures
Perforative
Gross pathological type
2. Peritoneal types
a) Wet type: ascitiesgeneralized or
localized
b) Dry plastic type: mesenteric thickening
caseous lymph nodes
Fibrous adhesions
c) Fibrotic fixed type: mass formation of omentum
Matting bowel loops
d) Acute primary peritonitis
 Cont.

3. Mesentric involvement
Mass
Abscess
Nodal
4. Solid organ: Liver, spleen, pancrease
Localized abscess
multiple miliary from
Clinical: illness depends on
Age
Sex
Immunocompromised condition
Diarrhea
HIV
Immuno-suppressive drug
Primary TB lesion usually occurs
Lung
Tonsil
Clinical presentation
Presentation varies
High index of suspicion
Insidious presentation
Abdominal pain
Fever, night sweats, weight loss,
anorexia ,nausea , vomiting,
diarrhea or constipation
Rare presentation: acute abdomen, perianal abscess,
fistula, GI bleeding,
 Cont.

On examination:
pallor, ascities, hepatomegaly
Abdominal mass:
enlarged lymph nodes
adherent bowel loops
cold abscess
Complications:
Obstruction, perforation, fistulae,
malabsorption
Intestinal tuberculosis
I. Hypertrophic
II. Ulcerative
III. Fibrotic
IV. Ulcero-fibrotic

I & II most common

Hypertrophic type
Commonly effect ileocaecal region
Absence of gross caseation
Marked thickness of submucosa of subserosa
May also affect
ascending colon
Transverse colon
Virulence infection with degree of
immunological resistance
Ulcerative type
Terminal ileum commonly affected
Multiple deep transverse ulcer extending to
serosa perforation.
Serosal surface thickened & studded with
tubercle
Healing multiple stricture with intervening
dilated segment

Bacterial over growth

Diarrhoea & malabsorption
Fibrotic
Commonly affect
Terminal ileum
Caecum
Ascending colon
Shortening & narrowing of long
segments.
Associated with generalized peritoneal
tuberculosis.
Diagnosis
Challenging
Accuracy of clinical diagnosis is only
50%
Clinical suspicion lead to graded
investigations
Diagnosis at an early stage lead to
medical management
Investigations
1.Increased ESR
2.Low Hb%
3.Sputum AFB.
Culture :
Luquid mediaBACTEC media Result obtained in 10-14 days
solid media ---- Lowenstein-Jensen media . Result obtained in
4-6 weeks
4. Mantoux test: Screening test
High false positive in endemic areas.
5. Ascitic fluid: AFB and culture low yield.
Biochemical investigations

Serum albumin to Ascitic fluid gradient (SAAG):<1.1

(exudative type)
Ascitic fluid: High protein content >2.5-3mg/dl
predominance of lymphocytes
neutrophils and monocytes
Adenosine deaminase : marker of host immune
response in abdominal TB.
Serum level >42IU/l significant
Ascitic fluid >33U/l sensitivity 100%
specificity 95%
( limitation in Cirrhosis and HIV infection)
 Biochemical test
Ascitic fluid interferon - (raised in severe infection)
Serum lactate dehydrogenase >90U/l
Serological test
Detect specific antibodies to mycobacterial
tuberculosis
Rapid diagnosis
IG g: high in abdominal TB
Monoclonal antibodies to surface antigen
 Genetic test
Rapid
Sensitive
Specific
Inexpensive
Result available in few hours
PCR (polymerase chain reaction). Can
detect as lillle as 1 to 2 bacili
Luciferase receptor assay promising new
modality
Radiological test
Chest X- ray
Abdominal X- ray ---multiple air fluid level
dilated small gut due distal stricture
Contrast study : Stricture with proximal dilatation
thickend ileocaecal valve
Narrow terminal ileum(Fleischner sign)
Small bowel enema
 USG of abdomen :
1. Lymph node involvement
periportal, peripancreatic,mesentric,retroperitoneal.

2. Matted together with calcification

3. Gross wall thickening, adherent bowel loop, enlarged

LN, mesenteric thickening---- complex mass

4. Loculated or focal ascites : Fluid collection in between

bowel loops (club sandwich sign).

5. Graded compression sonography: Mesentric disease

6. USG guided FNAB

 Cont.
CT-abdomen:
Essential for extraluminal,peritonal,nodal and
visceral involvement.

MRI:
Nodal and visceral involvement

Diagnostic laparoscopy:
 Endoscopic evaluation

Endoscopic brush or needle cytology

Endoscopic biopsy

Capsule endoscopy for small bowel

Differential diagnosis
GI lymphoma
Crohn`s disease
Ulcerative colitis
Disseminated carcinoma
Sarcoidosis
Peritoneal mesothelioma
Diagnosis
Abdominal tuberculosis Difficult
Culture mycobactereum from
Gastric washing
Faeces
Peritoneal fluid
Tissue biopsy i.e L.N.
Plain X-ray calicfication
Ba-studies
Altered motility
Stenotic area
Best diagnostic
Laparoscopy with
Peritoneal biopsy
Aspiration of fluid
Tuberculer peritonitis
May present as acute abdomen
Straw coloured fluid
Tubercol scattered over the peritoneum and
greater omentum.
Some time different to distinguish from
carcinoma.
Fluid aspirated & send for bacterilogical
examination.
Omental tissue taken from histopathology.
Wound closed without drainage.
Chronic
Presenting feature
Pain
Low grade fiver
Loss of weight
Night sweating
Abdominal mass
 Contd.
Origin of infection
Tuberculous mesenteric lymph nodes
TB of ileocael region
Tubercolus pyosalpinx
Blood born infection from pulmonary TB
(usually miliary)
Types of TB peritonitis
Ascitic
Encysted
Fibrous
Purulent
Ascitic
Peritoneum
Studded with tubercle filled with pale straw
coloured fluid
Onset - insidious
Features of ascitis
Loss of energy, pallor, loss of weight
Umbilical hernia
Rolled up greater omentum
Diagnosis
MT test, X-ray chest
Laparoscopy
Tubercle biopsy
Ascitic fluid pale yellow lymphocyte rich
Ensysted form
Usually one part of the abdominal cavity is
involved.
Localized intra-abdominal swelling.
D/D
Mesenteric cyst
Overian cyst
Laparotomy - fluid evaquated and abdomin
closed
Antitubercular drug therapy
Fibrous form
Wide spread adhesions
Acute or subacute intestinal obstruction
Distended loop blind loop statorrhoea
wasting
abdominal pain
Antitubercular drug
Purulent form
Rare
Secondary to tuberculous salpingitis
Tubercular pus may present amidst coils
of intestine
Evaquation of pus
Antitubercular drug
Prognosis relatively poor
 Tuberculosis can involve any part of the
gastrointestinal tract.
It the sixth most frequent site of
extrapulmonary involvement.
Source of abdominal TB
Haematogenous spread
Ingestion of infected sputum
Direct spread from infected contiguous lymph
nodes
Fallopian tubes
Gross pathology
Transverse ulcers
Fibrosis
Thickening
Structuring of the bowel wall
Enlarged and matted mesecteric lymph
nodes
Omental thickening
Peritoneal tubercles
 Ileocaecal region
Most common site of involvement
Oesophageal tuberculosis
Dysphagia
Odynophagia
mid oesophageal ulcer
Gastrodeudenal tuberculosis
Dyspepsia
Gastric outlet obstruction
Colonic tuberculosis
Lower abdominal pain
Haemotochezia
Investigation
Skin test
AFB detection in biopsy and culture
Excisional biopsy chemotherapy
When matted modified neck
dissection
Investigation
X-ray chest less than 25% cases have
concomitant lesion
Small bowel barium meal
Barium enema
Ultrasonography
CT Scan
Colonoscopy
Ascitic fluid examination
Laparoscopy
Treatment
Conservative: primarily medical.70%
response in abdominal TB.Failure to improve
need to rule out malignancy and crohn`s
disease
Surgical
Doubt in diagnosis,
Mechanical complications
Severe intestinal haemorrhage
Acute abdomen
Drugs
1st line
Baetericidal
Isoniazide
Rifampicin
Pyrazinamide
Streptomycin
Baeteriostatic
Ethambutol
Thiocectazone
 Contd.
2nd line
Amikacin
Kanamycin
PAS
Ciprofloxacin
Ofloxacin
Clarithromycin
Azithromycin
Surgery
Stricturoplasty
Resection and anastomosis
More conservative segmental resection
with 5cm margin.
Perforated gut: biopsy and segmental
resection with primary anastomosis
Surgery is limited to diagnosis and
treatment of complications.