Definition & Description

m b . wberulotis o elajed sranitms

involvi GIT incudes hepabbikay
paneat
Ritone
AA LN

Abd T e
1/19

Etiopathogenesis & Spread

m. uberckosi
Rae bov
A
r e ce li a

Rare moS

Honogena Auoineium Died

( o eeA sp
o |coaitty TB

Sites o f involvement in GIT

intestinai TE:65%)

Peritoneai TB:B0%
Glanduiar/Nodai(S%)

2/19
 Q: Why ileocecal region is most commonly affected?

A: Multiple reasons proposed

Increased physiological stasis

Abundant lymphoid tissue

Increased rates of fluid and electrolyte absorption

Minimal digestive activity

3/19

Pathological Types of Intestinal TB

OLerahve
(60) Ulceo
Hyeplahc hypeplth
esp co
i n SAM
no
Clot 3o
4/19
 1. Uicerative type
Actve form characterized by b w e t inflammation and was fibrosis, with
Initiai Fesion: î f i t t r a t i o nofmucosa &
patches

Shalo eine.

Supe-fei
Siye[muip Nor
les Feansva¢el placoo oris inests

with progression of the disease->

nsive
uicers becomeconfiuent and fibrosis
h i s r e s u i t s in
Bowelthickening
Strictures) Na in Ring Cansickm
-Pseudotumour masslesio
Fistulae

dular tubercles bn maY aiso be seen

5/19

MCQ Point
Q: Bleeding is rare in intestinal TB despite ulcers. Why?

A: Because there is associatedendarteritiy. This produces ischemia

of the bowel and contributes to stricture formation. Hence thee

ulcers don't bleed easily.

6/19
 2. Hypertrophic type
Seen in wel-nourished children
Thickening of bowel walI, scarring, fibrosis
Rigid-mass like pseudotumoursmay occur

3. Ulcero-hypertrophic type
Seen mainly in ileocecal region and colon
Ulcers hypertrophic presentation
+

May have a lump in theRIF

7/19

Types of Peritoneal TB
1. Wet/Ascitic type: Most common

Ascites Staw toloe

1 masarca
+(Umb Heania)

2. Dry/Plastic/Fibrous type
Exenpve fonxk
odhui Prudotm/mes
3Encysted/Loculated typ
w e Re ihmea rB
Subhy e d
4. Puruient type: Very rare in children, usually associated with TB salpingitis
8/19
Clinical Features oAbd TB

Vaned Presentation Ferer, Amoverie, wt lons ITTbiby

.ConstitutionalFeatures Pore qain t ht

Lump in abdomen ((Macc) Anqushare, mosy

mosyRIF
Reriumbi lical.
SAIO s Subaue int obsh Ab pavmihing, Canthpaj,

.Chronicdiarrhea

.Abdominaldistension
9/19
oen au undecying asute

MCQ Point: Causes of mass in abdominal TB

Pseudotumour due to stricture formation
(
Hyperplastic intestinal TB

.Nodal TB
.Loculated ascites

Rolled-up omentum

Thickened bowei loops

10/19
 Non-specific investigations
Anemia

alerohjnn does n o t coruse

R a i s e d ESR Degve ot h inid sereif.
HVpoalbuminemia S.AL <2 -o) )
T L C raised i n 50%)

M a n t o u x +ve in 50%s

Plain X-ray Abdomen

- Enteroliths

C a l c i f i e d LNS o r granuiomas

- Dilated bowel loops with múltiple air-fluid Tevels

Suspeed Fbd TB
in a
CXR as e l l
s a e y s do
11/19

Barium Studies
Hypersegmented barium column(Chicken intestine)
mucosai folds
Noduiar thickening of
Hour giass stenosis or Napkin ring constriction
and wide gaping
Fleischner Sign/inverted Umbrella Sign: Thickening
leum
of iteocecai vàive with narrowed terminal

Goose neck deformity: Loss of ieocecal angie and a dilated termina

e m appearing suspended îrom a retracted, ioroSed cectun
Cpo

Persistent narrovwing of colon due to sterOsis

String sign of Kantor.

With rapd emptying into a

Stierin's Sign Narrowing of the termanal ileum
thotened,k.SEEI

12/19
 Ascitic Fluid
Examination(v imp) R
A p p e a r a n e : Straw co»ioured
A A G :1.
P r o t i n c o n t e t : M o r e tthan
C e l eeunt: 150-40O0/mmaJOKLympphoeytes
A F B p o s i t i v i t y i n ornly 3 %
Cuture +
n20 but takes 6-8 week:
ADA evels: High t o f f is 3 UU

N Rele Paae
IGRA/Quantiferon AASsaY
Also called Quanti fero-TB Gold Test
A n i n v i t r o b l o o d t e s t t o d e t e c t C e l l n e d i a t e d i m m u n e r e s p o n s e t o TB.
baciHus

HiRhiy sensitive and specific

But can't distinguish betweenactive a n d 1 a t e n t TB

Nelson 21st E says...

T w o ciear advantages of the iGRAs a r e the need for aniy o n e .

p a t i e n t e n c o u n t e r ( v s t w o w i t h TST e . g - M a n t o u x ) a n d t h e l a c k o f
SsS-re ction with BCG vaccination and most other
13/19 y c o b a c t e r i a , t h e r e D y i n c r e a s i n g t e s t s p e c i ficity forTBI)

Newer Tests Cupbrtive

ELISPOT: An a s s a y t o d e t e c t T cells specific àgainst M tuberculosiss

NAAT= Nucieic Acid Amplification Tests

1 . PCR f o r TB

2 . G e n e Xpert MTB/RIF: A real-time PCR that also detects rifampicin

resistance in MOR TB(Expensive.

USG Abdomen
Ascites

Cliat-Sand wich S i g n / i v e r t e d Bread Sign: Fluid b e t w e e n t h e radialty

oriented bowel ioops

Pseudo-kidney sign: invoivement of the ileo c e a i region, which is pulled u p

L aSub-hepati pOSition

Mesenteric, Para aortic and para caval LNs may be eniarged and caicified

M a y s h o w mixeed h e t e r o g e n o u s echotextLure.

S m a l l a n s s h a i s a e g are highiy suggestive of caseous necrosis

14/19
 CTAbdomen
- Can detect bowel wall thickening. adherent loops, ulceration and

nodularity
Eniaged, Caseating LNs can be visualized- show hyp er
sEripheral ring enhancemen
- Calcification of LNs can also b e s e e n
- Retroperitoneal LN involvement is very rare as isolated finding
- CT can also detect complications like perforation
Mesemteric involvement can give a stellate a p p e a r a n c e

GIT EndoscOpy
Enteroscopy and Wireless capsuie Endoscopyare newer
modalities used in aduits and beine tried in children for small
b o w e l TB

colonoscopy can be done for colonic and terminal iteal TB. Shows
mucosaT ulcers and nodulessBiopsies can be taken from t h e - a
of the uicer
Coceou n2sot& macn
ophe
BioPY Cranulemaes inftamn E ebitneleid

15/19

USG/CT guided FNAC of abdominal mass can be performeed

Liver biopsy can be done for suspected iver tubercles

Laparoscopy in peritoneal TB
Thickened peritoneum with/without tubercles
Fibro-adhesive peritonitis

Laparotomy doneoniy in exceptional, diagnostic dilemma cases

16/19
 RNTCP - 1AP 2019

amhs (HRZE
m (HRE
17/19

Surgery in Pediatric Abdominal TB

indications
Bowel obstructiondue to strictures

B o e l per foration

- Massive hemorrhage

mcisiam- longi hutinnt f / 6 E u h placeo

Surgery inPediatric Abdominal TB vseler
Ophms Singe shrea
Leanrar
Stricturoplasty) muipe Sof
Resection of the segment
mie
muuipe shi s cAus led
in shra<s

Management of perforationn
Hufue
Rea keawe 9 do anathmosi'e d4
18/19
nemeini heiho get gra+

Additional Points
Tbrotic encapsulation of the boauelcansometimes lead to intestinal
obstruction, called asAbdominal Cocoon Syndrome - Adolescert
Can be seen in Abdominal TB, SLE, Le Veen Shunt for Ascites.CAPDAdrenergic
agents ike Practolol and use of povidone- iodine for abdominal wash-out
Cowenanas
Hyperplastic TB on
palpation may producej A doughy feel RtDi
TB can cause secondary malabsorption
-fore h Hidih,
east
L e a s t common site for abdominal TB: Esophagus (0.2% - Deroid ot
umphoid iskiue
Stomach TB is aiso uncommon. Covtens do no
sy far loy
19/19