ABDOMINAL TUBERCULOSIS

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

 Very varied presentation possible 

Great mimicker.

 TB of GIT- 6th most frequent extrapulmonary site.

PREVALENCE

 Isolated abdominal tuberculosis:

Unselected autopsy series- 0.02 -

5.1%
Higher prevalence in females in 1–
4:1
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 %
Incidence  severity of

abdominal TB will increase with

the HIV epidemic

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
 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.
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.

slight female predominance

 Clinical presentation  Acute / Chronic / Acute on

Chronic.
 Constitutional symptoms
 Fever (40%-70%)
 Weight loss (40%-90%)
 Anorexia
 Malaise
 Pain (80%-95%)
 Colicky (luminal stenosis)
 Continous ( LN involvement)
 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 historyMimics gastric Ca.
 Duodenal obstruction - extrinsic compression by tuberculous
LN
 Hematemesis / Perforation / Fistulae / Obstructive jaundice
 x-Ray usually normal
 Endoscopic picture - non specific
Ileocaecal tuberculosis
 Colicky abdominal pain

 ‘Ball of wind’ rolling in abdomen

 Borborygmi

 Right iliac fossa lump - ileocaecal region,

mesenteric fat and LN
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.
Perforation

 2nd commonest cause after typhoid

 Usually single and proximal to a stricture

 Clue - TB Chest x-ray

 Pneumoperitoneum in ~ 50% cases

Malabsorption

 Common
 Clue----h/o of pain
 Pathogenesis
 bacterial overgrowth in stagnant loop
 bile salt deconjugation
 diminished absorptive surface due to ulceration
 involvement of lymphatics and LN
Overall prevalence of malabsorption:

75% pt with intestinal malabsorption

40% of those without

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

 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 (total lymphocyte count)of 150-4000/µl,

Lymphocytes >70%

 ZN stain (Ziehl-Neelsen method stain)+ in < 3%

cases
 + culture in < 20% cases
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

 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.
 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
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
 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 thickened peritoneum and multiple thick
adhesions Caseating granulomas + in 85%-90%
of Bx
Management

 ATT for at least 6 months including 2 months

of Rif, INH, Pzide and Etham

 However in practice often given for 12 to 18

months

 2 recent reports  obstructing lesions may

relieve with ATT alone

However most will need surgery