Intestinal Tuberculosis

Second Affiliated hospitalYan Chen

Second Affiliated hospitalYan Chen

Intestinal tuberculosis

General situation

Etiology and pathogenesis

Pathology

Clinical manifestation

lab & other examination

Diagnosis and differential diagnosis

Treatment , prognosis and prevention

General ideasDeveloping countries (95%), especially poverty,

malnutrition, overcrowding and HIV coinfection.

Involvement of intestine is usually secondary to pulmonary tuberculosis.

The ileocecal region is the most common area of involvement in the intestinal tract .

Why ?

The abundance of

lymphoid tissue Long residence time

of bactera in ileocucum

The ileocecal region is the most common area of involvement in the intestinal tract .

Why ?

The abundance of

lymphoid tissue Long residence time

of bactera in ileocucum

Predisposing factors

Fatigue

poor sanitation

malnutrition

lowered resistance etc.

Pathogenic organism----tubercle bacillus

tubercle bacillus maybe either the human type or bovine type

human type----90%

bovine type----10%

Etiology and pathogenesis

Route of transmission

Propagation by mouth:

Hemotogenous dissemination: miliary TB

Spread straightly:

Bacilium: number, virulence

Decreased immunity of human

Weakening of intestinal resistance

Etiology and pathogenesis Etiology and pathogenesis

Caseation

Langhan’s giant cells

Clinical manifestation Systemic symptoms

● Fatigue

● low-grade fever

● Night sweats

● Loss of weight

● poor appetite

● anemia

Local symptoms

● abdominal distension

● ascites

● mass

● abdominal pain

● diarrhea & constipation

● complication

Local symptoms

● abdominal distension

● ascites

● mass

● abdominal pain

● diarrhea & constipation

● complication

Extraintestinal tuberculosis manifestation : pulmanory TBExtraintestinal tuberculosis manifestation : pulmanory TB

Cachexia

laboratory findingslaboratory findings

erythrocyte sedimentation rate, ESR

● ESR typically elevated in the active stage

● Stool routine test : occult blood

laboratory findingslaboratory findings

PPD test

purified protein derivative

tuberculin skin test

culture or histological examination of specimen

biopsy-microscopic tissue exam revealed tubercular histological feature of TB

PPD test

purified protein derivative

tuberculin skin test

culture or histological examination of specimen

biopsy-microscopic tissue exam revealed tubercular histological feature of TB

Straight arrow show Conical and shrunken cecum;curved arrow show the narrowing of the terminal ileum

RadiographyRadiography In advanced cases, symmetric annular stenosis

and obstruction associated with shortening, retraction, and pouch formation may be seen. The cecum becomes conical, shrunken, and retracted out of the iliac fossa due to fibrosis within the mesocolon, Ileocecal valve becomes fixed, irregular, gaping, and incompeten

In advanced cases, symmetric annular stenosis and obstruction associated with shortening, retraction, and pouch formation may be seen. The cecum becomes conical, shrunken, and retracted out of the iliac fossa due to fibrosis within the mesocolon, Ileocecal valve becomes fixed, irregular, gaping, and incompeten

TB

Colonoscopy

    Colonoscopy

Ulceration

TB

TB

Imaging featuresUltrasonography, CT, MRI

Asymmetric bowel wall thickening

Ascites

Inflammatory mass of bowel wall

Narrowing of the terminal ileum with thickening and gaping of the iliocaecal valve

Fluid surrounding bowel caused by inflammation of the bowel wall

Other examinationsLaparoscopic biopsy of tubercles found in

the peritoneum or other parts

Laparotomy

Capsule endoscopy

enteroscopy

Diagnosis & differential diagnosis

Younger patients presented with extraintestinal TB

Symptom: toxic symptom

diarrhea, abdominal pain, abdominal mass

X-ray: sterlin sign, stricture of bowel, deformation

Colonoscopy and biopsy: inflammation,ulcer,polyp,striction

caseating granuloma, bacterium(+)

PPD test :strongly positive

Exploratory laparotomy for patients difficult to be diagnosed

Experimental treatment :2-8 weeks

Diagnostic criteria

Diagnostic criteria

Diagnosis & differential diagnosisDiagnosis & differential diagnosis

Differential diagnosis Crohn’s disease: The major diagnostic dilemma of ITB is to

differentiate it from CD. Right-sided colonic carcinoma Amoebiasis or schistosomic granuloma Chronic bacillary Dysentery or cholera Malignant lymphoma FGID:IBS, functional diarrhea

Differential diagnosis Crohn’s disease: The major diagnostic dilemma of ITB is to

differentiate it from CD. Right-sided colonic carcinoma Amoebiasis or schistosomic granuloma Chronic bacillary Dysentery or cholera Malignant lymphoma FGID:IBS, functional diarrhea

TB & CDTB & CD

TB CD Extraintestinal TB √ Course(relief and relapse) √ Fistula/abscess/peri-anal lesion √ Segmental appearance √ Form of ulcer transverse longitudinal

Caseating granuloma by biopsy √ PPD test with strong positive √

Effective Anti-TB treatment √

TB CD Extraintestinal TB √ Course(relief and relapse) √ Fistula/abscess/peri-anal lesion √ Segmental appearance √ Form of ulcer transverse longitudinal

Caseating granuloma by biopsy √ PPD test with strong positive √

Effective Anti-TB treatment √

Female

19 years old

Right lower quadrant pain and fever

The ileocecal region

Sigmoid and Rectom

After treatmentAfter treatment

Treatment purpose: resolve symptom, improve constitutional condition,

promote curing, prevent complication

Measures: rest

nutritional support

anti-TB chemotherapy

relieve symptom

surgery

tuberculous peritonitisSame as tuberculous pleurisy