The document reviews the history and pathogenesis of gastrointestinal tuberculosis, describing how it has been recognized since ancient times. It examines the clinical manifestations and pathology of gastrointestinal tuberculosis across different organ systems. The conclusions emphasize that gastrointestinal tuberculosis remains an important public health issue that can mimic other diseases.
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Gi Tuberculosis Shokry Hunter
1.
2. INTRODUCTION
x Tuberculosis (T.B.) has existed from the
very dawn of civilization.
x Records of TB in mummies were found in
Egypt as far as 5000 years ago.
(Cave, 1935)
3. x Extrapulmonary tuberculosis was
also known since antiquity.
x Pott’s disease was described in
paints and statues of ancient
Egyptians.
(Ghalioungy, 1958)
4. GASTROINTESTINAL TUBERCULOSIS
Tuberculous enteritis as a complication of
pulmonary T.B. was appreciated by Hippocrates in
the 5th century B.C.
Diarrhea attacking a
person with phthisis is a
mortal symptom
(Walsh, 1909)
5. GASTROINTESTINAL TUBERCULOSIS
Ebn Sina
The Famous Arab Scientist (980-1037)
in his book “Al-Kanoun”
described tuberculosis (Al-Sol) in details.
He described
q Abdominal distention
q Diarrhea
q Borborygmi
In late stages of the disease.
(Hunter, 1999)
6. GASTROINTESTINAL TUBERCULOSIS
PATHOGENESIS
x Mycobacterium tuberculosis is the pathogen in
most cases.
x Mycobacterium bovis in some parts of the world
with no pasteurization of milk.
x Mycobacterium avium intracellulare has become a
major pathogen in HIV patients.
(Nial et al., 1997)
7. PATHOLOGY
Most active inflammation in submucosa.
Bacill in depth of mucosal glands
Inflammatory reaction
Phagocytes carry bacilli to Peyers Patches
Formation of tubercle
Tubercles undergo necrosis
Portis (1953)
9. PATHOLOGY
Inflammatory process in submucosa penetrates to serosa
Tubercles on serosal surface
Bacilli reach lymphatics
Bacilli via lymphatics
Lymphatic obstruction Regional lymph nodes
of mesentery and bowel • Hyperplasia
→ Thick fixed mass • Caseation necrosis
• Calcification
(Boyed, 1943)
10. FORMS OF GI TB
Ulceroconstrictive Hypertrophic
60% of patients 10% of patients
Highly virulent Chronic
Mostly small Intestinal Mostly Ileocoecal
Mixed 30% of patients
(Howell & Knapton, 1964)
12. T.B. stenotic surgical segment with involvement of
mesenteric fat
Makram Milad, Cairo University
T.B. transverse girdle ulcer small
intestine
Makram Milad, Cairo University
13. Pathology of the previous ulcer
Sub mucosal muscular and
subserous granulomas
Makram Milad, Cairo University
T.B. Lymphadenitis
Makram Milad, Cairo University
14. GASTROINTESTINAL TUBERCULOSIS POSES A
DIAGNOSTIC PROBLEM
x The disease is not common.
x Not familiar to clinicians.
x Involves inaccessible sites.
x May be associated with other serious disorders, the
manifestations of which obscure or modify those of
T.B.:
HIV, Chronic Renal Failure, Diabetes Mellitus,
Liver Cirrhosis, Neoplastic disease.
(Kramer et al., 1990)
15. The approach to the subject
was directed to these main points.
x Country and continent of origin.
x Age
x Gender
x Associated HIV infection
x Associated pulmonary disease
x Constitutional signs and symptoms
x Signs and symptoms related to the site of
involvement in the G.I. tract
16. To achieve this aim
The following was carried on
x Search on the Pubmed was done for all abstracts since
1965.
x Original articles tackling the subject and available in
Egyptian libraries were collected
x Abstracts and original articles that describe symptoms
and signs related to gastrointestinal tuberculosis were
selected.
x Abstracts and articles were classified according to
organ involvement in the gastrointestinal tract.
x Retrieved data were pooled, tabulated and statistically
analyzed.
17. Demonstration photos were kindly
provided by colleagues; staff members of
Faculty of Medicine, Cairo University
19. Distribution of gastrointestinal tuberculosis
r
d de
b la y
ll r
ga lia
o bi
ic
at
re
nc
pa r y
lia
bi
he
pa
to
cases (n=2204) by site
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ie
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rit
pe
39
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ta
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lo
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21
Site
n
lo
o co
ile e
tin
24
es
nt
li
al
sm
5
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ac
om
st
s
gu
ha
op
es
4
0
50
40
30
20
10
Percent
20. India
23.9% Malaysia
6.5%
S. Africa
11.6%
USA
8.5%
Saudi Arabia
Others 11.7%
37.8%
Distribution of gastrointestinal
tuberculosis cases by country
21. S. America
1.1%
Australia
5.0% Asia
Europe 57.0%
13.9%
Africa
23.0%
Distribution of gastrointestinal
tuberculosis cases by continent
22. Children
2.0%
Adults
98.0%
Distribution of gastrointestinal
tuberculosis cases by age group
23. Male
41.8%
Female
58.2%
Distribution of gastrointestinal
tuberculosis cases by sex
24. Present
55.9%
Absent
44.1%
Distribution of gastrointestinal tuberculosis
cases reporting associated HIV
25. 120%
100%
80%
60%
40%
20%
0%
ry
n
l
h
ry
us
ta
lo
ac
ilia
ilia
ec
g
co
om
ha
ob
or
ob
o
op
Ile
ol
St
at
tic
C
Es
p
a
He
re
nc
Pa
Distribution of gastrointestinal tuberculosis
cases reporting associated HIV by site
27. 120%
100%
80%
60%
40%
20%
0%
n
ry
l
h
um
ry
us
ta
lo
ac
ilia
ilia
ec
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co
ni
om
ha
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or
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St
at
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Pe
C
Es
p
a
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re
nc
Pa
Distribution of gastrointestinal tuberculosis
cases reporting associated pulmonary
tuberculosis by site
28. 0% 5% 10% 15% 20% 25% 30% 35% 40%
Fever 35.6%
Wt. loss 34.1%
Anorexia 35.0%
Night sweats 5.0%
Distribution of gastrointestinal tuberculosis cases
reporting for associated general manifestations
30. Esophageal Tuberculous Nodules
Abdel Magid Kasem
Cairo University
Caseating Granuloma of the esophagus
Makram Milad
Cairo University
31. 0% 10% 20% 30% 40% 50% 60%
Ulcer dyspepsia 52.4%
Outlet obstruction 26.2%
Mass 19.0%
Haematemesis 11.9%
Fistula 2.4%
Local manifestations of gastroduedenal
cases (n= 42)
32. Diffuse narrowing of the body of the stomach
Calcified Lymph node.
Ba. Meal
Yehia Aly
Cairo University
33. Tuberculous mass in the stomach
Abdel Magid Kasem
Cairo University
Mucosal T.B. granuloma of the stomach,
Endoscopic biopsy
Makram Milad
Cairo University
Duodenal T.B. ulceration with narrow lumen
Mazen Naga
Cairo, University
38. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45%
pain 39.1%
rectal bleeding 21.8%
mass 12.1%
distention 9.0%
Local manifestations of colorectal cases
(n= 463)
39. Colonic T.B. polypoid mass. Colonic T.B. polypoid mass.
Colonoscopy Colonoscopy
Mazen Naga, Cairo, University Hunter, Cairo, University
40. 0% 20% 40% 60% 80% 100%
ascitis 90.6%
pain 59.9%
mass 23.7%
lymphadenopathy 3.4%
jaundice 3.4%
distention 2.0%
diarrhoea 1.0%
Local manifestations of peritonitis cases
(n= 881)
41. Peritoneal T.B.
Laparoscopy
Hunter, Cairo University
T.B. peritonitis
granulomata with fibrosis in
the omentum
Makram Milad
42. T.B. Peritoneal adhesions
Peritoneal T.B with adhesions Ultrasonography
Laparoscopy Zakareya Salama
Hunter, Cairo, University Cairo University
Calcified T.B lymph nodes
C.T. scan
Yehia Ali, Cairo, University
43. 0% 20% 40% 60% 80% 100%
jaundice 94.4%
pain 64.8%
Local manifestations of hepatobiliary cases
(n= 71)
44. T.B. adhesion around the gall bladder T.B. Liver abscess
Laparoscopy, C.T. scan
Hunter, Cairo University Yehia Aly, Cairo University
Hilar stricture due to porta hepatis
lymphadenopathy
Waheed Doss, Cairo University
45. 0% 10% 20% 30% 40% 50% 60% 70%
Abd.pain 60.9%
jaundice 17.4%
Local manifestations of pancreaticobiliary cases
(n= 86)
46. Tuberculous distal common bile duct stricture
(Tuberculous Pancreatic Mass)
Waheed Doss, Cairo University
47. SUMMARY
x Most publications on GI tuberculosis were in
the last decade.
x The publications were mainly from Asia.
x In the Western hemisphere, the disease is
mainly in emigrants from endemic areas.
48. SUMMARY
x Adults represent the majority of G.I. T.B. cases.
x The disease is slightly more prevalent in
females.
x HIV infection is a main risk factor.
x Pulmonary T.B. is a frequent but not an
essential association.
49. SUMMARY
x Patients present with nonspecific constitutional symptoms,
pyrexia and weight loss are the most common.
x Local manifestations depend on the site of G.I. tract affection:
q The esophagus: Dysphagia, fistula and haematemesis.
q The stomach and duedenum: ulcer-dyspepsia, outlet
obstruction and abdominal mass.
q The intestine: pain, diarrhea, perforation & abdominal mass
q The colon: pain and rectal bleeding.
q The peritoneum: ascites and abdominal distension.
q Hepato-pancreaticobiliary: pain and jaundice.
50. Gastrointestinal T.B.
Differential Diagnosis
Gastrointestinal T.B. should be considered in the
differential diagnosis of :
x Chronic diarrhea
x Malabsorption syndrome
x Abdominal masses
x Ascitis
x Inflammatory bowel disease particularly Crohn’s
disease.
x Gastrointestinal lymphomas
x Other GIT malignancies.
51. CONCLUSION
x Since 1980s, a resurgence of tuberculosis has
occurred.
x The disease is still and will remain a serious
public health threat worldwide
x Still the great mimicker, gastro intestinal
tuberculosis.
(Jadvar, 1997)
52. Do not fear to repeat what has already been said.
Men need most things dinned into
their ears many times and from all sides
mak THE FI
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(Rene Laennec, 1781-1826)
53. G.I. TUBERCULOSIS, A FINAL WORD
Be aware
of Abdominal Tuberculosis
(Bouma et al., 1997)