tuberculosis of git
Post on 07-May-2015
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Tuberculosis of GITDr Parvathy S Nair
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
• Mycobacterium avium intracellulare has become a major pathogen in HIV patients.
Etiopathogenesis
• Mechanisms by which M. tuberculosis reach the GIT:
– Hematogenous spread from primary lung focus
– Ingestion of bacilli in sputum from active pulmonary 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
Pathology
• (A) Ulcerative form: Ulcers wit their long axis perpendicular to the axis of the intestines; with pseudopolyps
• (B) Hypertrophic form: Thickeningof bowel wall
• (C) Mixed type
Distribution of tuberculous lesions
Ileum > caecum > ascending colon > jejunum
>appendix > sigmoid > rectum > duodenum
> stomach > oesophagus
• More than one site may be involved
Illeoceacal TB (80-90%)PLAIN XRAY• Enteroliths with features of obstruction• Small or large lamellated stones
BARIUM ENEMA• Irregular thickened nodular folds in the
terminal illeum• ‘Stierlin sign’: on Ba enema -rapid emptying of
narrowed terminal illeum into the cecum which is shortened and rigid
• Thickened illeoceacal valve
• ‘Fleischner sign’: Inverted umbrella defect:- wide gaping patulous IC valve associated with narrowing of the immediately adjacent terminal illeum
• Deep fissures and large shallow linear/stellate ulcers with elevated margins
• Sinus tracts and fistulas• Symmetric annular ‘napkin ring ‘ stenosis
Enema shows wide gaping of ileocecal valve with thickening of valve
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.
CT• 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
USG
• Thickening of IC valve and adjacent medial wall of cecum- asymmetrically thickened.
• Crohn’s – Eccentric thickening in mesenteric border.
• Carcinoma- Variegated appearance.
• Pseudokidney mass.
• Advanced cases – Complex mass - wall thickening, adherent loops, regional nodes, mesenteric thickening.
Colonic TB (9%)
• Segmental colonic involvement-rt sided• Imaging:–Rigid,contracted cone shaped ceacum– Spiculations with wall thickening–Diffuse ulcerative colitis and pseudopolyps– Short hour glass strictures–Ulcer- Circumferential in TB, along the
mesenteric border in Crohn’s.
Gastroduodenal TB (1%)
• Simultaneous involvement of antrum,pylorus and duodenum
• Imaging:-– Stenotic pylorus with GOO– Narrowed antrum –linitis plastica appaearance– Antral sinus tracts/fistula– Multiple, large and deep ulcerations on the lesser
curvature – Thickened duodenal folds wit irregular contour
TB of esophagus(0.2%)
• More assc with HIV• Deep ulceration-mid esophageal• Strictures• Intramural dissection/fistula formation
Peritoneal tuberculosis occurs in 3 forms.
• Wet type – 90 %. - Ascitis, free or encysted fluid
High density 25-45HU.- Cellular / fibrin content.
• Fibrotic fixed type – Mescentric and omental thickening, matted lymph nodes with occasional fluid.
• Dry or plastic type – Caseous nodules, fibrotic peritoneal reflections.
Imaging• Omental cake.
- Irregular thickened outer contour- Malignancy. -Thin omental line, fibrous wall –TB - Extra peritoneal spread-TB
• Mesentery- Stellate sign- Mesentric contraction results in fixed loops of bowel and mesentery standing out as spokes from the root.
• Club sandwich sign – localised ascites in between the radially oriented bowel loops.
Omental cake and ascites
THANKYOU
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