Tuberculosis of GI Tract

Tuberculosis of GI Tract

TUBERCULOSIS OF THE GI TRACT


Tuberculosis – the problem-facts and figures

Tuberculosis is  a disease commonly found in third world countries and is linked to dense population, poor nutrition and sanitation. TB is the single largest infectious cause of death among adults in the world, accounting for nearly 2 million deaths per year.95% of new TB cases every year occur in developing countries, and TB is the single biggest killer of young women- one million per year in the developing world where women are  the bread winners , followed by malaria and maternal mortality Untreated or delayed treatment  can result in long morbid conditions, and hence early recognition is important

         India accounts for nearly one third of the global TB problem .  Every day in India more than 20, 000 people become infected, more than 5000 develop the disease and more than 1000 die from the disease. In  India  tuberculosis kills 14 times more people than all tropical diseases combined, and every year another 20 lakh people develop tuberculosis (RNTCP Status report). The problem has become more with the onset of HIV infection. However TB is curable with effective drugs .The disease may involve any body system and can mimic  inflammatory bowel disease, malignancy and any other infectious disease.

History: In the 4th century B.C Hippocrates described a condition resembling tuberculosis  in a patient with pulmonary lesion and intestinal disease and stated “ that pthysical persons die if diarrhoea sets in and it is a mortal symptom” In the 19th century John Bunyan referred to tuberculosis as “captain of the men of death” and a century later Oliver Wendell  Holmes described it as ‘white plague”

The organism Mycobacteria is  amongst the oldest bacteria on earth and are found in the environment.That it is an ancient disease is borne out  when acid fast bacilli were found in human remains of skeletons found in Heidelbergh Germany dating 5000 B.C and in mummies of Egypt dating back to3500B.The following  were the historical terms used to describe this disease depending upon the anatomical organ involvement-Galloping consumption, phthysis, scrofula, Kings evil ,tabes mesesenterica(abdominal TB). Potts disease to name a few.The Kings touch was attributed to healing cervical and skin tuberculosis by the monarch laying a hand. Many famous figures were victims of tuberculosis – to name a few- Voltaire, Sir WalterScott, John Keats Percy B.Shelley, Elizabeth Browning, The Bronte sisters, Robert Louis Stevenson D.H Lawrence, George Orwell etc.Many doctors died of the disease eg Trudeau and Laennec .If they survived they were put to work in sanatoriums! And Swiss sanatorias became famous.

In the 19th century tuberculosis was prevalent all over the world and was the major cause of strictures and obstructions of the bowel.

Robert Koch in 1882 identified the causative organism as Mycobacterium Tuberculosis, and with that positive identification there emerged the effective antimicrobial agents that  could eradicate the organism.It is of interest to note that Robert Koch worked in India and conducted research on Bubonic plague.

In 1998 the complete genetic sequence of Mycobacterium was identified and this served to identify virulence factors that could serve as targets for new antibacterial drugs and vaccines.

– There was dramatic decline of  tuberculosis in the mid 19th century due to effective drugs, but the mid 1980 showed a resurgence due to epidemic of HIV and incidence of drug resisitant organism

Definition- the term abdominal tuberulosis includes lesions of the stomach, small intestine colon rectum and anus, and other viscera such as liver spleen and pancreas

Route of infection of the organism in GI tuberculosis is  by ingestion of contaminated food or by swallowing sputum containing the tubercle bacilli.The peritonem ,Lymph node and intestine may become infected in the bacteremic phase.The infection could also come from an infected adjoining organ like the fallopian tubes or by hematogenous spread from a recent foci or old infection.

PATHOLOGY-FORMS.

  • Peritoneal tuberculosis-acute and chronic

A.TB of peritoneum-chronic form

  • (1)     wet or ascitic type
  • (2)     generalized
  • (3)     loca;lised(loculated)

(11) Dry or fibrous type

  • (1)  adhesive type
  • (2)  plastic type
  • (3)  miliary nodular type

B. TB of peritoneal folds and contents

  • mesenteric adenitis
  • mesenteric cysts
  • mesenteric abscess

Bowel adhesions and rolled up omentum

      II GI Tuberculosis

  • Ulcerative
  • Hypertrophic or hyperplastic
  • Sclerotic or hyperplastic
  • Sclerotic or fibrotic

III. TB of solid viscera
Liver pancreas spleen

LESIONS

The lesions usually occur at sites containing large amounts of lymphoid tissue and once there is colonisaion of the bacillus there is inflammatory response ,tubercle formation, ulceration of overlying mucosa or serosa and ulcer formation. The ulcers may heal with fibrosis inducing stenosis of the lumen and strictures or occasionally there may be marked  thickening of the wall  the hypertrophic type or may form a combination ulcerohypertrophic  type.The symptomatology is based on the  sequelae of these lesions- perforation obstruction hemorrhage  fistulae and disordered motility and function of the tract.. TB  and malignancy may coexist and this  can occur mainly in the stomach and caecum

Sites of intestinal involvement- the ileum (27%) is most common site followed by ileocaecal (22.9%) followed by much lesser incidence in other parts of the GI tract. The descending order of frequency is ileum caecum ascending colon jejunum, other parts of colon, rectum  duodenum and stomach. The ileocaecal TB is is often of the hyperplastic type. TB of the viscera is rarely seen as an isolated case and is usually part of disseminated disease .Liver and Spleen are the main organs involved and usually microabscesses or larger abscesses. Or as calcified granulomas visible  in late stages after healing. Pancreatic TB is rare and due to hematogenous spread or direct spread from an adjacent node

Differential diagnosis- has to be differentiated from Crohns disease, especially in the West. and from malignancy., and other infectious diseases

Lesions can be coincidental one has to keep in mind the PACT syndrome( peptic ulcer, Amoebiasis, Cirrhosis and Tuberculosis) (Madnagopalan M)

Clinical features The disease usually affects the younger age group  and is common between 30-50m years and there is a female preponderance of 2:1.The onset is insidious and there is vague non specific symptoms with fever night sweats  anorexia and loss of weight. The presenting symptoms are

  • Abdominal pain
  • Constipation
  • Vomiting
  • Abdominal distention
  • Ascitis
  • Borborygmi
  • Abdominal mass
  • Diarrhoea
  • Wt loss . fever,anorexia,amenorrhoea. Incidence of pulmonary TB ranges from 19-25%

Physical Findings The patient is malnourished with anemia The abdomen may be normal or distended due to ascitis or intestinal obstruction when distended bowel loops will be visible.There may be localizing signs in RLQ with doughy abdomen, rolled up omentum, loculated ascitis or mass.There may be pelvic masses or obstruction due to Lymphnode masses.Rectal examination may reveal the presence of strictures or fistula in  ano

The most common complication is intestinal obstruction due to strictures, masses or cocoon, and malabsoprption followed by perforation, hemorrhage intestinal fistulae and external fistula.

Investigations– Lab  diagnosis shows  anemia,leukopenia and raised ESR and with mantoux positivity.Analysis of ascitic fluid AD A, bacterial isolation and culture and serological studies for PCR  are helpful in diagnosis

The following radiological studies like plain xray chest-shows pulmonary tuberculosis ,free fluid under the diaphragm denoting perforation, abdominal xrays reveal ascitis, obstruction and clumping together of the bowel as in Cocoon .US, CT SCAN MRI reveal mass lesions and lymph nodal  enlargements and intestinal obstructions. Barium contrast studies are still useful for small bowel studies and  endoscopy- UGI, LGI  and capsule endoscopy and laparoscopy are  able to take tissue for biopsy and positive diagnosis and to differentiate from  malignancy or Crohns disease.

Role of Surgery – surgery is indicated in complications like obstructions, hemorrhage, perforations and doubtful
diagnosis.Surgical resection is limited and stricturoplasty is advocated for small bowel strictures which are not very dense and ileo caeco plasty for ileo caecal TB.Meticulous lysis is advocated for cocoon’ HPE is essential to rule out malignancy.

All patients must be put on anti TB drug regime post operatively

Recommended Reading:
Bockus     Gastroenterology
ICMR BULLETIN March 2002
Rangabashyam N  B.S Anand et al  Abdominal tuberculosis..Oxford textbook of Surgery ED. PJ Morris W.J.Wood p.3237-3249: 2002.
Sleisinger  & Fordtran   Gastroenterology
TB INDIA RNTCP status report 2001


Prof.Srikumari Damodaran MS.M.Ch(GE)MAMS FACS
Prof & Head
Dept. of Surgical Gastroenterology
Kilpauk Medical College Hospital
Chennai
E.Mail: [email protected]

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