ABDOMINAL TUBERCULOSIS

Prof. M.P. Sharma

Department of Gastroenterology All India Institute of Medical Sciences

Introduction

TB can involve any part of GIT from mouth to anus, peritoneum & pancreatobiliary system.
Very varied presentation possible

Great mimicker.

TB of site.

GIT-

6th most frequent extrapulmonary

PREVALENCE

Isolated abdominal tuberculosis:

Unselected autopsy series- 0.02 - 5.1% Higher prevalence in females in India (3:14:1) Despite increased Pul TB in males ? contamination of food and hands

Secondary to Pul. TB

Chuttani 0.8% hospital admissions due to

intestinal TB

Autopsies of pt of pulmonary TB before ATT era intestinal involvement in 55%-90%

Pimparker - abdo TB in 3.72% of 11,746

unselected autopsies in Bombay

HIV & TB

Before era of HIV infection > 80% TB confined to lung Extrapulmonary TB increases with HIV 40 60% TB in HIV+ pt - extrapulmonary Globally, propotion of coinfected pt > 8 % ~ 0.4 million people in India coinfected. 16.6% abdominal TB pt in Bombay HIV +.

Incidence severity of abdominal TB will increase with the HIV epidemic

Pathogenesis

Mechanisms by which M. tuberculosis GIT:

reach the

Hematogenous spread from primary lung focus

Ingestion of bacilli in sputum from active pulmonary focus.

Direct spread from adjacent organs. Via lymph channels from infected LN

In India, organism from all intestinal lesions M. tuberculosis and not M. bovis.

Most common site - ileocaecal region

Increased physiological stasis Increased rate of fluid and electrolyte absorption Minimal digestive activity Abundance of lymphoid tissue at this site.

Bhansali - ileum involved in 102 and caecum in 100

of 196 pt.

Prakash - ileocaecal involvement in 162 of 300 pt.

Distribution of tuberculous lesions

Ileum > caecum > ascending colon > jejunum >appendix > sigmoid > rectum > duodenum > stomach > oesophagus

More than one site may be involved

Peritoneal involvement occurs from :

Spread from LN Intestinal lesions or Tubercular salpingitis

Abdominal LN and peritoneal TB may occur without GIT involvement in ~ 1/3 cases.

Peritoneal tuberculosis occurs in 3 forms.

Wet type - ascitis. Encysted (loculated) type - localized swelling. Fibrotic type - masses composed of mesenteric &

omental thickening, with matted bowel loops.

Clinical Features

Mainly disease of young adults

~ 2/3 of pt. are 21-40 yr old Sex incidence equal. Indian studies slight female predominance

Clinical presentation Acute / Chronic / Acute on Chronic.

Constitutional symptoms

Fever (40%-70%) Weight loss (40%-90%) Anorexia Malaise Colicky (luminal stenosis) Continous ( LN involvement)

Pain (80%-95%)

Diarrhoea (11%-20%)

Constipation
Alternating constipation and diarrhoea

Tuberculosis of esophagus

Rare

~ 0.2% of total cases

By extension from adjacent LN Low grade fever / Dysphagia / Odynophagia / Midesophageal ulcer Mimics esophageal Ca

Gastroduodenal TB

Stomach and duodenum each ~ 1% of total cases

Mimics PUD - shorter history, non response to t/t

Mimics gastric Ca. Duodenal obstruction - extrinsic compression by tuberculous LN Hematemesis / Perforation / Fistulae / Obstructive jaundice

Cx-Ray usually normal

Endoscopic picture - non specific

Ileocaecal tuberculosis

Colicky abdominal pain Ball of wind rolling in abdomen Borborygmi Right iliac fossa lump mesenteric fat and LN ileocaecal region,

Obstruction

Most common complication Pathogenesis

Hyperplastic caecal TB Strictures of the small intestine--- commonly multiple Adhesions Adjacent LN involvement traction, narrowing and fixation of bowel loops.

In India ~ 3% to 20% of bowel obstruction Series of 348 cases of intestinal obstruction - TB in 54 (15.5%) (Bhansali and Sethna).

Perforation

5%-9% of SI perforations in India 2nd commonest cause after typhoid Usually single and proximal to a stricture Clue - TB Chest x-ray, h/o SAIO

Pneumoperitoneum in ~ 50% cases

Malabsorption

Common 2nd only to tropical sprue in India Clue----h/o of pain / SAIO

Pathogenesis

bacterial overgrowth in stagnant loop bile salt deconjugation diminished absorptive surface due to ulceration involvement of lymphatics and LN

Malabsorption in Intestinal TB
Glucose tolerance Lactose tolerance D-Xylose Fecal fat Schillings test

Stricture +

28 %

22 %

57 %

60 %

63 %

No Stricture

0%

0%

8%

25 %

30 %

Overall prevalence of malabsorption:

75% pt with intestinal obstruction 40% of those without

(Tandon et al)

Segmental / Isolated colonic tuberculosis

Involvement of the colon without involvement of the ileocaecal region 9.2% of all cases
Multifocal involvement in ~ 1/3 (28% to 44%) Median symptom duration <1 year

Colonic tuberculosis
Pain --- predominant symptom ( 78%-90% ) Hematochezia in < 1/3 - usually minor

Overall, TB accounts for ~ 4% of LGI bleeding

Other features--- fever / anorexia / weight loss / change in bowel habits

Rectal and Anal Tuberculosis

Hematochezia - most common symp. Due to mucosal trauma by stool

Constitutional symptoms Constipation Rectal stricture Anal fistula usually multiple

Diagnosis and Investigations

Non specific findings--

Raised ESR Positive Mantoux test Anemia Hypoalbuminaemia

Immunological Tests

ELISA
SAFA Competitive ELISA

Response to mycobacteria variable & reproducibility poor Value of immunological tests remain undefined

Ascitic fluid examination

Straw coloured
Protein >3g/dL TLC of 150-4000/l, Lymphocytes >70% SAAG < 1.1 g/dL ZN stain + in < 3% cases + culture in < 20% cases

Adenosine Deaminase (ADA)

Aminohydrolase that converts adenosine inosine

ADA increased due to mycobacterial Ag

stimulation of T-cells by

Serum ADA > 54 U/L

Ascitic fluid ADA > 36 U/L Ascitic fluid to serum ADA ratio > 0.985 ( Bhargava et al)

Coinfection with HIV normal or low ADA

Colonoscopy
Colonoscopy - mucosal nodules & ulcers Nodules

Variable sizes (2 to 6mm) Non friable Most common in caecum especially near IC valve. Large (10 to 20mm) or small (3 to 5mm) Located between the nodules Single or multiple Transversely oriented / circumferential contrast to Crohns Healing of these girdle ulcers strictures

Tubercular ulcers

Deformed and edematous ileocaecal valve

Colonoscopic Diagnosis

8 10 Bx from ulcer edge

Low yield on histopath as mainly submucosal disease Granulomas in 8%-48% Caseation in ~ 1/3 (33%-38%) of + cases AFB stains - variable Culture positivity in 40% Combination of histology & culture diagnosis in 60%

Laparoscopic Findings

Thickened peritoneum with tubercles

Multiple, yellowish white, uniform (~ 4-5mm) tubercles Peritoneum is thickened & hyperemic Omentum, liver, spleen also studded with tubercles.

Thickened peritoneum without tubercles Fibro adhesive peritonitis

Markedly

(Bhargava et al)

thickened peritoneum and multiple

thick adhesions

Caseating granulomas + in 85%-90% of Bx

Management

ATT for at least 6 months including Pzide and Etham

2 months of Rif, INH,

Balasubramanium et al ( TB research center, Chetput, Madras)

Randomized comparison of a 6 month vs 12 month course of ATT in 193 pt Cure rate - 99% & 94%

However in practice t/t often given for 12 to 18 months

2 recent reports obstructing lesions may relieve with ATT alone

However most will need surgery