This is a presentation detailing facts about abdominal tuberculosis. Intended for healthcare professionals and medical students Dr Manoj K Ghoda Gujarat Gastro Group

1. Abdominal Tuberculosis
Dr Manoj K Ghoda M.D., M.R.C.P.
Consultant Gastroenterologist
mkghoda@yahoo.com

2. 35/ M
•Recurrent RIF pain
•“Gola” formation
•Vomiting
•Weight loss
USG: ‘Stricture” in terminal ileum, s/o ?
Terminal ileal TB

3. Abdominal TB fact file

4. •Tuberculosis (TB) is very common in the developing
world. Its reappearance has increased in association with
the AIDS.
•TB in its various forms remains an important cause of
morbidity and mortality in developing countries and in
patients with AIDS.
•TB can occur in persons of any age, although it is more
common in children and in older persons whose immune
systems are weak.
•TB can be seen in any age group that is
immunocompromised

5. •The occurrence of abdominal TB is independent of
pulmonary disease in most patients, with an incidence
of coexisting disease varying from 5 to 36%.
•In patients with abdominal TB, the highest incidence
of disease was noted in the GI tract and in the
peritoneum, followed by the mesenteric lymph nodes.
•Within the GI tract, the ileocecal area is the most
common site of involvement. A third of patients will
report a family history of tuberculosis.

6. The mode of spread:
•The majority of abdominal disease is either through
hematogenous spread from active pulmonary or
miliary tuberculosis, swallowing of infected sputum
or ingestion of contaminated milk or food, and
contiguous spread from adjacent organs.
•Associated active pulmonary tuberculosis is only
seen in 5-36% of cases.

8. Pathology:
Three types of intestinal lesion are
seen;
•Ulcerative,
•Stricturous,
•Hypertrophic,
though the three may co-exist.

9. (1) The ulcerative form of
TB is seen in approximately
60% of patients. Multiple
superficial ulcers largely
confined to the epithelial
surface. This is considered a
highly active form of the
disease with the long axis of
the ulcers perpendicular to
the long axis of the bowel.

10. (2) The stricturous form shows multiple
or single stricture, often very tight.
(3) The hypertrophic form is seen in
approximately 10% of patients and
consists of thickening of bowel wall with
scarring, fibrosis, and a rigid, mass-like
appearance that mimics carcinoma.
The ulcerohypertrophic form is a
subtype seen in 30% of patients.
These patients have a combination of
features of the ulcerative and
hypertrophic forms.

11. The serosal surface may show nodular masses of
tubercles. In some cases, aphthous ulcers may be
seen in the colon.
Caseation may not always be seen in the
granuloma, especially in the mucosa, but they are
almost always seen in the regional lymph nodes.

12. Clinical presentations of abdominal TB:
•The commonest presentation is non-specific abdominal pain,
associated with anorexia, weight loss and low grade fever.
•Systemic manifestations including low grade fever, lethargy,
malaise, night sweats, and anorexia and weight loss are present
in approximately a third of patients with abdominal
tuberculosis.
•Alteration in bowel habit, diarrhea, constipation or together,
malabsorption, rectal bleeding etc.
•Ascites.

13. Complications of abdominal TB:
•Subacute or acute intestinal obstruction due to stricture or
adhesions is the commonest complication.
•Hemorrhage and perforation are recognized complications of
intestinal TB, although free perforation is less frequent than in
Crohn’s disease.
•Malabsorption may be caused by obstruction that leads to
bacterial overgrowth, a variant of stagnant loop syndrome.
Involvement of the mesenteric lymphatic system, known as
tabes mesenterica, may retard chylomicron removal because
of lymphatic obstruction and result in malabsorption.
•TB is a well recognized cause of rectal stricture. Isolated rectal
involvement is rare and may be mistaken for rectal malignancy

15. Investigations:
Endoscopy may show,
•Ulcers,
•Nodules,
•Deformed cecum and ileocecal valve,
•Strictures,
•Multiple fibrous bands, and
•Polypoid lesions

16. Barium examination:
A small-bowel barium study may show dilated loops,
thickened folds or even a stricture.

17. USG:
•Intra-abdominal fluid, free or loculated; clear or
complex with septae or debris
•Inter loop ascites.
•Lymphadenopathy, discrete or conglomerated,
•Bowel wall thickening, and
•Pseudo kidney sign.

18. CT :
•The CT features suggestive of abdominal TB include,
•Irregular soft-tissue densities in the omentum,
•Low-attenuating masses surrounded by thick solid
rims,
•Low-attenuating necrotic nodes,
•High-attenuating ascitic fluid and bowel loops forming
poorly defined masses.
•Splenomegaly and hepatomegaly with nodules,
•Pleural effusion,
•Intrahepatic, intrasplenic, and intrapancreatic masses.

19. In clinical practice, typical GI symptoms mentioned
above with USG evidence of either terminal ileal
involvement or ascites are reasonable evidence in a
proper set up.
Further confirmation is by diagnostic ascitic tapping
and endoscopic biopsy.

21. Differential Diagnosis:
•Crohn’s disease,
•Gastrointestinal malignancy,
•Sarcoma,
•Amebiasis,
•Yersinia infection, and
•Periappendiceal abscess

22. Treatment:
•Due to the difficulty and in the case of culture the delay
associated with making a diagnosis of abdominal tuberculosis,
empirical treatment of suspected cases may be warranted.
•Even lesions causing partial bowel obstruction often respond to
medical treatment.
•
•In the HIV co-infected patient as in this case the decision as to
whether to start both quadruple therapy and HAART depends on
the CD4 count. If CD4 > 200 HAART is deferred until completion of
TB treatment, if 100-200 then HAART should start 2 months after
initiation of TB treatment and soon after TB treatment if CD4
<100.

23. Surgery in TB:
Surgery is required if there is a tight fibrotic stricture
which is symptomatic. Resection anastomosis or
stricturoplasty are the standard approaches. Results
are excellent.

24. Entrance test

25. The following are true about abdominal tuberculosis:
1. Abdominal tuberculosis (TB) is very common in the
developing world but it is rarely seen in western countries.
2. Its reappearance has increased in association with the
acquired immunodeficiency syndrome (AIDS).
3. The occurrence of abdominal TB is dependent of pulmonary
disease in most patients.
4. In patients with abdominal TB, the highest incidence of
disease was noted in the gastrointestinal tract and in the
peritoneum, followed by the mesenteric lymph nodes.
5. Within the gastrointestinal tract, the ileocecal area is the most
common site of involvement.

26. 6. A third of patients will report a family history of tuberculosis.
7. TB can occur in persons of any age, although it is uncommon in
children and in older persons whose immune systems are
weak.
8. The mode of spread is either through hematogenous spread
from active pulmonary or miliary tuberculosis, swallowing of
infected sputum or ingestion of contaminated milk or food,
and contiguous spread from adjacent organs.
9. Most cases of abdominal tuberculosis involve the intestine
with the commonest site being the ileocecal region due to
abundance of lymphoid tissue (Payer’s patches).
10. Ileocecal junction is involved in 80-90% of the patients.
11. Proximal small intestinal disease is seen more commonly with
Mycobacterium avium-intracellulare (MAI) complex infection,
predominantly one involving the jejunum.

27. 12. Three types of intestinal lesion are seen; Ulcerative,
Stricturous and hypertrophic.
13. Patients may present with non-specific abdominal pain,
with ascites, alteration in bowel habit, diarrhea,
constipation or together, malabsorption, rectal bleeding
etc.
14. Colonic TB rarely is associated with ileal TB.
15. Subacute or acute intestinal obstruction due to stricture is
the commonest complication.
16. Hemorrhage and perforation are recognized
complications of intestinal TB, and free perforation is
more frequent than in Crohn’s disease.

28. 17. TB never involve rectum and isolated rectal involvement
suggests rectal malignancy.
18. A small-bowel barium study is the main radiographic
method for the evaluation of intestinal TB in regions of the
world where the disease is endemic.
19. However, because peritonitis is common in GI TB, abdominal
CT may be performed as a preferred examination, which
nearly always suggest the diagnosis in the presence of
necrotic lymph nodes or changes suggestive of TB
peritonitis.
20. Early changes on barium examinations reveal nodular
thickening of mucosal folds with loss of symmetry in fold
pattern.
21. Definitive diagnosis is by showing AFB microbiologically by
culture or by both smear and PCR positivity.
22. If the diagnosis of TB is not possible using both of these
methods, a clinical diagnosis of TB is ruled out.