intetinal tuberculosis

INTESTINAL TUBERCULOSIS

House surgeonSadia Shabbir

Introduction

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

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

• Mycobacterium tuberculosis is the pathogen in most cases.

• Mycobacterium bovis in some parts of the world

Etiopathogenesis

• Mechanisms by which M. tuberculosis reach the GIT:

By ingestion– Ingestion of food contaminated with tubercle

bacilli causing Primary Intestinal Tuberculosis– Ingestion of sputum containing tuberculous

bacteria from primary pulmonary focus - Secondary Intestinal Tuberculosis

Hematogenous spread from primary lung focus

Direct spread from adjacent organs.

Via lymph channels from infected LN

PATHOGENESIS

Bacilli in the depth of mucosal glands

Inflammatory Reaction

Phagocytes carry bacilli to Peyer’s Patches

Formation of tubercle and necrosis

Endarteritis,edema and sloughing

Ulcer formation

Accumulation of collagen-Thickening and stenosis

Inflammation spreads from submucosa to serosa

Bacilli via lymphatics – Lympahtic obstruction and Regional Lymphadenitis

Ileocaecal Tuberculosis

• Most common site of abdominal tuberculosis due to:– Stasis– Abundant payer’s patches– Alkaline media– Bacterial contact time is more– Minimal digestive activity– Maximum absorption in the area

Characterisitc lesions

A.Ulcerative :• Multiple circumferential

transverse ulcers (Girdle ulcers) with skip leisons

• Napkin ring strictures in longstanding ulcers (common in ileum)

• Intestinal nodes involvement with caseation and abscess

B. Hyperplastic Type • Chronic granulomatous

lesions in ileoceacal region

• Fibroblastic activity in submucosa and subserosa causes thickening of bowel wall with lymph node enlargement

C. Stricturous type: • Characterized by strictures – multiple or single

D. Diffuse colitis: • Rare form, very similar to ulceratice colitis

Distribution of tuberculous lesions

Ileum > caecum > ascending colon > jejunum

>appendix > sigmoid > rectum > duodenum

> stomach > oesophagus

• More than one site may be involved

Symptoms

• Local symptoms depending upon site involved • Constitutional symptoms are: • Fever • Malaise • Anemia • Night sweats • Loss of weight • Pain abdomen: colicky if luminal compromise, dull

and continuous when mesenteric lymph nodes are involved

• Alteration in bowel habit, diarrhea, constipation or together, malabsorption, rectal bleeding etc.

Complications

• Intestinal Obstruction:Most common complication

Mechanism: hyperplastic intestinal lesion, strictures, adhesion and adjacent lymph node involvement • Malabsoprption, blind loop syndrome

• Perforation: 2nd commonest cause of small intestinal

perforation, first being typhoid fever • Usually single & proximal to a stricture

• Dissemination of tuberculosis Cold abscess • formation Hemorrhage• Fecal fistula • Gastric outlet obstruction

Investigations

• Blood investgations: Anaemia Leucopenia with lymphocytosis Raised ESR• Mantoux test: Gives supportive evidence to the diagnosis Positive in

50 – 70% cases • Chest Xray: may reveal either healed or active

pulmonary tuberculosis

Plain X ray abdomen:

• Intestinal obstruction• Calcified lymph nodes• Hollow viscus perforation

• On Barium enema

• Loss of normal ileocaecal angle and dilated terminal ileum, appearing suspended from a retracted fibrosed caecum – goose neck deformity

Contrast barium enema image demonstrates marked narrowing of the caecum, ascending colon and terminal ileum. Dilatation of the small intestine proximal to the narrowed segment of ileum is also seen.

USG abdomen

Thickened bowel wall– Loculated ascitis– Interloop ascitis– Mesenteric thickening– Lymph node

enlargement– Pulled up caecum

(Pseudokidney sign)Ultrasound image. Multiple enlarged conglomerate lymphnodes in retroperitoneum with hypoechoic centers due to caseation

CT Abdomen

• Circumferential wall thickening of cecum and terminal ileum

• Asymmetric thickening of ileoceacal valve and medial wall of ceacum

• Localized mesenteric lymphadenopathy with areas of central low attenuation

Treatment • Mediacal management: on same lines as for pulmonary

tuberculosis • › First line drugs: INH Rifampicin

Pyrazinamid Ethambutol • › Second line drugs:

Amikacin, kanamycin, PAS, Ciprofloxacin, Clarithrymycin, Azythromycin, Rifabutin

• › Treatment to be continued for 6 months › Supportive nutrition

Surgical Management:

• › Indications: Intestinal obstruction Severe hemorrhage Acute abdomen (perforation) Intra-abdominal abscesses/ fistula formation Uncertain diagnosis

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THANK YOU….

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