Abdominal Tuberculosis

Pathophysiology/ Pathology Intestinal TB

Areas involved

• Most commonly involves distal ileum & caecum

• Less commonly:

• ileum, jejunum, colon, anorectum

• Proximal small bowel rare

• Tracheoesophageal fistula

PathologyIntestinal TB

• Hypertrophic

• Ulcerative

• Ulcero-hypertrophic

• Mesenteric thickening

• Strictures

• Vascular involvement

Makharia G et al.The American Journal of Gastroenterology 105, 642-651 (March 2010) | doi:10.1038/ajg.2009.585

Peritoneum & Nodal Disease

• Three types: predominant ascites, fibrotic, encysted

• Mesenteric & para-aortic glands: may occur in absence of

overt intestinal disease

How do they present?

How do they present?

Symptoms and

Signs (%)

Talwar [11],

2000,

n= 125

Johnson [8],

1987,

n= 59

Davies [3],

1982,

n=55

Saczek [7],

2001,

n=45

Veeragandham [9],

1996,

n= 26

Abdominal pain 100 44 60 51 71

Abdominal

distension

38 92 42 64 35

Growth failure,

weight loss

58 78 30 56 69

Fever 74 34 47 50

Loss of appetite 54 24 15

Ascites 44 44 7 20 35

Abdominal mass 12 56 47 23

Extra-abdominal

lymph node

enlargement

N/A 47 18 49 19.2

(extra-abdominal

tuberculosis)

Case

• 12 year old boy

• Informal settlement

• 3 month history of• Abdominal pain

• Significant blood loss in stool

• Weight loss

• Initially treated by PHP as dysentery

Colonoscopy

HistologyExtensive inflammation with multiple granulomas

Diagnosis

How do we make the diagnosis?

High index of suspicion in an endemic area (is the

child at risk?).

Most children chronically ill

Malnutrition

Signs of systemic disease: ESR, fever, anaemia

BUT

Acute presentations occur

How do we make the diagnosis?

Evidence of contact or infection.

Household contact (36% in Western Cape)

In developed countries often no history of

contact!

TST (44-68%, RSA)

Beware of false negative results

Interpretation differs according to the

population exposure

Case

• No household TBC (but uncle

has PTB)

• TST N/A

• No peripheral

lymphadenopathy

Radiography

Radiological Evidence of PTB

Author Year N %

Davies

(Cape Town)

1982 46 28

Johnson

(Cape Town)

1987 59 54

Saczek (Cape Town) 2001 45 64

Talwar

(India)

2000 125 16

Abdominal X-Ray

Non-specific

Calcifications

Ultrasound

Lymphadenopathy

Ascites

Inflammatory mass

Thickened omentum

Intestinal involvement

Liver and spleen

Sonar graphic features of Tuberculous Lymph nodes {Bodh, 2016 }

• Hypoechoic, patch anechoic/hypoechoic

• Calcification

• Sharply demarcated borders

• Conglomerate of nodes

• Larger than reactive lymph nodes

• EUS guided FNA {Puri, 2012 } {Chen, 2004}

Abdominal Ultrasound

• Calcified lesion in the liver• Small amount of ascites• Large necrotic nodes through-

out the abdomen

Colonoscopy

http://www.gastrointestinalatlas.com/english/tuberculosis_of_the_colon.html

Colonoscopy{Larsson, 2014 #2274} {Huang, 2015 #2259} {Makharia, 2010 #2270}

CD TBExtensive disease Mucosal nodularity

Multiple segments involved (skip lesions)

Distal disease more common Mostly limited to the right colon & TI

Aphtous or linear ulcers or superficial ulcers

Ring ulcers

Cobble stone appearance Ulcer scars

Erythema

Friability

Perianal disease

Histology{Kirsch, 2006 #2273}

• Granulomas in TB• More common• More per biopsy site• Larger (>0.05mm)• Confluent• Caseous necrosis• Submucosal more common (mucosal equal in TB & CD)

• Ulcer• Epithelioid cells more common in TB

• Disproportionate submucosal chronic inflammation

CT/MRI

CT/MRI{Andronikou, 2002 #2256}

Lymphadenopathy (common 77%)

• Para-aortic, periportal, mesenteric, pelvic, omental, peripancreatic, pararenal

• Enlarged and/or calcified

• Low density centre, rim enhancement

CT AbdomenSolid organ disease

• Hepatic & splenic granuloma/abscess

• Low density

• Ring enhancement

• Calcify

• Pancreatic involvement rare in children

CT Abdomen{Andronikou, 2002 #2256}

• Ileocaecal

• Bowel wall thickening

• Inflammatory mass

• Inflamed omentum with adherent bowel

• Ascites (dense)

Laparoscopy

{Muroni, 2015}

{Islam, 2014} KZN{Malik, 2011} Pakistan

>60% - 80%• histology suggestive or • Typical appearance

BUT

Complications: 2 bowel perforations, 3 intra-operative bleeds, 6 required conversion to laparotomy due to adhesions

What should we do?

Do we have enough information to make a

therapeutic decision?

When can we treat without a bacteriological diagnosis?

Where is this appropriate?High prevalence

Presentation consistent with abdominal tuberculosis (“typical”)

Caveats“atypical” clinical presentation

Monitor response carefullyGeneral condition

Fever

Ascites

Abdominal mass

Lymphnodes

Nutrition

Incorrect diagnosis e.g. lymphoma, CD

Clinical Outcome

• 4 drug treatment for extra-pulmonary TB

• Large intestinal haemorrhage 2 days after the endoscopy

• Continue treatment: weight gain (2 kg), feels better

BUT

• Hb 7,7g/dl

• Rectal bleeding after 6 months

What are the principles of treatment?

Nutritional support

AscitesPoor response to diuretics

Anti-Tb drugs4 drugs intensive phase/ 2 drugs consolidation

6 months

SurgeryDiagnostic

Obstruction not responding to conservative measures

Perforation

Fistula

Haemorrhage

Conclusions

• TB mimics other diseases

• Definitive diagnosis not always possible

• Closely monitor the response to treatment