1. Tuberculous Abdomen Dr. JIAN ANG The 2 nd Affiliated Hospital of ZJU

5. Circumferential ulceration is characteristic of intestinal tuberculosis.

6. Epidemiology of GI TB Extrapulmonary TB represented 28.2% of all reported TB cases. Gastrointestinal TB was the 2nd most common type of TB.

7. Extrapulmonary TB: difficult to diagnose?? Several forms of extrapulmonary TB lack any of the localizing symptoms or signs. Cutaneous anergy to PPD was noted in 35-50% of patients. No clinical or radiological evidence of pulmonary TB could be found in up to one 3rd of these patients.

8. Introduction TB can involve any part of GIT from mouth to anus, peritoneum & pancreatobiliary system. Varied presentations.

9. PREVALENCE Isolated abdominal tuberculosis: Unselected autopsy series- 0.02 - 5.1% Higher prevalence in females Despite increased Pul TB in males Secondary to Pul. TB

10. HIV & TB Before era of HIV infection > 80% TB confined to lung Extrapulmonary TB increases with HIV 40 –60% TB in HIV+ pt - extrapulmonary

11. Incidence  severity of abdominal TB will increase with the HIV epidemic

12. Pathogenesis Mechanisms by which M. tuberculosis reach the GIT: 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

13. Robert Koch, a German Scientist who found out the causative organism and revealed his invention in1882

14. Gram negative bacillus – Mycobacterium tuberculosis

15. Tuberculous abdomen is a condition in which there is tuberculous infection of the peritoneum or other organs in the abdomen

16. Tuberculous peritonitis Acute tuberculous peritonitis Chronic tuberculous peritonitis

17. Acute tuberculous peritonitis Acute abdomen with severe pain Acute inflammation of the peritoneum Straw coloured fluid Tubercles in the greater omentum and peritoneum Tubercles may casseate Anti tuberculous treatment

18. Chronic tuberculous peritonitis The condition presents with abdominal pain Fever Loss of weight Ascites Night sweats Abdominal mass

19. Origin of infection Tuberculous mesenteric lymph nodes Tuberculosis of the ileocaecal region Tuberculous pyosalpinx Blood borne infection from pulmonary tuberculosis, usually the ‘miliary’ but occasionally the cavitating form

20. Varieties of tuberculous peritonitis Ascitic form – peritoneal fluid  distension of abdomen. Patient comes with the complaint of swelling of the abdomen. – increased abdominal pressure  umbilical hernia, inguinal hernia Purulent form Rare – usually secondary to tuberculous salpingitis – pockets of adherent intestines and omentum containing tuberculous pus. – cold abscesses Encysted form Inflammation and ascites are confined to one part of the abdominal cavity Fibrous form Wide spread adhesions  adhesive obstruction

21. 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.

22. GI TB GI tuberculosis is usually secondary to pulmonary tuberculosis, radiologic evaluation often shows no evidence of lung disease

23. GI Tuberculosis Ileocecum and Colon The ileocecal region is the most common area of involvement in the gastrointestinal tract due to the abundance of lymphoid tissue. The natural course of gastrointestinal tuberculosis may be ulcerative hypertrophic or ulcerohypertrophic.

24. 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.

25. Distribution of tuberculous lesions Ileum > caecum > ascending colon > jejunum >appendix > sigmoid > rectum > duodenum > stomach > oesophagus More than one site may be involved

26. Clinical Features Mainly disease of young adults ~ 2/3 of pt. are 21-40 yr old Sex incidence equal. slight female predominance Clinical presentation  Acute / Chronic / Acute on Chronic.

27. Constitutional symptoms Fever (40%-70%) Weight loss (40%-90%) Anorexia Malaise Pain (80%-95%) Colicky Continous Diarrhoea (11%-20%) Constipation Alternating constipation and diarrhoea

28. Tuberculosis of esophagus Rare ~ 0.2% of total cases By extension from adjacent LN Low grade fever / Dysphagia / Odynophagia / Midesophageal ulcer Mimics esophageal Ca

29. 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

30. Ileocaecal tuberculosis Colicky abdominal pain ‘ Ball of wind ’ rolling in abdomen Right iliac fossa lump - ileocaecal region, mesenteric fat and LN

31. 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

32. 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

33. Rectal and Anal Tuberculosis Hematochezia - most common symp. Due to mucosal trauma by stool Constitutional symptoms Constipation Rectal stricture Anal fistula – usually multiple

34. Complications GIT bleeding Obstruction Perforation Malabsorption

35. 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. Series of 348 cases of intestinal obstruction - TB in 54 (15.5%) (Bhansali and Sethna).

36. Perforation Usually single and proximal to a stricture Clue - TB Chest x-ray Pneumoperitoneum ?

37. Malabsorption Common Decreased absorption Increased Consumption

38. Emaciation due to TB

39. Overall prevalence of malabsorption: 75% pt with intestinal obstruction 40% of those without (Tandon et al)

40. Investigations Blood routine PPD test Ascitic fluid examination X-ray s Endoscope Laparoscopy

41. Blood tests Non specific findings--- Raised ESR Positive PPD test Anemia ADA Hypoalbuminaemia Co HIV infection ?

42. PPD Test

43. PPD test – positive

44. Measuring the induration – PPD test

45. Ascitic fluid examination Straw coloured Protein >3g/dL Lymphocytes >70% SAAG < 1.1 g/dL + culture in < 20% cases

46. Adenosine Deaminase (ADA) Aminohydrolase that converts adenosine  inosine ADA increased due to stimulation of T-cells by mycobacterial Ag 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

47. X-rays

48. Gastrointestinal Tuberculosis Barium studies demonstrate spasm and hypermotility with edema of the ileocecal valve in the early stages Later thickening of the ileocecal valve. A widely gaping ileocecal valve with narrowing of the terminal ileum (Fleischner sign) A narrowed terminal ileum with rapid emptying of the diseased segment through a gaping ileocecal valve into a shortened, rigid, obliterated cecum (Stierlin sign) Focal or diffuse aphthous ulcers : tend to be linear or stellate, following the orientation of lymphoid follicles (ie, longitudinal in the terminal ileum and transverse in the colon)

49. Gastrointestinal Tuberculosis In advanced cases, symmetric annular stenosis and obstruction associated with shortening, retraction, and pouch formation may be seen. The cecum becomes conical, shrunken, and retracted out of the iliac fossa due to fibrosis, ileoceacal valve becomes fixed, irregular, gaping, and incompetent.

52. 52

53. Tuberculous peritonitis – USGM – Intestines floating in peritoneal fluid - ascites

54. Colonoscopy Colonoscopy - mucosal nodules & ulcers Nodules Variable sizes (2 to 6mm) Most common in caecum especially near IC valve. Tubercular ulcers 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 Deformed and edematous ileocaecal valve

63. Colonoscopic Diagnosis 8 –10 Bx from ulcer edge Low yield on histopath as mainly submucosal disease Granulomas in 8%-48% Culture positivity in 40% Combination of histology & culture  diagnosis in 60%

64. 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 thickened peritoneum and multiple thick adhesions (Bhargava et al)

65. Differential diagnosis CD Cancer Lymphoma Chronic colitis

66. Management isoniazid rifampicin pyrazinamide ethambutol Surgical intervention when needed

67. at least 6 months including 2 months of Rif, INH, Pzide and Etham However in practice t/t often given for 12 to 18 months obstructing lesions may relieve with Med alone However most will need surgery

68. Tx duration Newly diagnosed: 2HRZE/4HR 、 2SHRZ/4HR Relapsed: 2HRZSE/4~6HRE

69. CD or TB???

70. The ultimate course of these two disorders is different. Intestinal TB is entirely curable, provided that the diagnosis is made early enough and appropriate treatment is instituted. In contrast, CD is a progressive relapsing illness. Unfortunately, it is difficult to differentiate intestinal TB from CD because of similar clinical, pathological, radiological, and endoscopic findings.

72. Diagnosis: intestinal TB or CD They can present exactly with same clinical pictures (same age group, symptoms and signs) Same radiological findings and same endoscopic findings Mostly with same pathological findings So how can we make the diagnosis?

73. ? Other features History of previous TB CXR findings of TB The tuberculin skin test is less helpful, because a positive test does not necessarily mean active disease. Perianal fistulae and extraintesitnal manifestations of CD If all negative: any other clues??

74. Multiple attempts!! Endoscopic findings? Laproscopic findings? Histological findings? PCR? Empirical TB?

75. Endoscopic diagnosis? CD (4 parameters) Anorectal lesions, longitudinal ulcers, aphthous ulcers, and cobblestone appearance Intestinal TB (4 parameters) involvement of fewer than four segments, a patulous ileocecal valve, transverse ulcers, and scars or pseudopolyps Endoscopy. 2006 Jun;38(6):592-7.

76. Endoscopic diagnosis? Lee et al hypothesized that a diagnosis of Crohn's disease could be made when the number of parameters characteristic of Crohn's disease was higher than the number of parameters characteristic of intestinal tuberculosis, and vice versa. Endoscopy. 2006 Jun;38(6):592-7.

77. Endoscopic findings: TB In tuberculosis patients, transverse ulcers with surrounding hypertrophic mucosa and multiple erosions were usual colonoscopic findings. Am J Gastroenterol 1998;93: 606–609. Gastrointest Endosc 2004;59:362-8.

78. Typical transverse ulcer

79. Gastrointest Endosc 2004;59:362-8.

80. Radiology thickened bowel wall with distortion of the mucosal folds and ulcerations. CT may show preferential thickening of the ileocecal valve and medial wall of the cecum and massive lymphadenopathy with central necrosis. Calcified mesenteric lymph nodes and an abnormal chest film are other findings that aid in the diagnosis of intestinal tuberculosis.

82. At surgery: TB Reduced largely since introduction of colonoscopy Indications: Mass lesions associated with the hypertrophic form, because they can lead to luminal compromise with complete obstruction. Surgery also may be necessary when free perforation, confined perforation with abscess formation, or massive hemorrhage occur. Findings: The bowel wall appears thickened with an inflammatory mass surrounding the ileocecal region. The serosal surface is covered with multiple tubercles. The mesenteric lymph nodes frequently are enlarged and thickened.

83. Histologically Intestinal TB: granulomas are Large, multiple, confluent with caseation Ulcers lined by epitheliod histiocytes CD Fissuring ulcer, lymphoid aggregates, transmural inflammation, and Infrequent, small, noncaseating granulomas. Am J Gastroenterol 2002;97:1446 – 1451. Pulimood et al. Gut 1999

84. Empirical anti-TB If intestinal TB still possibility, give 4-6 weeks of anti-TB 30% of CD patietns at China receives anti-TB before final diagnosis

85. Presumptive diagnosis can be established in A patient with active pulmonary tuberculosis and radiologic and clinical findings that suggest intestinal involvement. Response to anti-TB

86. Thank you!