2. Introduction
• Before era of HIV infection > 80% TB confined to lung
• Extrapulmonary TB increases with HIV
• TB can involve any part of GIT from mouth to anus,
peritoneum & pancreatobiliary system.
• TB of GIT(peritoneal)- 6th most frequent
extrapulmonary site.
• (Lymphatic..1st,Genitourinary,Bone&joints,Miliary,Meni
ngeal------ 5th )
• Ileum > caecum > ascending colon > jejunum >appendix
> sigmoid > rectum > duodenum > stomach >
oesophagus
• Most common site - Ileocaecal region
• More than one site may be involved
3. • 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 case from reactivation of latent
peritonial disease, previously established
hematogenously from primary pulmonary
focus
• In India, organism from all intestinal lesions –
M. tuberculosis and not M. bovis.
4. • Peritoneal involvement occurs from :
– Spread from Lymph node
– Intestinal lesions
– Tubercular salpingitis
• Abdominal lymph node 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
5. Clinical features
• Mainly disease of young adults.~ 2/3 of pt. are 21-40 yr old .Sex
incidence equal
• Clinical presentation Acute / Chronic / Acute on Chronic.
• Abdominal swelling caused by ascitis is the most common symptom
• 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
6. Tuberculosis of esophagus
• Rare ~ 0.2% of
total cases
• By extension from
adjacent LN
• Low grade
fever/Dysphagia/Od
ynophagia/
Midesophageal
ulcer
• Mimics esophageal
Ca
Esophagograms showing a long
Stricture in the middle third of the esophagus
with multiple diverticula
7. Gastroduodenal TB
• Stomach and duodenum each ~
1% of total cases
• Mimics PUD - shorter history, non
response to t/t
• Mimics gastric Ca.
• Duodenal obstruction - extrinsic
compression by tuberculous LN
• Hematemesis / Perforation /
Fistulae / Obstructive jaundice
• Cx-Ray usually normal
• Endoscopic picture - non specific
Marked narrowing of the body
of stomach due to TB
9. Ileocaecal tuberculosis
• Right iliac fossa lump - ileocaecal region, mesenteric fat and 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.
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
10. 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
11. Fleischner sign
• Thickening of the
ileocaecal valve lips
and/or wide gaping of
the valve, with
narrowing of the
terminal ileum
• Inverted umbrella sign
12. Pulled up caecum
• Caecum becomes
conical, shrunken,
retracted out of the
illiac fossa due to
contraction of the
mesocolon
13. Goose neck deformity
• Loss of normal
ileocaecal angle and
dilated terminal ileum
appears as suspended
and hanging from a
retracted , shortened
caecum
14. Stierlin’s sign
• Conical and shrunken
cecum, widely open
ileocecal valves, narrowing
terminal ileum, rapid
emptying of diseased
segment
• Represents acute
inflammation superimposed
on a chronically involved
segment of the ileum,
caecum or ascending colon
16. Rectal and Anal Tuberculosis
• Hematochezia - most common symp. Due to
mucosal trauma by stool
• Constitutional symptoms
• Constipation
• Rectal stricture
• Anal fistula – usually multiple
17. Diagnosis and Investigations
• Non specific findings---
– Raised ESR
– Positive Mantoux test
– Anemia
– Hypoalbuminaemia
• ELISA
Response to
mycobacteria variable
& reproducibility
poor.Value of
immunological tests
remain undefined
18. • ASCITIC FLUID ADENOSINE DEAMINASE ACTIVITY IS HIGHLY
SENSITIVE AND SPECIFIC FOR TUBERCULOUS PERITONITIS
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
19. 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
20. 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
21.
22. Management
• ATT for at least 6 months including 2 months
of Rif, INH, Pzide and Etham
• However in practice t/t often given for 12 to
18 months
• 2 recent reports obstructing lesions may
relieve with ATT alone
However most will need surgery
