Tuberculous Abdomen 11062006

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1 DR TARIQ AHMAD RESHI PG SU-5 MODERATOR Dr N . A . Salroo Associate prof. and H.O.U SU-5 Abdominal tuberculosis

History:

History The disease known as “consumption” has been observed in humans for over 7000 years. The remains of skeletons from about 4000 BC show the characteristic changes of tuberculosis. In 1882 , Koch discovered the cause of TB. Ehrlich then discovered the acid-fast nature of the bacillus in 1882. 2

Epidemiology :

Epidemiology The World Health Organization (WHO) estimates that one third of the world's population is infected with Mycobacterium tuberculosis and there are 8 to 10 million new active cases of TB each year ( WHO, 1997 ). 3

Epidemiology :

Epidemiology In the United States, the number of reported cases declined annually until 1985, when the trend was dramatically reversed. The factors responsible for this increase included:: the emergence of the acquired immunodeficiency syndrome (AIDS), immigration, and the neglect and deterioration of the public health infrastructure 4

India :

India Accounts for nearly 1/3 rd of global burden of TB 1.8 million persons develop TB of each year, of which o.8 million are new smear positive. 4.17 lakh people die of TB each year. 0.8% hospital admissions due to intestinal TB 5

Classification of mycobacteria:

Classification of mycobacteria Type 1: obligate pathogens: M . Tuberculosis M . Leprea M . Bovis Type 2: skin pathogens: M . Ulcerans M . Murium Type 3: opportunistic pathogens: M . Avium complex Type 4: non pathogens: M. smegmatis Type 5: animal pathogens: M. paratuberculosis 6

Definition :

Definition Tuberculous abdomen is a condition in which there is tuberculous infection of the peritoneum or other organs in the abdomen. It is more common in developing countries. It is 6 th most common type of extra pulmonary tuberculosis. 7

Modes of spread of abdominal tuberculosis.:

Modes of spread of abdominal tuberculosis. By ingestion ingestion of food contaminated with tubercle bacilli causing primary tuberculosis ingestion of sputum containing tuberculous bacteria from primary pulmonary focus causing secondary tuberculosis. Haematogenous spread from lung tuberculosis. From neck lymph nodes through lymphatics. From fallopain tubes by retrograde spread to involve peritoneum. 8

Potential fates.. :

Potential fates.. The bacilli have 4 potential fates: 1.they may be killed by the immune system, 2.they may multiply and cause primary TB, 3.they may become dormant and remain asymptomatic, or 4. they may proliferate after a latency period (reactivation disease). 9

TYPES OF ABDOMINAL TUBERCULOSIS:

TYPES OF ABDOMINAL TUBERCULOSIS Intestinal Ileocaecal region Ulcertive-60% Hyperplastic Ulcero-hyperplastic Ileal region, commonly- Stricture type Peritoneal Acute Chronic 1. Ascitic type 2. Encysted type 3. Plastic type 4. purulent type 10

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11 Tuberculosis of mesentery and its lymph nodes. Ano-recto-sigmoidal tuberculosis. Involvement of liver and spleen Tuberculosis of omentum. Genitourinary TB

Ileocaecal tuberculosis:

Ileocaecal tuberculosis Most common site of abdominal tuberculosis due to --- Stasis Abundant peyer’s patches Minimal digestive activity Bacteria contact time with mucosa more TYPES ULCERATIVE ; Secondary to pulmonary TB Virulent organism Poor body resistance , old people Multiple transverse ulcers commonly in the ileum , often in caecum. Clinically presents with diarrhea , bleeding P/R , loss of appetite , weight loss , and night sweating Complications; strictures, obstruction. 12

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13 Circumferential ulceration is characteristic of intestinal tuberculosis.

Hyperplastic:

Hyperplastic Less virulent organism Primary GIT tuberculosis , could be bovine type Good body resistance , young people Chronic granulomatous lesion in ileocaecal region. Present as RIF mass Complication; SAIO 14

Clinical features:

Clinical features Abdominal pain is the most common symptom(90%) Loss of weight and appetite (80%) Anaemia Diarrhoea(10-20%) Fever (50-70%) Mass in RIF(35%) Can cause obstruction(20%) 15

Peritoneal tuberculosis:

Peritoneal tuberculosis Post primary Becoming more common Activation of long standing latent focus Blood spread Can develop from diseased mesenteric lymph nodes, intestine, or fallopain tubes 16

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

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Chronic tuberculous peritonitis The condition presents with chronic abdominal pain Fever Loss of weight Ascites Night sweats Abdominal mass 19

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Varieties of tuberculous peritonitis Ascitic form Purulent form Rare – usually secondary to tuberculous salpingitis Encysted form : Inflammation and ascites are confined to one part of the abdominal cavity Fibrous form 20

Tuberculosis of mesentery and lymph nodes::

Tuberculosis of mesentery and lymph nodes: It presents with general symptoms(fever, malaise, weight loss) Pain in umbilical region and RIF, mass in RIF, which is matted, nonmobile. It may present with features of acute appendicitis. Mesenteric tuberculous adenitis is more common in children. 21 Infection is usually through peyer’s patches of the intestine. Usually several lymph nodes are involved often causing massive lymph node enlargement.

Ano-Rectal-Sigmoidal TB:

Ano-Rectal- Sigmoidal TB It mimics Ca rectum It presents as tenesmus , diarrhoea , and discharge from fistula Rectal tuberculosis occurs usually within 10cm of anal verge. Fistulas are painful and characteristically not indurated . Tuberculous fistulas are commonly multiple. Tuberculous ulcers when occur are shallow , bluish , with undermined edges . 22

Tuberculosis of omentum:

Tuberculosis of omentum It usually occurs as a part of other types of abdominal tuberculosis. Rolled up omentum with thickening is characteristic. 23

Rare form of abdominal tuberculosis:

Rare form of abdominal tuberculosis Gastric tuberculosis : rare due to gastric acid. 0.6% incidence. Symptoms are nonspecific , include abdominal pain nausea, vomiting , GI bleeding , fever and wt loss. Ulcerative type common(80%) , involve lesser curvature , fistulous communication with other organs (rare) Diagnosis is retrospective, 24

Hepatobiliary tuberculosis:

Hepatobiliary tuberculosis -congenital TB -primary hepatic TB -miliary tuberculosis Using needle biopsy specimen , epithelioid granulomas can be demonstrated in hepatic TB in 80% to 100% of cases ; caseation necrosis in 30 to 83% and acid-fast bacilli in up to 59% 25

Pancreatic TB:

Pancreatic TB Pancreatic TB is rare. It is often associated with miliary TB . occurs more in immunocompromised pts . Spread through lymphohaematogenous route and from other adjacent organs. Clinical manifestations are : anorexia , malaise , low grade fever , wt loss , night sweating , malena , pancreatic mass , or abscess or obstructive jaundice , Pancreatic TB may present as acute or chronic pancreatitis or mimic malignancy 26

Splenic TB:

Splenic TB TB involvement of spleen can occur due to miliary form of disease. In developed countries the disease is most commonly encountered in HIV seropositive pts. Multiple abscess have been described in pts with HIV infection Clinically , these pts may manifest with splenomagaly , or hepatosplenomagaly and can present with a FUO 27

Diagnosis :

Diagnosis From clinical history and exam. h/o exposure to tuberculosis pt. h/o wt. loss , appetite loss , evening raise temp. , night sweating , blood with sputum , bleeding P/R , diarrhoea , constipation , tenesmus , recurrent colicky abdominal pain. On examination: anaemia , emaciated , peripheral lymphadenopathy , distention of abdomen , visible peristalsis , abdominal tenderness , doughy feel of abdomen , lump abdomen . 28

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Investigations ( non specific ) Blood routine ESR CXR Plain x-ray abdomen, if presentation is of obstruction , shows air fluid levels. It often shows calcification. It shows calcified lesion in bowel; in lymph node; in liver. Perforation when it occur shows gas under diaphragm. 29

Plain radiograph of abdomen with diffuse calcified mesenteric lymphadenopathy in a patient with tuberculosis:

Plain radiograph of abdomen with diffuse calcified mesenteric lymphadenopathy in a patient with tuberculosis 30

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USG abdomen shows : -thickened bowel wall , mesentery, omentum, peritoneum -loculated ascites fine septae -interloop ascites with alternate echogenic and echofree areas-Club sandwich appearance. -Bowel loops radiates from its mesenteric roots (stellate sign) -mesenteric thickness more than 15mm -lymph node enlargement matted -pulled up caecum –sonologically visible( pseudokidney sign) 31

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Barium enema and barium follow through X-ray -pulled up caecum -obtuse ileocaecal angle -hurrying of barium due to rapid flow and lack of barium in inflamed segment( stierlin sign ) -narrow ileum with thickened ileocaecal valve( fleischner sign)(inverted umbrella sign) -incompetent ileocaecal valve -persistent narrow stream(string sign) - 33

Delayed image from follow-through series shows a collapsed colon and markedly distended long segment of ileum from chronic obstruction:

Delayed image from follow-through series shows a collapsed colon and markedly distended long segment of ileum from chronic obstruction 34

Barium meal follow-through study in a patient with stricture of the ileocecal region extending into proximal ascending colon.:

Barium meal follow-through study in a patient with stricture of the ileocecal region extending into proximal ascending colon . 35

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Ascitic fluid analysis - exudate with protein level >3gm/dl -SAAG <1.1 -lymphocyte predominant cells with cell count as high as 4000 / mm3 -AFB + ve seen only < 3% -specific gravity > 1.016 -glucose < 30mg -LDH > 90 units/lit 36

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CT scan shows -thickened bowel wall; thickened peritoneum -ileocaecal valve thickened -enlarged / necrosed / matted mesenteric lymph node -adhesions -nodules in peritoneum /solid organs - ascitis 37

CT scan of the abdomen in a patient with AIDS shows edematous jejunal loops:

CT scan of the abdomen in a patient with AIDS shows edematous jejunal loops 38

Tuberculin skin test:

Tuberculin skin test A + ve tuberculin skin test has been reported in 55 to 100 % pts. with abdominal tuberculosis. However in areas where TB is highly endemic , + ve tst neither confirms the diagnosis of abdominal TB nor excludes it 39

Specific investigation :

Specific investigation AFB CULTURE Estimation of ADA & IFN- γ ( QUANTIFERON TEST) PCR BECTEC ENDOSCOPY LAPAROSCOPY FNAC PERITONEAL BIOPSY 40

AFB:

AFB 41

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2. Colonies of Mycobacterium tuberculosis Lowenstein-Jensen med:

2. Colonies of Mycobacterium tuberculosis Lowenstein-Jensen med 43

Adenosine Deaminase (ADA):

Adenosine Deaminase (ADA) Aminohydrolase that converts adenosine à 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 44

QUANTI-FERON TB TEST:

QUANTI-FERON TB TEST Whole blood cytokine assay Approved by U.S. food and drug administration as an aid in the diagnosis of latent TB infection Recommended for screening for latent TB infection in population at low risk of TB. The test‘s performance will probably be enhanced by use of antigen such as ESAT-6 and CPF-10 that are present in M. tuberculosis but absent in others. 45

BACTEC:

BACTEC This system is commercially available. Can be used for both isolation and drug sensitivity test. Radiometric system for mycobacteria detection. The BACTEC instrument measures quantitatively the radioactivity in terms of numbers on scale ranging from 0 to 999 , designated as growth index. The daily increase in growth index is directly proportional to the rate and amount of growth in the medium. 46

Endoscopy :

Endoscopy Colonoscopy is of value to rule out malignancy. It is easiest and most direct method in establishing the diagnosis. Shows mucosal nodules or ulcers , deformed ileo caecal valve, mucosal oedema and pseudopolyps and occasionally diffuse colitis. Biopsy can be taken to confirm diagnosis. Capsule endoscopy is also useful to see small intestine pathology in difficult cases . 47

Tuberculous ulcers in the intestine:

Tuberculous ulcers in the intestine 48

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Laparoscopy :

Laparoscopy - is very useful method of investigation . - Transabdominal peritoneoscopy is visualization of the peritoneal cavity using endoscope through small incision in the abdomen. - It aids in visualization ,to collect ascitic fluid for analysis and to biopsy. 54

Video :

Video 55

FNAC:

FNAC shown to have a high accuracy. In pts with lymphadenopathy , abscess , and focally pts with palpable mass , FNAC confirms diagnosis . 56

Peritoneal biopsy:

Peritoneal biopsy Blind percutaneous peritoneal needle biopsy and open parietal peritoneal biopsy under L/A are also useful procedure for confirming diagnosis of abdominal TB. 57

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TREATMENT :

TREATMENT THERE ARE TWO MODILATIES OF TREATMENT: Medical treatment Surgical treatment 60

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61 The cornerstone of antituberculous therapy is multidrug treatment to decrease the duration of therapy and diminish the likelihood that drug-resistant organisms will develop Medical treatment

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62 Antituberculosis Drugs Drug/Formulation Adult Dosage (Daily) Main Adverse Effects First-Line Drugs Isoniazid (INH) [*] 5 mg/kg (max 300 mg) PO, IM, IV Hepatic toxicity, peripheral neuropathy 100, 300 mg tabs 50 mg/5 mL syrup 100 mg/mL injection Rifampin (Rifadin, Rimactane) 10 mg/kg (max 600 mg) PO, IV Hepatic toxicity, flulike syndrome, pruritus 150, 300 mg caps 600 mg injection powder

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63 Pyrazinamide 500 mg tabs 20-25 mg/kg PO Arthralgias, hepatic toxicity, hyperuricemia, gastrointestinal upset Ethambutol [‡] (Myambutol ) 100, 400 mg tabs 15-25 mg/kg PO Decreased red-green color discrimination, decreased visual acuity Drug/formulation Dosage Adverse effect

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64 Drug Dosage Adverse effect streptomycin 15mg/kg IM Vestibular and auditory toxicity, renal damage

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65 Second-Line Drugs Capreomycin (Capastat) 15 mg/kg IM (max 1 g) Auditory and vestibular toxicity, renal damage Kanamycin (Kantrex and others) 15 mg/kg IM, IV (max 1 g) Auditory toxicity, renal damage Amikacin (Amikin) 15 mg/kg IM, IV (max 1 g) Auditory toxicity, renal damage Cycloserine [¶] (Seromycin and others) 10-15 mg/kg in two doses (max 500 mg bid) PO Psychiatric symptoms, seizures Ethionamide (Trecator-SC) 15-20 mg/kg in two doses (max 500 mg bid) PO Gastrointestinal and hepatic toxicity, hypothyroidism Ciprofloxacin (Cipro and others) 750-1500 mg PO, IV Nausea, abdominal pain, restlessness, confusion Ofloxacin (Floxin) 600-800 mg PO, IV Nausea, abdominal pain, restlessness, confusion Drug Dosage Adverse effect

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66 Levofloxacin ( Levaquin ) 500-1000 mg PO, IV Nausea, abdominal pain, restlessness, confusion Gatifloxacin [¶] (Tequin) 400 mg PO, IV Nausea, abdominal pain, restlessness, confusion Moxifloxacin [¶¶] (Avelox) 400 mg PO, IV Nausea, abdominal pain, restlessness, confusion Aminosalicylic acid (PAS; Paser) 8-12 g in 2-3 doses PO Gastrointestinal disturbance Drug Dosage Adverse effect

Treatment categories according to DOTS strategy::

Treatment categories according to DOTS strategy: 67 Category of treatment Type of patient Regimen Category I New sputum smear- positive -Seriously ill sputum smear negative -seriously ill extra-pulmonary 2(HRZE)3 4(HR)3 Category II - Relapse - Failure - Defaulters 2(HRZES)3 1(HRZE)3 5(HRE)3 Category III Sputum smear negative, not seriously ill Extra-pulmonary , , not seriously ill 2(HRZ)3 4(HR)3

Surgical treatment :

Surgical treatment Indication for surgery: Intestinal obstruction Severe haemorrhage Acute abdominal presentation like perforation Intraabdominal abscess formation or fistula formation Uncertain diagnosis 68

Surgeries are::

Surgeries are: Limited ileocaecal resection(with 5cm margin)is the surgical therapy of choice for ileocaecal TB . In single ileal stricture –stricturoplasty may be done. But if bowel is edematous and friable then resection would be the ideal choice. In multiple strictures resection of ileum and anstomosis is done(ideal). 69

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70 In perforation of ileal bowel, resection and anstomosis is done. Adhesive obstruction may be released through laparoscopic adhsiolysis. Drainage of Intraabdominal abscess ,perianal abscess, and treatment for tuberculous fistula in ano is done when necessary .

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