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ABDOMINAL TB: DIAGNOSTIC APPROACH Presenter: Dr. Mukesh Kumar(PG Student) Guide: Dr. K.C.Vyas. Department of Surgery, R.N.T.Medical College, Udaipur, Rajasthan. :

ABDOMINAL TB: DIAGNOSTIC APPROACH Presenter: Dr. Mukesh Kumar(PG Student) Guide: Dr. K.C.Vyas . Department of Surgery, R.N.T.Medical College, Udaipur, Rajasthan.

INTRODUCTION:

INTRODUCTION Abdominal tuberculosis is one of the common extra pulmonary tubercular infections. Its clinical presentation is variable and it has diagnostic dilemma, as most of the investigations are non-specific and less sensitive.

ABDOMINAL TB CLASSIFICATION:

ABDOMINAL TB CLASSIFICATION Intestinal - ulcerative - hyperplastic - perforative Peritoneal - wet - dry/plastic - fibrotic fixed - acute primary peritonitis Mesenteric involvement - mass - abscess - nodal Solid organ - liver , spleen,pancreas

ETIOPATHOGENESIS:

ETIOPATHOGENESIS Primary Secondary Route of abdominal infection Direct ingestion Haematogenous spread Direct extension from contiguous organ Through lymph channels

INTESTINAL TUBERCULOSIS:

INTESTINAL TUBERCULOSIS Primary form – non-pasteurised dairy products (Myco. Bovis) Primary rarely seen in India Secondary form – swallowing infected sputum, haematogenous from primary focus

CLINICAL PRESENTATION:

CLINICAL PRESENTATION Intestinal obstruction Acute Subacute Chronic Perforation Ascites Diffuse Loculated Organized Lump Abscess LN Mass Bowel mass Ileo-caecal mass Omental mass

Aims & Objectives:

Aims & Objectives To find out diagnostic utility of various laboratory & radiological investigations in cases of abdominal tuberculosis in view of prescribing ATT.

Materials &Methods :

Materials &Methods This is a observational study carried out in the department of surgery RNTMC Udaipur during, July 2009 to June 2010. It includes twenty-five consecutive patients with either sex diagnosed as Abdominal tuberculosis. All patients were clinically evaluated with detailed history, physical examination & investigated by various tests like..

Cont.:

Cont. Routine blood Investigations CBC, ESR ADA-serum&ascitic fluid,TB IgG&IgM AFB-smear&culture Radiological-CXR;FPA;USG;CT Abd;Barium study PCR;Bactec test;Nanoparticle tech. Laparoscopy;HPE

USG IN ABDOMINAL TB:

USG IN ABDOMINAL TB FINDINGS Intra abdominal fluid Septae Peritoneal Thickening Lymphadenopathy GUIDED PROCEDURES Ascitic tap FNAC / Biopsy

BARIUM CONTRAST STUDY:

BARIUM CONTRAST STUDY FINDINGS Fleishner sign Conical caecum Increased Ileo-caecal angle Multiple strictures

CT SCAN ABDOMEN:

CT SCAN ABDOMEN FINDINGS Lymphadenopathy – m/c I C Mural thickening High density ascities Irregular soft tissue densities in omental area

BACTEC FAST METHOD OF TB CULTURE:

BACTEC FAST METHOD OF TB CULTURE Liquid (BACTEC) – results available in 10-14 days Solid (LJ Media) media – 4-6 wks

TB PCR:

TB PCR It is genetic test Sensitivity and specificity Rapid & Result available in few hours Quantitative – 1 to 2 bacilli

LAPAROSCOPY:

LAPAROSCOPY Advantage Diagnostic Biopsy Therapeutic May avoid empirical use of ATT Disadvantage Invasive investigation Difficult Costly

OBSERVATION & RESULTS:

OBSERVATION & RESULTS Abdominal pain 20 (80) Fever 6 (24) Weight loss 20 (84) Anorexia 18 (72) Diarrhoea 12 (48) Constipation 4 (16) Nausea / vomiting 8 (32) Melena 1 (4)

Contd…:

Contd … Abdominal tenderness 12 (48) Abdominal distension or ascites 7(28) Hepatomegaly 4 (16) Abdominal mass or doughy abdomen 6 (24) Peritoneal signs 2 (8) Cervical lymphadenopathy2(8 )

Contd…:

Contd … Anaemia (Hb) 16 (64) WBC count (> 11000/ cumm) 4 (16) ESR>20 in 12 (48) Albumin (<35 g/l) 12 (48) Serum ADA>30 in 10(40) Ascitic fluid ADA>40in 4 pt

Contd...:

Contd... CXR-pulmonary TB 5(20) FPA-mutiple air fluid level 7(28) -gas ↓diaphragm 2(8) USG(n=20) -ascites 4(20) - mass at ICJ 3(15) - abd lymphadenopathy2(10)

X-RAY ABDOMEN WITH CALCIFIED LYMPH NODE:

X-RAY ABDOMEN WITH CALCIFIED LYMPH NODE

X-RAY ABDOMEN WITH INTESTINAL OBSTRUCTION:

X-RAY ABDOMEN WITH INTESTINAL OBSTRUCTION

USG SEPTATE ASCITES:

USG SEPTATE ASCITES

USG NECROTIC/CALCIFIED LYMPH NODE MASS:

USG NECROTIC/CALCIFIED LYMPH NODE MASS

Contd...:

Contd... Barium meal follow through (n=9) (Ulceration, narrowing deformity)6 (66) CT Scan of abdomen (n=5) -Enlarged lymphnodes4(80) -Mass (Matted loops or omental thickening)1(20) Morphology(n=9) (e.g. tubercles)3(33) Biopsy(n=9) (e.g. Caseating Granuloma)8(89)

BARIUM CONTRAST STUDY WITH IC-TUBERCULOSIS:

BARIUM CONTRAST STUDY WITH IC-TUBERCULOSIS

BARIUM CONTRAST STUDY WITH STRICTURES:

BARIUM CONTRAST STUDY WITH STRICTURES

CT-SCAN MESENTERIC AND PERITONEAL THICKENING:

CT-SCAN MESENTERIC AND PERITONEAL THICKENING

CT SCAN BOWEL THICKENING:

CT SCAN BOWEL THICKENING

TREATMENT:

TREATMENT ATT as per dots/rntcp recommendation Empirical ATT to be avoided Aspiration of abscess Surgery for unrelieved obstruction & perforation

ABDOMINAL TB AND HIV:

ABDOMINAL TB AND HIV Both incidence and severity increased EP TB 10-15% of all cases 50% of patient with AIDS Mainly MDR TB Second line drugs can be used

Slide 31:

CONCLUSION : Suspicion is must Diagnosis is possible although AFB detection is difficult, a representative tissue biopsy(when approachable) and radiological findings are good method of diagnosis of abdominal tuberculosis. Strongly suggestive clinical features with positive non specific investigation findings are also an indication for ATT. Confirmatory diagnosis →HPE Surgery for unavoidable reasons only

Slide 32:

THANK YOU

SURGERY FOR OBSTRUCTION:

SURGERY FOR OBSTRUCTION IC TB Subacute obstruction Coccon abdomen

SURGERY FOR PERFORATION:

SURGERY FOR PERFORATION Resection of involved segment and primary anastomosis Primary repair – risk of re-perforation or fistulisation

COMPLICATIONS:

COMPLICATIONS Obstruction & perforation Malnutrition and superinfection Blind loop Malabsorption Enterocutaneous fistula Short bowel syndrome Infertility

ASCITIC FLUID:

ASCITIC FLUID Routine microscopy AFB stain AFB culture TB PCR ADA Serum > 42 IU/L Ascites fluid > 33 IU/L SAAG < 1.1

:

Category of treatment Type of patient Regimen Category I New sputum smear +ve TB Seriously ill new smear –ve TB Seriously ill new EPTB 2 H3R3Z3E3 + 4 H3R3 Category II Sputum smear positive relapse Sputum smear positive failure Sputum smear +ve treatment after default 2 H3R3Z3E3S3 + 1H3R3Z3E3 + 5H3R3E3 Category III New sputum smear –ve PTB New EPTB, not seriously ill 2H3R3Z3 + 4 H3R3

RNTCP Classification of EPTB:

RNTCP Classification of EPTB SERIOUSLY ILL TB meningitis Disseminated TB TB pericarditis TB peritonitis/intestinal TB Bilateral pleurisy Spinal TB with neurological complications Genitourinary tract NOT SERIOUSLY ILL Lymph node TB Pleural effusion (unilateral) Bone (excluding spine) Peripheral joints

UNCOMMON PRESENTATION:

UNCOMMON PRESENTATION Gastro-duodenal TB Oesophagus Segmental colonic Rectal Anal TB Genitourinary TB

FLOW CHART OF PATHOGENESIS:

FLOW CHART OF PATHOGENESIS Primary infection Primary complex Bacteremia Good immunity Poor immunity Lodging of bacillus in organs & nodes dormant Reactivation/ dec immunity Secondary TB Severe TB

USG BOWEL/MESENTERIC THICKENING:

USG BOWEL/MESENTERIC THICKENING

CT SCAN TB LYMPHADENITIS:

CT SCAN TB LYMPHADENITIS