Abdominal tuberculosis is most commonly seen in the ileocecal region due to factors like stasis and abundant lymphoid tissue. It typically presents with abdominal pain and a mass in the right lower quadrant. Diagnosis involves imaging studies like ultrasound and CT scan showing thickened bowel walls and enlarged lymph nodes. Confirmation is by biopsy and PCR analysis. Treatment involves anti-tubercular drugs for 6-9 months along with surgery for complications like obstruction or hemorrhage. Prognosis is generally good with medical management but depends on early diagnosis and treatment.

1. Dr. Minhajuddin Khurram
AL-AMEEN MEDICAL COLLEGE HOSPITAL,
bIJAPUR

2.  A common disease in India and other developing
countries
 It the 6th most common type of extra-pulmonary
tuberculosis
 40% of Indians harbour tb bacilli
 In 2010,
Global Incidence – 9.4million
In india – 2.3million
Prevalence in India is 3.1 million
3,20,000 deaths…
-WHO

4.  24th March 1882- World Tb day
 TB declared as notifiable disease by
INDIAN GOVERNMENT on may9th 2012

5. 1. Intestinal (Koenig’s syndrome)
A. Iliocaecal region
 Ulcerative -60%
 Hyperplastic-10%
 Mixed-30%
B. Ileal region
 Stricture type
2. Peritoneal tuberculosis
A. Acute
B. Chronic
 Ascitic
 Encysted
 Plastic
 Purulent

6. 3. Tuberculous mesenteric lymphadenitis
A. Calcified lesion
B. Acute Meseneteric lymphadenitis
C. Pseudo-mesenteric cyst
D. Tabes mesenterica
E. Chronic Lymphadenitis
4. Ano-recto-sigmoidal
5. Involvement of solid organs as a part
of milary tuberculosis
6. Involvement of omentum
7. Rare types
A. Oesophageal (0.2% of abdominal)
B. Gastroduodenal

7. 1. 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
2. Hematogenous spread from lungs
3. Through lymphatics (neck)
4. Fallopian tubes (retrograde spread)

10.  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

11. A. Ulcerative type (60%):
◦ Secondary to pulmonary tuberculosis
◦ Virulent organism
◦ Poor body resistance
◦ Multiple circumferential transverse ulcers (Girdle
ulcers) with skip leisons
◦ Commonly in ileum
◦ Rarely in caecum

12. ◦ Napkin ring strictures in longstanding ulcers
(common in ileum)
◦ 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

14. B. Hyperplastic Type -10%
◦ Primary GIT tuberculosis
◦ Less virulent organism
◦ Good body resistance
◦ 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)
◦ Caseation is very rare

15. B. Hyperplastic Type -10%
◦ No primary leision in the chest
◦ Complication: May cause sub-acute intestinal
obstruction due to mass

16.  Others
◦ Abdominal pain (90%)
 Colicky type in intestinal tuberculosis
 Dull aching in mesenteric lymphadenitis
◦ Mass in right iliac fossa (35%)
 Hard, nodular, fixed, nontender mass mimicing ca
caecum
◦ Subacute intestinal obstruction (20%)
◦ Can be associated with adenocarcinoma of caecum

17. 1. Ca Caecum
2. Ameboma
3. Appendicular mass
4. Lymph node mass
5. Psoas abscess
6. Crohn’s disease

18.  Chest Xray – for primary focus
 Blood investgations: Mantoux, ELISA, serum
IgG
 ESR- raised
 Plain Xray abdomen
◦ Intestinal obstruction
◦ Calcified lymph nodes
◦ Hollow viscus perforation
◦ Calcified Granuloma in liver

20.  USG abdomen
◦ Thickened bowel wall
◦ Loculated ascitis
◦ Interloop ascitis
◦ Mesenteric thickening
◦ Lymph node enlargement
◦ Pulled up caecum (Pseudokidney sign)

21.  Barium study Xray (barium enema or barium
follow through)
◦ Pulled up caecum
◦ 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
◦ Napkin leisons
◦ Chicken intestine: Hypersegmentation
◦ Mega Ileum: Dilatation of proximal ileum

24.  Barium
Study
showing
Mega Ileum

25.  Colonoscopy
◦ To rule out ca
◦ Shows mucosal nodules, ulcers, strictures,
deformed ileocaecal valve, mucosal oedema and
diffuse colitis
◦ Biopsy can be taken to eslablish the diagnosis

26.  CT Abdomen
◦ CT scan shows thickening
of the cecum with
pericecal inflammatory
changes. Mesenteric
lymph nodes are also
evident (arrows).

27.  Diagnostic laproscopy
◦ Direct visualization
◦ Collect acsitic fluid
◦ Take biopsy from mass, omentum or peritoneum

28.  PCR of tissue
 Acsitic tap fluid analysis
◦ Exudate fluid (protein >2.5gm%)
◦ Lymphocyte predominant cells >250 cu mm (upto
4000 cu mm)
◦ Glucose <30mg%
◦ Specefic gravity >1.016
◦ ADA (Adenosine deaminase activity) 95% specificity
and 98% sensitivity
◦ LDH > 90 units/litre

29. 1. Obstruction 20%
2. Malabsoprption, blind loop syndrome
3. Dissemination of tuberculosis
4. Cold abscess formation
5. Hemorrhage
6. Perforation
7. Fecal fistula

30.  Mediacal management:
◦ First line drugs:
 INH
 Rifampicin
 Pyrazinamide
 Ethambutol
◦ Second line drugs:
 Amikacin, kanamycin, PAS, Ciprofloxacin,
 Clarithrymycin, Azythromycin, Rifabutin
 Drug: RNTCP 2H3R3Z3 E3 + 4H3R3
◦ Treatment to be continued for 6-9 months
◦ Supportive nutrition

31.  Surgical Management:
◦ Indications:
 Intestinal obstruction
 Severe hemorrhage
 Acute abdomen (perforation)
 Intra-abdominal abscesses/ fistula formation
 Uncertain diagnosis

32.  Surgical Management:
1. 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

33.  Surgical Management:
6. Early perforation: resection and anastomosis (due
to friable bowels)
7. Perforation with severe contamination: resection
with colostomy
8. Adhesiolysis by laproscopy (Very difficult
procedure)
9. Drainage of abscesses and treatment for fistula in
ano

34.  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
 Resection and anastomosis with Anti-
tubercular drugs

35.  It is post primary
 Becoming more common
 Activation of long standing latent foci
 Blood spread
 Can develop from diseased mesenteric lymph
nodes, intestines or fallpian tubes

36.  Basic pathology
◦ Enormous thickening of the parietal peritoneum
◦ Multiple tiny yellowish tubercles
◦ Dense adhesions in peritoneum and omentum with
small intestines
◦ May precipitate obstruction
◦ Thickening of bowel wall

37.  Abdominal Cocoon Syndrome
◦ Dense adhesions in peritoneum and omentum with
contents inside as small bowel causing intestinal
obstruction

38. A. Acute –mimics acute abdomen
◦ Rare
◦ On-table diagnosis
◦ Features of peritonitis
◦ Due to perforation or rupture of mesenteric lyph nodes
◦ Exploratory laprotomy 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
◦ To be closed without drains

39. A. Chronic
◦ Presents as
 Abdominal pain
 Fever
 Ascites
 Loss of appetite and weight
 Abdominal mass
 Doughy abdomen (10%)
◦ Types
a) Ascitic form
b) Encysted form
c) Plastic form
d) Purulent form

40. a) Acsitic peritoneal tuberculosis:
◦ Intense exudate caused ascitis
◦ Common in children and young adults
◦ Enormous 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

41. a) Acsitic peritoneal tuberculosis:
◦ Doughy abdomen
◦ Shifting dullness
◦ Asitic tap reveals straw coloured fluid from which
AFB can be isolated (<3%)
◦ Anti-tubercular drugs for one year
◦ Repeated tapping may be required

42. b) Encysted (Loculated) peritoneal tuberculosis
◦ Exudation with minimal fibroblastic reaction
◦ Ascites gets loculated due to fibrinous deposition
◦ Non shifting Dullness is the typical feature
◦ May present as intra-abdominal mass mimicing
ovorain cyst, mesenteric cyst
◦ USG guided aspiration and antitubercular drugs to
be given

43. c) Plastic Peritoneal Tuberculosis
◦ Extensive fibroblastic reaction
◦ Widespread adhesions
◦ Between coils of intestine (matted intestines),
abdominal wall, omentum
◦ Obstruction  Distension of abdomen
◦ Colicky abdominal pain (recurrent)
◦ Diarrhoea, loss of weight, mass per abdomen
◦ Doughy abdomen

44. c) Plastic Peritoneal Tuberculosis
◦ Open or laproscopic biopsy (to rule out peritoneal
carcinomatosis)
◦ Anti-tubercular drugs
◦ Surgery to relieve obstruction by adhesolysis

45. d) Purulent peritoneal tuberculosis
◦ Direct spread from tuberculous salpingitis
◦ Mass per abdomen containing pus, omentum,
fallopian tubes, small and large bowel
◦ Cold abscess may get adherant to umbilicus
◦ May cause umbilical discharge
◦ Genitourinary tuberculosis usually present
◦ Aanti-tubercular drugs with exporation of
umbilical fistula

46. 1. Calcified lesion:
◦ 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

47. 2. Acute mesenteric lymphadenits
◦ Common in children
◦ Mimics acute appendicitis
◦ Tender mass of lymph node palpapble in Right
iliac fossa which are matted and non-mobile
◦ Intestines adherant to caseating lymph nodes
obstruction
◦ Surgery for appendicitis or obstruction with lymph
node biopsy
◦ Antitubercular drugs

48. 3. Pseudo-mesenteric cyst
◦ Caseating material collected between the layers of
mesentery
◦ Forms cold abscess
◦ Mimicking a mesenteric cyst
4. Tabes mesenterica
◦ Massive enlargement of mesenteric lymph nodes due
to tuberculosis
5. Chronic Lyphadenitis
◦ Children
◦ Failure to thrive
◦ Protuberant abdomen and emaciation
◦ Lymph node on deep palpation in right iliac fossa

49.  Mimics ca rectum
 Occurs within 10 cmof anal verge
 Presents with tenesmus, diarrhoea and multiple
discahrging fistula in ano
 Fistula is painless, not indurated with undermined
edges
 Shallow bluish ulcers with undermined edges
 Investigation:
◦ Sigmoidoscopy
◦ USG
◦ Discharge study
◦ fistulectomy and biopsy
 Treatment: Drugs, fistulectomy or sigmoid resection

50.  As a part of other abdominal tuberculosis
 Rolled up omentum
 Cold abscess in omentum
 Anti-tubercular drugs
 Syrgery for cold ascess

51.  As a part of other abdominal tuberculosis
 Rolled up omentum
 Cold abscess in omentum
 Anti-tubercular drugs
 Syrgery for cold ascess

52.  Age: 25 to 50 yrs
 Equal in both sexes
 Constitutional symptoms:
o Fever (50-70%)
o Anorexia (80%)
o Cachexia
o Diarrhoea (10-20%)
o Anemia