Date post: | 09-Aug-2015 |
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Health & Medicine |
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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
FOR YOUR KIND LISTENING
THANK YOU….
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