Abdominal Tuberculosis in Nursing

1. ABDOMINAL TUBERCULOSIS
P R E S E N T E D B Y: N AVA N E E TA K U S U M
M . S C . N U R S I N G
( 2 N D Y E A R )
C O L L E G E O F N U R S I N G

2. Introduction:
World TB day- 24th March 1882
TB declared as notifiable disease by Indian Government on
May, 9th 2012.

3. TUBERCULOSIS
Major health problem
7-10 million new cases annually
6% of deaths world wide
Abdominal tuberculosis is a common extrapulmonary
manifestation of tuberculosis.
non HIV patients 10 – 15 % have extrapulmonary manifestations of
tuberculosis .
HIV infected patients > 50% have extra pulmonarymanifestations of
TB

4. Epidemiology
 Global burden of TB is nearly 12 million.
 A/C WHO (2013) 8.6 million annual incidence of TB globally and 1.3
million people died from disease in 2012.
 India has the world’s largest TB cases is around 26% of the world TB
cases, followed by China and South Africa.
 An estimated 0.45 million new cases of MDR TB worldwide in 2012. >
half in India.

5. In India, around 3 – 20 % of all cases of bowel obstruction are due
to ATB.
Tuberculosis accounts for 5 – 9 % of all small intestinal perforations
in India, second commonest cause after typhoid fever.
ATB is an important cause of Malabsorption syndrome in India.

6. 4
• Epidemiology:
– Both gender: equally affected
– 35-45 years
• Riskfactors:
– Alcoholic liver disease
– HIV infection
• 9% of all new TB cases are related to HIV
– Advanced age
– Low socioeconomic status

7. Etiology
Mycobacterium tuberculosis
Pathogen for most cases of abdominal tuberculosis
Mycobacterium bovis
Cause in small percentage of cases, in developing Transmitted by
unpasteurized dairy products.
Mycobacterium Avium more likely in HIV infected
patients

8. MYCOBACTERIUM

10. Mode ofinfection
Swallowing of
infected sputum
Hematogenous spread
from pulmonary focus
Ingestion of contaminated
milk products
Direct spread from
adjacent organs
Pathogenesis of Abdominal TB

11. 49% 42% 4%
Intestinal Peritoneal Nodal Solid visceral
5%
Abdominal tuberculosis Classification:
Others
1.3%

12. 1. Intestinal Tuberculosis
Ileocaecal
region
Small bowel &
colon

13. Order of Frequency ITB:
Ileum > caecum > ascending colon > jejunum
>appendix > sigmoid > rectum > duodenum
> stomach > oesophagus
• More than one site may be involved

14. 1. Intestinal Tuberculosis
Ileocaecal region Ileal region
• Ulcerative (60%)
• Hypertrophic (10%)
• Ulcerohypertrophic (30%)
Stricture type

15. • 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
Ileocaecal Tuberculosis

16. A. Ulcerative type (60%)
– Secondary to pulmonary tuberculosis
– Old malnutritioned people
– Virulent organism
– Poor body resistance
– Commonly in ileum
– Rarely in caecum
Ileocaecal Tuberculosis

17. – Intestinal nodes involvement with caseation and
abscess
– May present with blood in stools, diarrhoea, loss of
appetite and reduced weight
– Complications:
• Acute: Ulcer perforation
• Chronic: Stricture  Subacute obstruction
Ileocaecal Tuberculosis

18. B. Hyperplastic Type -10%
• Primary GIT tuberculosis
• Less virulent organism
• Chronic granulomatous lesions in ileoceacal region
• Fibroblastic activity in submucosa and subserosa causes
thickening of bowel wall with lymph node enlargement
• Presenting as Mass in Right Iliac Fossa (Nodular fixed and firm
mass)
Ileocaecal Tuberculosis

19. B. Hyperplastic Type -10%
Ileocaecal Tuberculosis

20. 20
 30% of patients
 Inflammatory mass with thickened and
ulcerated mucosa
 Commonly in ileocaecal region
 Cone shaped deformity of caecum
 Shortening of ascending colon
C. Ulcerohypertrophic type-30%

21. • It is usually stricture type
• May be multiple
• Presents with intestinal obstruction
• Bowel adhesions, localization, fibrosis, secondary infection are
common
• Perforation (5%)
• Plain Xray – Multiple air fluid levels
2. Ileal Tuberculosis

22. 2. Peritoneal Tuberculosis
Acute Chronic
Ascitic
Clear straw-coloured ascitic fluid
Fibrous
Intestines and viscera matted
together causing obstruction
Encysted
Matted intestines enclosing a
loculation of serous fluid
Purulent
Purulent ascitic fluid
Tuberculous peritonitis
•Acute abdomen
•Exploratory laparotomy
ascitic fluid
thickened omentum
scattered tubercles

23. • It is post primary
• Becoming more common
• Blood spread
• Can develop from diseased mesenteric lymph
nodes, intestines or fallopian tubes
Peritoneal Tuberculosis

24. • Abdominal Cocoon Syndrome
– Dense adhesions in peritoneum and omentum with contents inside
as small bowel causing intestinal obstruction
Peritoneal Tuberculosis

25. A. Acute type –mimics acute abdomen
– Rare
– Features of peritonitis
– Due to perforation or rupture of mesenteric lymph nodes
– Exploratory laparotomy reveals straw coloured fluid with tubercles
in the peritoneum, greater omentum and bowel wall
– Fluid evacuated and sent for culture and AFB study
– Biopsy taken from omentum
Peritoneal Tuberculosis

26. B. Chronic
• Abdominal pain
• Fever
• Ascites
• Loss of appetite and weight
• Abdominal mass
– Types
a) Ascitic form
b) Encysted form
c) Plastic form
d) Purulent form
Peritoneal Tuberculosis

27. – Common in children and young adults
– abdominal distension
– May cause congenital hydrdocele, umbilical hernia, shifting
dullness, fluid thrill and mass per abdomen
– Rolled up omentum and nodular due to extensive
fibrosis
Ascitic peritoneal tuberculosis:

28. 89
Ascitic Fluid Analysis
-exudate with protein level >3gm/dl
-SAAG <1.1
-lymphocyte predominant cells with cell count as
high as 4000 / mm3
-AFB +ve seen only < 3%
-specific gravity > 1.016
-glucose < 30mg
-LDH > 90 units/lit
-

29. – Ascites gets loculated due to fibrinous deposition
– Dullness is the typical feature
– May present as intra-abdominal mass mimicing ovarian cyst,
mesenteric cyst
– USG guided aspiration and antitubercular drugs to be given
Encysted (Loculated) peritoneal tuberculosis

30. – Widespread adhesions b/w coils of intestine (matted intestines),
abdominal wall, omentum
– Obstruction  Distension of abdomen
– Colicky abdominal pain (recurrent)
– Diarrhoea, loss of weight, Doughy abdomen
– Open/ laproscopic biopsy (to rule out peritoneal carcinomatosis)
– Anti-tubercular drugs
– Surgery to relieve obstruction by adhesolysis
Plastic Peritoneal Tuberculosis

31. – Direct spread from tuberculous salpingitis
– Mass per abdomen containing pus, omentum, fallopian
tubes, small and large bowel
– May cause umbilical discharge
– Genitourinary tuberculosis usually present
– Anti-tubercular drugs with exporation of umbilical
fistula
Purulent peritoneal tuberculosis

32. 3. Nodal/ Glandular tuberculosis
A. Calcified lesion
B. Acute Mesenteric lymphadenitis
C. Pseudo-mesenteric cyst
D. Tabes mesenterica
E. Chronic Lymphadenitis
• Complications
– Abscess formation

33. – Along the line of the mesentery a single or multiple
calcified lesions
– Payer’s patches involved
– No active infection
– May be on right or left side (R>L)
– Antitubercular drugs
Calcified lesion:

34. – Common in children
– Mimics acute appendicitis
– Tender mass of lymph node palpable in Right iliac
fossa which is non-mobile
– Intestines adherant to caseating lymph nodes
obstruction
– Surgery for appendicitis or obstruction with lymph
node biopsy
– Antitubercular drugs
Acute Mesenteric Lymphadenits

35. – Mimicking a mesenteric cyst
3. Tabes mesenterica
– Massive enlargement of mesenteric lymph
nodes due to tuberculosis
4. Chronic Lymphadenitis
– Children
– Failure to thrive
– Lymph node on deep palpation in right iliac fossa
PSEUDO-MESENTERIC CYST

36. 4. Solid visceral tuberculosis
Intraabdominal viscera:
 Liver‘
 Spleen
 Pancreas

37. • portal of entry :hematogenous dissemination
• miliary tuberculosis :hepatic artery (lesions are small 1 to
2 mm epitheloid granulomas)
• focal liver tuberculosis :portal vein.
HEPATIC TB

38. INVESTIGATIONS
– Percutaneous liver biopsy.
– laparoscopy liver biopsy- cheesy white irregular nodules.
– CT SCAN.

39. CT abdomen
– miliary micronodular with miliary calcifications
– Multiloculated cystic mass(cluster sign)

40. • It can occur due to disseminated or miliary form of the disease
• Most commonly encountered in HIV pt(developed countries)
• Fever, weight loss, diarrhea, left upper abdominal pain,
splenomegaly
• -Percutaneous needle biopsy is the gold standard for diagnosis.
• - CECT-abdomen-multiple hypo echoic foci(<2cm)
SPLEENIC TUBERCULOSIS

41. Gross pathology of resected spleen showing innumerable caseating granulomas consistent with splenic tuberculosis.
Mackowiak P A et al. Clin Infect Dis.2011;52:418-420
The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights
reserved. For Permissions, please e-mail: journals.permissions@oup.com.

42. Computed tomograph scan of the abdomen showing a spleen diffusely infiltrated by small, hypodense lesions
consistent with splenic granulomas.
Mackowiak P A et al. Clin Infect Dis.2011;52:418-420
The Author 2011. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights
reserved. For Permissions, please e-mail: journals.permissions@oup.com.

43. • It is rare
• Often associated with miliary TB & immunocompromised pt
• Result from lymphohaematogenous dissemimation after pulmonary
exposure
• Anorexia,malaise fever,weight loss
• Investication: FNAC & BIOPSY
PANCREATIC TB

44. A. Oesophageal (0.2% of abdominal)
B. Gastroduodenal(1%)
C. Retroperitoneal tuberculosis
5. Rare types

45. Esophageal Tuberculosis
• Extension from mediastinal lymph nodes or pulmonary.
• Ulceration, nodularity, stricture, sinus track formation, and fistulae
• Dysphagia, odynophagia, choking, and aspiration due to
tracheoesophageal or bronchoesophageal fistula and upper GI bleeding.
• CXR, CT scan, Barium swallow
• Upper GI Endoscopy with biopsy is the diagnostic procedure of choice.

46. PATHOPHYSIOLOGY
Tubercles undergo necrosis
Submucosal tubercles enlarge
Bacilli in depth of mucosal glands
Inflammatory reaction Phagocytes carry bacilli to Peyers Patches
Formation of tubercle

47. PATHOPHYSIOLOGY
Endarteritis & edema
Sloughing Ulcer formation
Accumulation of collagenous tissue
Thickening & Stenosis

48. PATHOPHYSIOLOGY
Lymphatic obstruction of
mesentery and bowel
 Thick fixed mass
Regional lymph nodes
• Hyperplasia
• Caseation necrosis
• Calcification
Inflammatory process in submucosa penetrates to serosa
Tubercles on serosal surface
Bacilli reach lymphatics
Bacilli via lymphatics

49. • Constitutional symptoms
– fever, night sweats, anorexia, weight loss, failure to thrive(in
children), malaise, anemia, lethargy, lassitude
– Observed in 30% patients
• Atypical symptoms
– Lower GI bleed, fistulas, PID like pain, dysphagia
• Pain (80%-95%)
– Colicky (luminal stenosis)
– Continous ( LN involvement)
CLINICAL MANIFESTATION

50. • Diarrhoea (11%-20%)
• Alternating constipation and diarrhoea
• Abdominal mass
– in right iliac fossa (35%)
– Hard, nodular, fixed, nontender
mass mimicing ca caecum
• Subacute intestinal obstruction (20%)
26

51. Diagnostic Findings
• No specific diagnostic blood tests available
• Common blood parameters:
– Elevated ESR
• Almost always raised but not exceed 60 mm/hr
– Mild anemia
– Mild leukocytosis
– Raised CRP
– Hypoproteinemia
– Hypoalbuminemia

52. Tuberculin skin test
A +ve tuberculin skin test has been reported in 55 to 100 % pts. with
abdominal tuberculosis. However in areas where TB is highly endemic
, +ve tst neither confirms the diagnosis of abdominal TB nor excludes
it
30

53. 33
– Thickened bowel wall
– Loculated ascites
– Interloop ascites-club sandwitch sign
– Mesenteric thickening hyperechoic >15mm
– Lymph node enlargement
– Pulled up caecum (Pseudokidney sign)
USG abdomen

54. COMPUTED TOMOGRAPHY
• Abdominal lymphadenopathy -commonest
manifestation
• Enlarged lymph nodes
–mesenteric,
–peri-portal,
–peri-pancreatic.

55. CECT
• Ascites can be free or loculated because of high protein
and cellular contents of the fluid.
• Mesenteric involvement and presence of
macronodules (> 5mm in diameter),
a thin omental line
peritoneal or extraperitoneal masses
 splenomegaly or splenic calcification

56. Barium study
• Pulled up caecum, conical caecum, pulled down hepatic flexure
– Obtuse ileocaecal angle; straightening (Goose neck)
– Steirlin sign: Hurrying of barium due to rapid flow and lack of barium in inflamed site
– Fleischner sign (Inverted umbrella sign): Narrow ileum with thickened ileocaecal valve
– Mega Ileum: Dilatation of proximal ileum

57. • Barium Study
showing Mega
Ileum

58. Endoscopy
 Colonoscopy is of value to rule out malignancy.
 It is easiest and most direct method in establishing the
diagnosis.
 Shows mucosal nodules or ulcers , deformed ileo-cecal
valve, mucosal oedema
 Biopsy can be taken to confirm diagnosis.
 Capsule endoscopy is also useful to see small intestine
pathology in difficult cases .
56

59. 60

60. 61

61. Tissue Biopsy
• Peritoneal tapping
• Endoscopic biopsy
• Laparoscopy
• Laparotomy
Histological
exam
Microbiological Smear
& culture

62. 1. Obstruction (20%)
2. Malabsoprption, blind loop syndrome
3. Dissemination of tuberculosis
4. Hemorrhage
5. Perforation
6. Fecal fistula
Complications

63. TREATMENT
THERE ARE TWO MODILATIES OF TREATMENT:
1. Medical treatment
2. Surgical treatment
70

64. Antituberculosis Drugs
Drug/Formulation Adult Dosage (Daily) Main Adverse Effects
First-Line Drugs
5 mg/kg (max 300 mg) PO, IM, IV
Hepatic toxicity,
peripheral neuropathyIsoniazid (INH)[*]
100, 300 mg tabs
50 mg/5 mL syrup
100 mg/mL injection
Rifampin (Rifadin, Rimactane)
10 mg/kg (max 600 mg) PO, IV Hepatic toxicity,
flulike syndrome,
pruritus150, 300 mg caps
600 mg injection
powder

65. 73
Pyrazinamide 500 mg tabs
20-25 mg/kg
PO
Arthralgias, hepatic
toxicity,
hyperuricemia,
gastrointestinal upset
Ethambutol[‡] (Myambutol) 100,
400 mg tabs
Streptomycin
1
5-25 mg/kg
PO
15mg/kg IM
Decreased red-green
color discrimination,
decreased visual acuity
Vestibular and auditory
toxicity, renal damage
Drug/formulation Dosage Adverse effect

66. Second-Line Drugs
Capreomycin (Capastat) 15 mg/kg IM (max 1 g) Auditory and vestibular
toxicity, renal damage
Kanamycin (Kantrex and others) 15 mg/kg IM, IV (max 1 g)
Amikacin (Amikin) 15 mg/kg IM, IV (max 1 g)
Auditory toxicity, renal
damage
Auditory toxicity, renal
damage
Cycloserine[¶] (Seromycin )
Ethionamide (Trecator-SC)
10-15 mg/kg in two doses
(max 500 mg bid) PO
15-20 mg/kg in two doses
(max 500 mg bid) PO
Ciprofloxacin (Cipro and others) 750-1500 mg PO, IV
Psychiatric symptoms,
seizures Gastrointestinal
and hepatic toxicity,
hypothyroidism
Nausea, abdominal pain,
restlessness, confusion
Ofloxacin (Floxin) 600-800 mg PO, IV
Nausea, abdominal pain,
restlessness, confusion75
Drug Dosage Adverse effect

67. 76
Levofloxacin (Levaquin) 500-1000 mg PO, IV Nausea, abdominal pain,
restlessness, confusion
Gatifloxacin[¶] (Tequin) 400 mg PO, IV
Nausea, abdominal pain,
restlessness, confusion
Moxifloxacin[¶¶] (Avelox)
Aminosalicylic acid (PAS; Paser)
400 mg PO, IV
8-12 g in 2-3 doses PO
Nausea, abdominal pain,
restlessness, confusion
Gastrointestinal
disturbance
Drug Dosage Adverse effect

68. Treatment categories according to DOTS strategy:
77
Category of
treatment
Type of patient Regimen
Category I
New sputum smear- positive
2(HRZE)3
4(HR)3
- sputum smear negative
- extra-pulmonary
Category II
- Relapse
- Failure
- Defaulters
2(HRZES)3
1(HRZE)3
5(HRE)3

69. –Indications:
• Intestinal obstruction
• Severe hemorrhage
• Acute abdomen (perforation)
• Intra-abdominal abscesses/ fistula formation
• Uncertain diagnosis
Surgical Management:

70. 1. Limited Ileocaecal resection with 5 cm margin
2. Stricturoplasty- single stricture
3. Single strictutre with friable bowel : Resection
4. Multiple Strictures: Resection and anastomosis
5. Multiple strictures with long segment gaps: Multiple
stricturiplasty
Surgical Management:

71. NURSING MANAGEMENT
1. Altered body temperature related to diseases process as evidenced by raised body
temperature .
2. Impaired gas exchange related to an imbalance in ventilation-perfusion ratio as
evidenced by Ascites, tachycardia and laboured breathing.
3. Acute Pain related to disease condition as evidenced by verbal reports of pain in the
abdominal region.
4. Fatigue related to anemia and advanced disease as evidenced by anemia and
physical complaints of tiredness.
5. Imbalanced nutrition less than body requirements related to disease condition as
evidenced by frequent nausea, vomiting and loss of appetite.

72. NURSING DIAGNOSIS
6. Self-care deficit related to surgical procedure secondary to increased work of breathing and
insufficient ventilation and oxygenation.
7. Electrolyte imbalance related to inadequate dietary intake and diarrhoea as evidenced by serum
electrolyte levels.
8. Altered bowel pattern related to low fiber diet and inactivity (as evidenced by infrequent, hard
stools; painful defecation; abdominal distention)
9. Impaired Skin Integrity related to surgical incision, Immobility, poor circulation, chronic disease state
as evidenced by redness.

73. Altered body temperature related to diseases process
as evidenced by raised body temperature
•Monitor vital signs
•Provide tepid water sponging to axilla, forehead and whole body
•Give oral liquid fluid
•Administer Antipyretics as per prescription.
•Remove unnecessary clothing
•Promote a well ventilated area to patient
•Promote adequate rest periods.

74. Impaired gas exchange related to an imbalance in ventilation-
perfusion ratio as evidenced by Ascites, tachycardia and
laboured breathing.
Nursing Interventions:
• Monitor vital signs
• Give Sem ifowler position.
• Administer oxygen therapy by nasal catheter 3 L/m.
• Continued with pulse oximeter and record patient’s ventilatory parameters.
•Reporting any changes.
•Assist for abdominal Paracentesis (if required)

75. Acute Pain related to disease condition as evidenced by
verbal reports of pain in the abdominal region
•Monitor vital sign (T,P,R, BP)
•Assess the level of pain
•Determining the client’s pain area, frequency and threshold.
•Perform physical examination to identify abdominal mass, nodules etc.
•Administering analgesics according to the prescription.

76. Fatigue related to anemia and advanced disease as evidenced
by anemia and physical complaints of tiredness
Nursing Interventions:
•Ensure that the client has adequate periods of rest.
•Monitoring sleep pattern.
•Guiding to avoid physical exertion.
• Administer prescribed BT.

77. Imbalanced nutrition less than body requirements related to
disease condition as evidenced by frequent nausea,
vomiting and loss of appetite.
Nursing Interventions:
•Monitor daily intake of prescribed diet and observe dietary acceptance.
•Ask for the food preferences.
•Prepare a diet plan a/c to that.
•Provide small, frequent and tolerating feed.
•Watch for occurrences of nausea and vomiting after feeding; medicating with
prescribed antiemetic.

78. References
Sharma R. Abdominal Tuberculosis. Imaging Science Today 2009: 146. Available from:
URL: http://www.imagingsciencetoday.com/node/146
Sood R, Sethu Madhavan M. Diagnostic approach to abdominal tuberculosis. In: Agarwal
AK, Jain DG, editors. Clinical Medicine: A Practical manual for students and
practitioners. India: Jaypee Brothers Medical Publishers (P) Ltd, 2007: 249
World Health Organization. Global tuberculosis report 2013. Geneva: WHO. 23 Oct
2013. Available from: URL: http://apps.who.int/iris/bitstream/10665/91355/1/
9789241564656_eng.pdf

79. THANK YOU