Gastrointestinal Tuberculosis

D i.e., Longitudinal ulcers are more common

Ileocecal tuberculosis

–       It is the most common site of gastrointestinal tuberculosis (80 -90%). The ileum particularly terminal part and ileocecal valve are most commonly affected. The main radiological features are – mucosal fold thickening, discrete (usually transverse or star shaped & circum ferential) ulcers and stricture formation involving terminal ileum associated with funneled contracted caecumQ.

In ileocecal TB, terminal ileum is narrowed & thickened and ileocecal valve becomes_.irregular thickened, rigid, incompetent, wide gaping and patulous giving rise to Fleischner sign or inverted umbrella defect. Steirlin sign is rapid hyper motality (emptying) of narrowed terminal ileum into shortened rigid & obliterated cecum on barium examinationQ.

–       Symmetrical annular napkin ring stenosis & widened ileocecal angleQ (normal IC angle is 90° & it becomes obtuse in ileocecal tuberculosis).

Characterstically ulcers tend to be descrete, & transverse or star shaped (stellate) + deep fissures with elevated margins, in contrast to chron’s disease where they are usually longitudinalQ. Rt colonic TB presents with rigid shortened contracted cone shaped amputated cecum with hourglass stricture. Amputated cecum means retraction of cecum out of ileal fossa d/t fibrosis of mesocolon.

Ans is ‘d’ ie Conservative Management is t/t of choice 

Tuberculosis of the small intestine occurs in two forms.

• Primary infection is usually due to bovine strain of mycobacterium tuberculosis and results from ingesting infected milk. In India the human strain may also cause such primary tuberculosis. This produces hyperplastic tuberculosis
• Secondary infection occurs due to swallowing of tubercle bacilli in a patient with pulmonary tuberculosis. This leads to ulcerative tuberculosis, the more common form of intestinal tuberculosis.

Hyperplastic tuberculosis

• Caused by ingestion of Mycobacterium tuberculosis by pts with a high resistance to the organism. The infection established itself in lymphoid follicles and the resulting chronic inflammation causes thickening of the intestinal wall and narrowing of the lumen. There is early involvement of the regional lymph nodes which may caseate.
• Untreated sooner or later subacute intestinal obstruction will supervene often together with the impaction of an enterolith in the narrowed lumen.
• It usually occurs in the ileocecal region.
• Clinical features

– Attacks of acute abdominal pain with intermittent diarrhoea.

– Sometimes the presenting picture is of a mass in the rt iliac fossa in a pt with vague ill health.

– Features of blind loop syndrome may develop due to stasis, distention and chronic infection in the segment of ileum proximal to obstruction.

• Barium meal radiography will reveal

Persistent narrowing of the affected segment ie the terminal ileum and the caccum.

the caecum is pulled up * and may become subhepatic

– as the caecum is pulled up the ileo-caecal angle is widened. Normal ileo-caecal angle is 90⁰. In ileocaecal tuberculosis this angle may increase upto 150°. *

• Treatment : This depends on the presence or absence of obstructive symptoms.

– A TT is given in both cases.

– If obstruction is present ileocaecal resection is best method of t/t (along with AT7′)

Thus, all the options are correct in this question but (d) option is partly correct as conservative m/n is not the t/t of choice. The t/t of choice depends on the presence or absense of obstructive sympt. In case of obstruction, surgery is the t/t of choice.

Ulcerative tuberculosis

• It is usually secondary to pulmonary tuberculosis and results from swallowing tubercle bacilli in the sputum (cf. Hyperplastic tuberculosis is usually primary there is no pulmonary tuberculosis)
• Usually longer parts of the terminal ileum is involved.
• There are multiple ulcers in the terminal ileum lying transversely [(cf.) Typhoid ulcers are longitudinal. (Mnemonic to remember this is —> Tie (in the neck) is longitudinal)]
• Pt presents with diarrhoea and wt loss
• Barium meal shows –> absence of filling of the lower ileum, caecum and most of the ascending colon as a result of narrowing and hypermotility of the ulcerated segment.
• Treatment :

– A course of ATT is adequate

–        Operation is rarely required, in rare events of perforation or intestinal obstruction.

Ans is ‘a’ i.e. Megaloblastic anemia 

Vitamin BI2 and intrinsic factor are absorbed in the terminal ileum; thus any pathology involving this region can lead to megaloblastic anemia.

Ans. is (a) i.e. Diarrhoea; (c) Stricture 

Ans. is ‘c’ i.e., Surgery is the treatment of choice 

Ans. is ‘b’ i.e., iletun 

Ans. D: Should be managed by surgical resection of the involved segment

On gross pathologic examination, intestinal TB can be classified into 3 categories:

• The ulcerative form of TB is seen in approximately 60% of patients. Multiple superficial ulcers are largely confined to the epithelial surface. This is considered a highly active form of the disease, with the long axis of the ulcers perpendicular to the long axis of the bowel.
• The hypertrophic form is seen in approximately 10% of patients and consists of thickening of the bowel wall with scarring; fibrosis; and a rigid, mass like appearance that mimics that of a carcinoma.
• The ulcero-hypertrophic form is a subtype seen in 30% of patients. These patients have a combination of features of the ulcerative and hypertrophic forms.

The ileum is more commonly involved than the jejunum. Ileocecal involvement is seen in 80-90% of patients with GI TB. This feature is attributed to the abundance of lymphoid tissue (Peyer patches) in the distal and terminal ileum.

Clinical features of intestinal TB include abdominal pain, weight loss, anemia, and fever with night sweats. Patients may present with symptoms of obstruction, right iliac fossa pain, or a palpable mass in the right iliac fossa. Hemorrhage and perforation are recognized complications of intestinal TB, although free perforation is less frequent than in Crohn disease. Early changes on barium examinations reveal nodular thickening of mucosal folds, with loss of symmetry in the fold pattern. As with Crohn disease, deep fissures, sinus tracts, enterocutaneous fistulae, and perforation can occur, although less commonly.

A cobblestone appearance of the mucosa is a feature seen in Crohn disease that is not seen in TB.

Ulceration may be demonstrated on double-contrast examinations, typically perpendicular to the long axis of the bowel; these heal with the formation of short annular strictures.

Because of persistent irritability from inflammation in the terminal ileum, rapid emptying of that segment may occur (Stierlin sign).

The ileocecal angle is obliterated with a widely patent ileocecal valve

The most common site of GI TB is the ileocecal region, if the area can be reached with a flexible endoscope.

A rapid diagnosis can be achieved if smear or culture results are positive or if caseating granulomas are seen in biopsy samples.

In countries where GI TB is endemic, a therapeutic trial of antituberculosis treatment may be justified if the clinical picture is compatible with TB.

Ans. A: Ileum

Any part of the GI system may be infected, although the ileum and colon are common sites. Colonic TB most often is associated with ileal TB. The involvement is segmental and especially involves the right colon

Ans. Apple core appearance

Ans. is ‘d’ i.e., Ileocecal junction

Tubercular ulcer

• The ileocecal region is the most common site of involvememt; i.e. ileocecal tuberculosis.
• Intestinal TB is divided into three types :‑

1. Ulcerative form : It is the most common form. It is characterized by multiple superficial ulcers placed transversly along ileum.
2. Hypertrophic form : There is thickening of bowel wall with scarring, fibrosis and narrowing of lumen.
3. Ulcerohypertrophic form : It has combination of features of both ulcerative and hypertrophic forms.

• In contrast to typhoid ulcer, stricture is common in Tubercular ulcer.