abdominal tuberculosis

2. INTRODUCTION
• Declared as a global emergency by the WHO
• Most common communicable disease in the developing
countries like India.
• It accounts for 3 million deaths every year
• Accounts for 12% of extrapulmonary tuberculosis

3. Causative organism
 Mycobacterium tuberculosis in immunocompetant
individuals
 Mycobacterium bovis
 Atypical mycobacteria ( Mycobacterium avium
intercellulare) in immunosuppressed individuals

4.  Tuberculosis has a varied spectrum of presentation
 Hence it is a great mimicker of neoplastic diseases like
lymphoma and inflammatory diseases like ulcerative
colitis and crohn’s disease.

5. ORGANS INVOLVED
GASTROINTESTINAL TRACT
PERITONEUM
LYMPH NODES
LIVER
SPLEEN
PANCREAS

6. GASTROINTESTINAL TUBERCULOSIS
 Tuberculosis of the GIT is the sixth most common
site of extrapulmonary tuberculosis.
 It is a common form of abdominal tuberculosis.
 Accounts for up to 90% of patients with abdominal
tuberculosis.
 Most common site – terminal ileum & ileocaecal region .
 Rarely found in stomach, duodenum & esophagus.
 Patients with gastrointestinal tuberculosis present
with diarrhea, abdominal pain and distension, anorexia,
wt. loss.

7. The most frequent region of involvement in descending order
of frequency
 Ileocecal junction
 Ileum
 Cecum,
 Ascending colon,
 Jejunum
 Rest of the colon, rectum,
 Duodenum and stomach.

8. COMPLICATIONS :
 Obstruction,
 Perforation,
 Perianal fistula,
 Enterolithiasis formation proximal to the stricture,
 Hemorrhage.

9. MORPHOLOGICAL TYPES
 ULCERATIVE
 HYPERTROPHIC
 STRICTUROUS
 A combination of these types can also occur.

10. site Type Clinical features
Small intestine Ulcerative Diarrhoea,
malabsorption
Stricturous obstruction
Large intestine Ulcerative Rectal bleeding
Hypertrophic Lump, obstruction
Peritoneum Ascitis
Adhesive
Pain, distension
obstruction
Lymph node Lump, obstruction

11. IMAGING IN GASTROINTESTINAL
TUBERCULOSIS
 Plain Xray
 Barium study (for demonstration of mucosal details)
 Enteroclysis
 Ultrasonography
 CT
 MRI
 Small bowel enteroscopy
 Capsule endoscopy

12. Oesophageal tuberculosis
• Very rare
• Usually secondary to advanced pulmonary or mediastinal
disease
• Primary disease involves most commonly the tracheal
bifurcation
 Spread : From tubercular laryngitis,
Adjacent caseating lymph nodes,
Vertebral body,
Lymphatics and
Hematogeneous route

13.  Patients usually presents with dysphagia, odynophagia,
chest pain or cough.
• Barium studies shows extrinsic compression by enlarged
lymph nodes , smooth strictures, ulceration, mucosal
irregularity & traction diverticulum.
 Sinus tracts and fistulous communication may develop with
the mediastinum or tracheobronchial tree.
• CT is more reliable
• In HIV patients it manifests as deep ulceration, transmural
inflammation with fistula & sinus formation .

14. Barium Swallow- esophageal stricture with ulceration and
periesophageal leak - Tubercular

15. CT Concentric mural, esophageal wall thickening with
periesophageal leak with mediastinal adenopalthy

16. GASTRIC TUBERCULOSIS
• SYMPTOMS : Epigastric discomfort, vomiting, weight
loss , fever & haemorrhage
• Palpable lump may be present
• Pathological types:
1. Ulcerative (commonest)
2. Hypertrophic
3. Miliary tubercles
4. Tubercular pyloric stenosis
5. Solitary tuberculoma
6. Tubercular lymphadenitis

17. GASTRIC TUBERCULOSIS
 Charecterised by multiple large & deep ulcers mostly involving the lesser
curvature of the antrum or pyloric region. Scarring may lead to stricture of
the antrum & causing gastric outlet obstruction.

18. DUODENAL TUBERCULOSIS
• Intrinsic involvement may be ulcerative or hyperplastic
lesions.
• Incompetance of sphincter of oddi leads to reflux of air
into biliary tract
• Barium study shows lymphadenopathy leading on to
widening or impressions on the medial aspect of C loop
• Healing causes contraction & stenosis leading to duodenal
obstruction

19. LONG STRICTURE OF DUODENUM CAUSED BY TUBERCULOSIS
 Can present as diffuse mucosal fold thickening, ulcers or stricture formation
& is complicated by fistula formation

20. Ba MUGIT in a case of duodenal tuberculosis with both extrinsic and
intrinsic involvement

21. TUBERCULOUS ENTERITIS
Most common cause of small bowel obstruction in India
Ulcerative type is the most common form .
Ulcers are stellate or linear shape
Stellate ulcers are characterised by barium speck with
converging folds.
Linear ulcers are perpendicular to long axis resulting in
spasm & strictures.

22.  Hypertrophic form is less common
 Bowel loops are matted & fixed by adhesion & fibrosis.
 Small bowel enteroclysis provides better mucosal details
 Early & incomplete strictures can be detected as
evidenced by prestenotic dilatation

23. Imaging in pathological state of disease
First stage:
Superficial invasion of the mucosa
Imaging reveals:
• An accelerated transit time.
• Disturbances in tone & peristaltic contractions results in
hypersegmentation of barium column called as ‘chicken
intestine’
• Disturbances in secretion, results in precipitation, flocculation
or dilution of barium.
• Changes in intestinal contour are irregular & crenated
• Changes in mucosal pattern is seen as softened & thickened
folds.

24. Ba MFT: Accelerated transit time is seen with barium reaching large bowel in
Ist film

25. Ba MFT. Early TB with mucosal irregularity and spiculation

26. • Second stage :
Comprise of ulcerations seen as a barium fleck surrounded
by either a thickened wall or converging walls.
• Third stage:
Has sclerosis, hypertrophy & stenosis.
Leads to ‘hour glass stenosis’ with smooth but stiff contours.
Mucosal relief will disappear.
Multiple strictures with segmental dilatation can occur .

27. PLAIN X RAY ABDOMEN (SUPINE) SHOWS MULTIPLE AIR FLUID
LEVELS IN A PATIENT WITH ACUTE TUBERCULAR PERITONITIS

28. BaMFT - Fixed matted and dilated small bowel loops with mucosal
thickening

29. ILEOCAECAL TUBERCULOSIS

30. Ileocaecal region is most commonly affected
in small bowel TB .
Why?
1) Physiological stasis,
2) Abundant lymphoid tissue (payers patch),
3) Increased rate of absorption in the region
4) close contact of the bacilli with the mucosa.

31. The lesion may be:
i. Hyperplastic with long segments of narrowing,
rigidity and loss of distensibility, i.e., the 'pipe
stem colon', commonest,
ii. Ulcerative
iii. Ulcerohyperplastic, and
iv. Carcinoma type with a short annular defect and
overhanging edges.

32. Early stages of ileocaecal TB manifest as spasm
and hypermotility with edema of the valve.
Radiological features:
Thickening of the ileocaecal valve lips,
Wide gaping of the valve,
Narrowing of the terminal ileum ('Fleischner or inverted
umbrella' sign).

33. Fleischner or inverted umbrella sign
 Wide gaping of the ileocaecal valve & narrowing of the terminal
ileum

34. Ba MFT - Thickening of ileocecal valve with narrowing of terminal ileum
FLEISCHNER SIGN

35. CT - narrowing of terminal ileum with thickening in region of I.C Valve

36. Double contrast barium enema may show shallow
ulcers that are linear or stellate with characteristic
elevated margins
Advanced disease shows
 symmetric,annular, napkin ring stenoses.
 obstruction or shortening,
 retraction & pouch formation
 Caecum classically becomes conical, shrunken
and retracted out of the iliac fossa due to
contraction of the mesocolon and appears
amputated.

37. Hepatic flexure may also be pulled down.
Loss of the normal ileocecal angle,
Dilated terminal ileum may appear suspended
and hanging from a retracted, shortened cecum
(goose neck deformity)

38. BARIUM STUDIES
• Demonstrate multiple
strictures
• Distended caecum or
terminal ileum
• Mucosal irregularity
• Flocculation &
fragmentation of barium

39. AMPUTATED CAECUM WITH STRING SIGN

40. BaMFT-Retracted and contracted caecum with terminal ileum appearing
suspended with loss of I-C angle.
GOOSE NECK DEFORMITY

41. STERLING SIGN
Narrowed terminal ileum with rapid emptying of the diseased
segment through a gaping ileocaecal valve into a shortened,
rigid obliterated caecum.
STRING SIGN
A persistent narrow stream of barium in the bowel indicates
stenosis.
Both Stierlin's sign and string sign are also noted in Crohn's
disease and cannot be considered specific for tuberculosis.

42. BaMFT : Persistent narrow stream of barium in bowel indicating stenosis
String sign :

43. BaMFT - Advanced IC Koch's with symmetric annular napkin ring stenosis with
conical shrunken and caecum

44. Multiple stenotic segments of the colon in double
contrast barium enema with colonic fistula

45. Ultrasonography
 Dilated small bowel loops & bowel wall thickening
 Non-specific bowel wall thickening with a hypoechoic
halo of >5mm

46. •Circumferential thickening of the terminal ileum and caecum
( Club sign).
Pseudokidney sign – TB involvement of the ileocaecal region
which is pulled up to a subhepatic position

47. USG-Retracted and pulled up caecum wall with thickening in the subhepatic
region

48. CT in gatrointestinal TB
• Bowel wall thickening is a
non specific manifestation
• Mural thickening affecting
the ileocaecal junction is
the most common finding
• Caecal involvement is
concentric ;may be
eccentric involving medial
caecal wall.

49. TUBERCULOSIS CROHN’S DISEASE
Asymmetric and irregular wall thickening ; Circumferential bowel wall thickening ;
ulceration on mesentric surface
Fleischner sign on barium Cobble stone appearance on barium
No creeping fat Creeping fat (abnormal quantity of mesentric
fat) present
Positive chest film Negative chest film
Omental & peritoneal thickening Normal omentum & peritoneum
Enlarged lymph nodes with low density centres Enlarged soft tissue density lymphnodes

50. Cobblestone appearance

51. APPENDICEAL TB
 Isolated appendicular involvement is rare
CHRONIC APPENDICITIS
 Due to intrinsic disease of appendix
 Involvement by surrounding lymphnodes
 Occlusion of lumen by a caecal mass

52. ANORECTAL TUBERCULOSIS
 May rarely present as ulcerating proctitis.
 Fistulas , strictures & chronic ischiorectal abscess may
occur.
 DD: LGV,
Amoebiasis,
Actinomycosis &
Schistosomiasis

53. TUBERCULOUS PERITONITIS
 Peritoneum and its reflections are common sites of
tuberculous involvement of the abdomen.
 Most cases are as a result of reactivation of latent
tuberculous foci in the peritoneum or due to tubercular
salpingitis or discharge of caseous material from diseased
lymph nodes.
 Mode of spread:
 Haematogenous spread
 Secondary to lymph node rupture
 Perforated gastrointestinal tract
 Perforated fallopian tubes

54. Three forms of tuberculous peritonitis
 i. Wet ascitic type-seen in 90% cases characterized by
large amounts of free or loculated ascitic fluid.
 ii. Fibrotic fixed type-characterized by mesenteric and
omental thickening and masses, matted bowel loops
and occasionally loculated ascitis.
 iii. Dry or 'plastic' type-unusual caseous nodules,
fibrous peritoneal reaction and dense adhesions

55. USG: Voluminous free fluid with floating bowel loops in a case of peritoneal TB

56. USG. Complex ascitis with loculations and septae seen in perihepatic pouch

57. On CT,
High density (25-45 HU) of fluid due to high fibrin content and cellular debris is
characteristic of TB.
In earlier transudative stage of immune reaction the ascitis may be near water
density.
Fat fluid level, a feature of chylous ascitis with supportive evidence of mesenteric
adenopathy has been described in tuberculosis.
CT fails to show multiple, thin interlacing septa in most patients, especially in sub
diaphragmatic and pelvic regions.

58. CT: Ascitis with omental thickening and spread out bowel loops

59. Barium Meal FT-Mildly dilated small bowel loops with increased interloop
distance in tubercular peritonitis

60. TB peritonitis Vs carcinomatosis
Smooth peritoneum with minimal
thickening and marked enhancement
Nodular and irregular peritoneal
thickening

61. Abdominal cocoon -sclerosing encapsulating peritonitis
CT showing small bowel loops congregated at the centre of the
abdomen encased by a sac like soft tissue density mantle

62. OMENTUM
• Omental thickening is present in both tuberculosis &
peritoneal carcinomatosis,
Nodular,
Smudged (Infiltration with ill-defined lesions)
Caked appearance (Soft tissue replacement).
• The smudged type is the most common type
• Nodular type is not seen in tuberculosis
• Omental caking is seen in both

63. USG -smooth omental thickening and ascitis

64. Mesenteric tuberculosis
• Micro (<5mm) or macro (>5mm) mesentric nodules are
present
• Mesentric thickening of >15mm is found abnormal
• Thickening is a result of lymphadenopathy , fat
deposition & edema due to lymphatic obstruction that
makes it more echogenic on USG.

65. Arbitrary value of 15 mm is considered as a threshold for disease.
Mesentery becomes echogenic as a result of increased fat
deposition due to lymphatic obstruction.
Presence of enlarged lymph nodes adds to the diagnosis of early
tuberculosis.
Other conditions like portal hypertension and lymphoma can also
give rise to mesenteric thickening.
Fixed loops of bowel and mesentery standing out as spokes
radiating out from the mesenteric root are described as US 'stellate'
sign.
CT demonstrates thickened mesentery by its increased vascularity
and thickened strands, tethering of bowel loops, forming an
abdominal mass.

66. USG-echogenic and thickened mesentry

67. CT-Ascitis with omental thickening

68. Club sandwich sign or sliced bread appearance
 Localised or focal ascites between radially oriented bowel
loops as a result of local exudation from inflamed bowel
loops or ruptured lymph nodes.
USG- Mesenteric thickening seen between loops-
"club sandwich"appearance

69. Nodal Involvement
• Mesentric or retroperitoneal involvement
• With or without calcification or caesation.
• Nodes involved are mesentric, peri pancreatic periportal or
para-aortic groups of lymph nodes.
• Reflects the lymphatic drainage of sites in the small bowel
and liver that are seeded haematogenously.

70. Plain x ray
 Erect & supine films
 Calcification of the nodes

71. Ultrasonography
Multiple hypoechoic enlarged discrete nodes in periportal and
peripancreatic region

72. USG-Multiple enlarged hypoechoic mesenteric nodes,
with foci of calcification

73. CT OF NODES
• Most common
manifestation on CT
• Contrast enhancement
patterns
1. Peripheral rim
enhancement
2. Non-homogenous
enhancement
3. Homogenous
enhancement
4. Non-enhancement

74. CT scan at the level of
porta showing
multiple
hypodense nodes
showing peripheral
rim enhancement in
tuberculous
lymphadenitis.

75. CT- Large
conglomerate
hypodense nodal
mass in periportal
and peripancreatic
region

76. Peripheral rim enhancement is highly suggestive of
tuberculosis
 Differential diagnosis:
Malignant adenopathy
Metastases from testicular tumours
Whipples disease
Lymphoma after radiotherapy

77. Non contrast axial CT shows lymphadenopathy
with central caeseus necrosis

78. TUBERCULOSIS LYMPHOMA
Distribution-
Mesenteric,lesser omental,anterior
pararenal or upper para-aortic nodes.
Predominantly lower para-aortic,
retrocural nodes.
.
Enhancement pattern-
Peripheral and multiloculated Homogenous enhancement
Others finding.
Mesenteric thickening,
I-C region and ascites present.
Absent

79. HEPATOSPLENIC TUBERCULOSIS
 Part of disseminated or miliary tuberculosis
 Appear as tiny low density masses scattered throughout
the organ on CT

80. AXIAL CONTRAST ENHANCED CT SHOWS MULTIPLE NON-
UNIFORM LOW ATTENUATION LESIONS WITHIN THE LIVER WITH
AN ENLARGED GASTROHEPATIC LYMPH NODE

81. MICROMILIARY HEPATOSPLENIC TB

82. MACRONODULAR TUBERCULOSIS
 Macronodular form is an
uncommon manifestation
 It appears as multiple low
attenuation (15-50HU) 1-3
cm round lesions or simple
tumour like lesions.

83. MRI
 Coronal T1 weighted
image shows hypointense
masses within the liver.
 May show peripheral
enhancement with honey
combing appearance

84. MRI
• Coronal T1 weighted
image shows peripheral
rim enhancement with
Honey comb appearance
within the mass
Diagnosis of tuberculosis
was confirmed on USG
guided biopsy

85.  Coronal T2 weighted image shows hyperintense lesion
with perihepatic fluid collection

86. PANCREATIC TUBERCULOSIS
• May present as pancreatitis
• Usually localised to head but can also involve body & tail
• USG may show well defined hypoechoic areas
• CT may show hypodense necrotic lesions within the
enlarged pancreas
• Peripancreatic nodes are involved
• Calcifications can be present

87. PANCREATIC TUBERCULOSIS

88. HIV & TUBERCULOSIS
• Extrapulmonary dissemination with atypical presentations
are common
• Infection is commonly by atypical mycobacteria MAC
• In 25% of cases , large nodes with low attenuation with no
peripheral enhancement is seen
• Large bulky retroperitoneal or mesentric lymphadenopathy
can occur simulating lymphoma or kaposi’s sarcoma

89. • Hepatosplenic involvement is more frequent
• Also causes hepatosplenomegaly in 15% of the cases
• MAC produces intrahepatic & extrahepatic stenosis &
dilatation leading to cholangitis
• Ileocaecal involvement is same as non- HIV patients

90. EDEMATOUS JEJUNAL LOOPS WITH EXTENSIVE
LYMPHADENOPATHY IN A HIV/AIDS PATIENT

91. ASCITES WITH MARKED OMENTAL THICKENING ON BOTH FLANKS
WITH MESENTRIC STRANDING IN A HIV PATIENT

92. ORGANS NOT AFFECTED BY
TUBERCULOSIS????

93. A high degree of clinical suspicion & familiarity with
various radiological manifestations of the disease allow
early diagnosis & timely initiatiation of appropriate
therapy
to reduce patient mortality & morbidity

95. `