Professional Documents
Culture Documents
TUBERCULOSIS
ETIOPATHOGENESIS AND INVESTIGATIONS
WHY SHOULD WE
KNOW ABOUT
TB??
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
http://articles.timesofindia.indiatimes.com/2012-05-09/india/316405
62_1_mdr-tb-tb-cases-tb-diagnosis
Risk Factors
Case series involving 60 patients
38% Cirrhosis
http://www.med.unc.ed
24th march
1882
World TB DAY
PATHOGENESIS
STAGE 1
ESTABLISHMENT
ALVEOLAR MACROPHAGE
INGESTS TB BACILLI
Racial differences in macrophages microbicidal
enzymes. Africans have macrophages less
capable of destroying tb bacilli.
Mutations in NRAMP-1 gene involved in
pushing out Fe2+ ions from the
phagolysosome.
Cellier MF, et
al.
Microbes Infect
2007; 9:1662.
STAGE 2 SYMBIOSIS
STAGE 2 SYMBIOSIS
Secrete IFN
Activates
Macrophag
es
TCELL
Kills the inactivated
macrophages which were
allowing the tb bacilli
growth inside them
WHAT IS THE
INITIAL RESPONSE
OF THE HOST??
CMI or DTH???
Main difference is concentration of
antigen required.
Non activated
Macrophages which
allowed the growth of
TB bacilli are killed by
DTH mediated by Tcells
Forming solid caseous
necrosis
J Leukoc Biol.
1996;60:692703.
ACTIVATED MACROPHAGES
WALLS OFF THE EXPANDING
CAVITY AND PREVENTS
FURTHER INCREASE IN
SIZE IN HOST WITH GOOD
CMI.
POOR CMI
when the caseum liquefies, the entering
macrophages do not function effectively.
Possibly, the entering macrophages are killed
by toxic fatty acids originating from host cells,
or the bacilli, or both.
CAUSE OF LIQUEFACTION???
GENERAL INVESTIGATIONS
. Types of specimens:
1.Pulmonary specimens
-Sputum
-Gastric lavage
-Transtracheal aspirations
-Bronchoscopy
-Laryngeal swabbing
2.Urine specimens
3.Tissue and body fluid specimens
4.Blood specimens
5.Wounds, skin lesions, and aspirates
Microscopy
Sputum smears stained by Z
N stain
What is Smear Positivity
All patients who have
submitted two
Specimens and found
to be positive for
identification of AFB
Detecting AFB by
fluorochrome stain using
fluorescence microscopy
Agar based
4egg based
6weeks
BACTEC 14.8days
MGIT- 13.3days
NEWER METHODS
QuantiFERONTB
SENSITIVITY-81%
SPECIFICITY-91.2%
TB SPOT
SENSITIVITY-87.5%
SPECIFICITY-86.3%
GASTROINTESTINAL
TUBERCULOSIS
Epidemiology
Pathogenesis
Clinical features
Diagnosis
Epidemiology
TB & HIV
Incidence severity of
abdominal TB will increase with
the HIV epidemic
Pathogenesis
Types
Ulcerative
Hyperplastic
Ulcerohyperplastic
Diffuse colitis
Sclerotic
PATHOLOGY
Most active inflammation in submucosa.
Bacilli in depth of mucosal glands
Inflammatory reaction
Phagocytes carry bacilli to Peyers Patches
Formation of tubercle
PATHOLOGY
Submucosal tubercles enlarge
PATHOLOGY
Lymphatic obstruction
of mesentery and bowel
Thick fixed mass
Order of Frequency
WHY?
Increased physiological stasis
Increased rate of fluid and electrolyte absorption
Minimal digestive activity
Abundance of lymphoid tissue at this site.
Clinical features
Constitutional symptoms
Fever (40%-70%)
Weight loss (40%-90%)
Anorexia
Malaise
Pain (80%-95%)
Ileocecal TB
mesenteric fat
Isolated Colonic TB
Anorectal TB
Gastroduodenal TB
Esophageal TB
Complications
OBSTRUCTION
PERFORATION
MALABSORPTION
Obstruction
Pathogenesis
Hyperplastic caecal TB
Strictures (napkin ring) of the small intestine
Adhesions
Adjacent LN involvement traction, narrowing
and fixation of bowel loops.
In India ~ 3% to 20% of
(Bhansali and Sethna).
bowel obstruction
Malabsorption
Perforation
Investigations
Intestinal TB cont.
CT scan shows thickening
of the cecum with pericecal
inflammatory changes.
Mesenteric lymph nodes are
also evident (arrows).
Endoscopy
Nodules
TB mass in stomach
Esophageal TB Nodules
Is endoscopy diagnostic?
PERITONEAL
TUBERCULOSIS
AN
OVERLOOKED
DIAGNOSIS
DIAGNOSTIC
CHALLENGES
EPIDEMOLOGY
PATHOGENESIS
CLINICAL FEATURES
DIAGNOSIS
TREATMENT
EPIDEMOLOGY
PATHOGENESIS
CLINICAL PICTURE
CLINICAL
PRESENTATION
wet-ascitic
(most common)
ascites
peritonitis
fibrotic-fixed
Mass formation
Matting of bowel
loops
dry-plastic
form(less
common)
adhesions
doughy feel
tender
abdominal
masses.
Encysted(loculate
d)
localized
abdominal
swelling
CLINICAL FEATURES
INVESTIGATIONS
Haematological indices.
Microbiological diagnosis.
Ascitic fluid analysis.
New diagnostic tools-Adenosine deaminase,
Gene amplification.Immunodiagnostic tests.
Imaging studies
CXR- concomitant TB in less than 25% cases
Barium studies .
ultrasound and computed tomography.
Gross Appearance:
Straw coloured .
EXUDATIVE
WBC cell count-500 and 1500cells/mm3 lymphocytosis.
LDH raised->90U/L
Protein > 3g /dl.
SAAG <1.1mg/dl
RBC 7%.
Adenosine deaminase.
Purine-degrading enzyme
Assists with maturation and differentiation of Tlymphoid cells.
Adenosine deaminase
Cut-off value of 30 U/L
94% Sensitive
92% Specific.
Elevated CA-125
-Not sensitive
Also raised in peritoneal carcinomatosis,
ovarian malignancy.
Can use to follow treatment response
Imaging studies
Peritoneum(white arrow)
Smooth and uniform thickening
If nodular, think Peritoneal
Carcinomatosis.
Omentum(open arrow)
Smudged, omental cake or
nodular..
Mesentery
Loss of normal mesenteric
configuration
-Thickened mesentery (>15mm) with
mesenteric lymph nodes- early sign
Lymphadenopathy.(black arrow)
DIAGNOSTIC TOOL
OF CHOICE?
DIAGNOSTIC
LAPROSCOPY
DIAGNOSTIC YEILD
LAP FINDINGS
PIT FALLS
ROLE OF
LAPAROTOMY?
unnecessary
ideal diagnostic test
requires the
demonstration of
mycobacteria
BUT
TREATMENT
MEDICAL vs SURGICAL
UNCOMPLICATED
solely pharmacological.
CAT I ATT
Response to therapy is manifested by resolution of
symptoms and disappearance of ascites
Surgery is reserved for complications or
uncertainty in diagnosis.
DREADED
COMPLICATION
ROLE OF
CORTICOSTEROIDS?
four trials of adjuvant corticosteroids use in TBP and
all of them cited modest benefit.
Tuberculous
peritonitis--do not
it
miss
Laparoscopy,
SOLID ORGAN
TUBERCULOSIS
HEPATIC TB
three forms
diffuse hepatic involvement- most common
granulomatous hepatitis
focal/local tuberculoma or abscess- rare
INVESTIGATIONS
Percutaneous liver biopsy.
laparoscopy liver biopsy- cheesy white irregular
nodules.
CT SCAN.
CT abdomen
MILIARY TB
TUBERCULOMA
Masses larger than 2mm in diameter
SPLENIC
TUBERCULOSIS
Computed tomograph scan of the abdomen showing a spleen diffusely infiltrated by small,
hypodense lesions consistent with splenic granulomas.
PANCREATIC TB
It is rare
Often associated with miliary TB &
immunocompromised pt
Result from lymphohaematogenous
dissemimation after pulmonary exposure
Anorexia,malaise fever,weight loss,mass
Investication: FNAC & BIOPSY (CT guided)
CT enhanced conrast-
RENAL TB
Ovarian TB
Ovarian TB
Tuberculous tuboovarian abscess
(a) Contrast-enhanced
CT scan shows a
multiloculated mass
with peripheral
enhancement around
centers .(arrow).
Surgeons
Viewpoint
A 24 yr old female comes with pain RIF,
MANTRELS 7/10 diagnosed as acute
appendicitis.
On opening an inflammed appendix is found
but studded with tubercles, omentum and
caecum show multiple tubercles
Do we do appendicectomy ?
Patient comes with features of perforation
peritonitis
On opening TB peritonitis with ileac
perforation with a stricture of about 3 cm 2
feet distal to perforation
Primary closure?
Stricturoplasty?
Resection?
A 60 yr old male, known case of pulmonary TB
presenting with acute intestinal obstruction
On opening ileocecal mass with peritonium
and omentum showing features of TB
Rt hemicolectomy?
Limited resection?
Bypass?
Patent known case of pulmonary TB ,
presenting with ascites and subacute
obstruction.
On diagnostic Lap we find Milliary TB with
multiple adhesions
Do we do adhesiolysis?
Appendicectomy
Stricturoplasty/
Resection
Stricturoplasty
Perforation primary
closure?
Bhansali et al.,1968
Pujari, 1979
Resection Anastomosis
Is it safe?
Two-stage procedures
Reversal of stoma in a well-prepared gut with
ATT cover
Muhammad Saaiq et al
Turkish Journal of Trauma & Emergency
Surgery vol 17 2011
Rankie et al
Recio et al
Piechaud et al
Asian J Surg2002:25(2):145-8
Resection is a safe and effective procedure in
treating abdominal TB complications.
Resection of a tuberculous lesion where
feasible is the procedure of choice
ournal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (7): 393
Agarwal et al , BHJ 2000
Fistulas
Adhesiolysis / ATT
Anand et al
Balasubramaniam et al
To summarise
Thank You