結(jié)核性腹膜炎的診療

TuberculousAbdomen

腹部結(jié)核

Circumferentialulcerationischaracteristicofintestinaltuberculosis.

EpidemiologyofGITBExtrapulmonaryTBrepresented28.2%ofallreportedTBcases.GastrointestinalTBwasthe2ndmostcommontypeofTB.ExtrapulmonaryTB:difficulttodiagnose??SeveralformsofextrapulmonaryTBlackanyofthelocalizingsymptomsorsigns.CutaneousanergytoPPDwasnotedin35-50%ofpatients.NoclinicalorradiologicalevidenceofpulmonaryTBcouldbefoundinuptoone3rdofthesepatients.IntroductionTBcaninvolveanypartofGITfrommouthtoanus,peritoneum&pancreatobiliarysystem.Variedpresentations.PREVALENCEIsolatedabdominaltuberculosis:

Unselectedautopsyseries-0.02-5.1%HigherprevalenceinfemalesDespiteincreasedPulTBinmalesSecondarytoPul.TBHIV&TBBeforeeraofHIVinfection>80%TBconfinedtolungExtrapulmonaryTBincreaseswithHIV40–60%TBinHIV+pt-extrapulmonaryIncidence

severityof

abdominalTBwillincreasewith

theHIVepidemic

PathogenesisMechanismsbywhichM.tuberculosisreachtheGIT:HematogenousspreadfromprimarylungfocusIngestionofbacilliinsputumfromactivepulmonaryfocus.Directspreadfromadjacentorgans.VialymphchannelsfrominfectedLNRobertKoch,aGermanScientistwhofoundoutthecausativeorganismandrevealedhisinventionin1882Gramnegativebacillus–Mycobacteriumtuberculosis

TuberculousabdomenisaconditioninwhichthereistuberculousinfectionoftheperitoneumorotherorgansintheabdomenTuberculousperitonitisAcutetuberculousperitonitisChronictuberculousperitonitisAcutetuberculousperitonitisAcuteabdomenwithseverepainAcuteinflammationoftheperitoneumStrawcolouredfluidTuberclesinthegreateromentumandperitoneumTuberclesmaycasseateAntituberculoustreatmentChronictuberculousperitonitisTheconditionpresentswithabdominalpainFeverLossofweightAscitesNightsweatsAbdominalmassOriginofinfectionTuberculousmesentericlymphnodesTuberculosisoftheileocaecalregionTuberculouspyosalpinxBloodborneinfectionfrompulmonarytuberculosis,usuallythe‘miliary’butoccasionallythecavitatingformVarietiesoftuberculousperitonitisAsciticform–peritonealfluid

distensionofabdomen.Patientcomeswiththecomplaintofswellingoftheabdomen.–increasedabdominalpressure

umbilicalhernia,inguinalherniaPurulentform Rare–usuallysecondarytotuberculoussalpingitis–pocketsofadherentintestinesandomentumcontainingtuberculouspus.–coldabscessesEncystedform InflammationandascitesareconfinedtoonepartoftheabdominalcavityFibrousform Widespreadadhesions

adhesiveobstructionPeritonealinvolvementoccursfrom:SpreadfromLNIntestinallesionsorTubercularsalpingitisAbdominalLNandperitonealTBmayoccurwithoutGITinvolvementin~1/3cases.GITBGItuberculosisisusuallysecondarytopulmonarytuberculosis,radiologicevaluationoftenshowsnoevidenceoflungdiseaseGI

TuberculosisIleocecumandColon

Theileocecalregionisthemostcommonareaofinvolvementinthegastrointestinaltractduetotheabundanceoflymphoidtissue.Thenaturalcourseofgastrointestinaltuberculosismaybe

ulcerative

hypertrophicor

ulcerohypertrophic.Mostcommonsite-ileocaecalregionIncreasedphysiologicalstasisIncreasedrateoffluidandelectrolyteabsorptionMinimaldigestiveactivityAbundanceoflymphoidtissueatthissite.DistributionoftuberculouslesionsIleum>caecum>ascendingcolon>jejunum>appendix>sigmoid>rectum>duodenum>stomach>oesophagusMorethanonesitemaybeinvolvedClinicalFeaturesMainlydiseaseofyoungadults~2/3ofpt.are21-40yroldSexincidenceequal.slightfemalepredominanceClinicalpresentation

Acute/Chronic/AcuteonChronic.ConstitutionalsymptomsFever(40%-70%)Weightloss(40%-90%)AnorexiaMalaisePain(80%-95%)ColickyContinousDiarrhoea(11%-20%)ConstipationAlternatingconstipationanddiarrhoeaTuberculosisofesophagusRare~0.2%oftotalcasesByextensionfromadjacentLNLowgradefever/Dysphagia/Odynophagia/MidesophagealulcerMimicsesophagealCaGastroduodenalTBStomachandduodenumeach~1%oftotalcasesMimicsPUD-shorterhistory,nonresponsetot/tMimicsgastricCa.Duodenalobstruction-extrinsiccompressionbytuberculousLNHematemesis/Perforation/Fistulae/ObstructivejaundiceCx-RayusuallynormalEndoscopicpicture-nonspecificIleocaecaltuberculosisColickyabdominalpain‘Ballofwind’rollinginabdomenRightiliacfossalump-ileocaecalregion,mesentericfatandLNSegmental/IsolatedcolonictuberculosisInvolvementofthecolonwithoutinvolvementoftheileocaecalregion9.2%ofallcasesMultifocalinvolvementin~1/3(28%to44%)Mediansymptomduration<1yearColonictuberculosisPain---predominantsymptom(78%-90%)Hematocheziain<1/3-usuallyminorOverall,TBaccountsfor~4%ofLGIbleedingOtherfeatures---fever/anorexia/weightloss/changeinbowelhabitsRectalandAnalTuberculosisHematochezia-mostcommonsymp.DuetomucosaltraumabystoolConstitutionalsymptomsConstipationRectalstrictureAnalfistula–usuallymultipleComplicationsGITbleedingObstructionPerforationMalabsorptionObstructionMostcommoncomplication

PathogenesisHyperplasticcaecalTBStricturesofthesmallintestine---commonlymultipleAdhesionsAdjacentLNinvolvement

traction,narrowingandfixationofbowelloops.Seriesof348casesofintestinalobstruction-TBin54(15.5%) (BhansaliandSethna).PerforationUsuallysingleandproximaltoastrictureClue-TBChestx-rayPneumoperitoneum?MalabsorptionCommonDecreasedabsorptionIncreasedConsumptionEmaciationduetoTBOverallprevalenceofmalabsorption:75%ptwithintestinalobstruction40%ofthosewithout(Tandonetal)InvestigationsBloodroutinePPDtestAsciticfluidexaminationX-raysEndoscopeLaparoscopyBloodtestsNonspecificfindings---RaisedESRPositivePPDtestAnemiaADAHypoalbuminaemiaCoHIVinfection?PPDTestPPDtest–positiveMeasuringtheinduration–PPDtestAsciticfluidexaminationStrawcolouredProtein>3g/dLLymphocytes>70%SAAG<1.1g/dL+culturein<20%casesAdenosineDeaminase(ADA)AminohydrolasethatconvertsadenosineàinosineADAincreasedduetostimulationofT-cellsbymycobacterialAgSerumADA>54U/LAsciticfluidADA>36U/LAsciticfluidtoserumADAratio>0.985(Bhargavaetal)

CoinfectionwithHIV

normalorlowADAX-rays

GastrointestinalTuberculosisBariumstudiesdemonstratespasmandhypermotilitywithedemaoftheileocecalvalveintheearlystagesLaterthickeningoftheileocecalvalve.Awidelygapingileocecalvalvewithnarrowingoftheterminalileum(Fleischnersign)Anarrowedterminalileumwithrapidemptyingofthediseasedsegmentthroughagapingileocecalvalveintoashortened,rigid,obliteratedcecum(Stierlinsign)Focalordiffuseaphthousulcers:tendtobelinearorstellate,followingtheorientationoflymphoidfollicles(ie,longitudinalintheterminalileumandtransverseinthecolon)GastrointestinalTuberculosisInadvancedcases,symmetricannularstenosisandobstruction

associatedwithshortening,retraction,andpouchformationmaybeseen.

Thececumbecomesconical,shrunken,andretractedoutoftheiliacfossaduetofibrosis,ileoceacalvalvebecomesfixed,irregular,gaping,andincompetent.

52Tuberculousperitonitis–USGM–Intestinesfloatinginperitonealfluid-ascitesColonoscopyColonoscopy-mucosalnodules&ulcersNodulesVariablesizes(2to6mm)MostcommonincaecumespeciallynearICvalve.TubercularulcersLarge(10to20mm)orsmall(3to5mm)LocatedbetweenthenodulesSingleormultipleTransverselyoriented/circumferentialcontrasttoCrohnsHealingofthese‘girdleulcers’

stricturesDeformedandedematousileocaecalvalve

ColonoscopicDiagnosis8–10BxfromulceredgeLowyieldonhistopathasmainlysubmucosaldiseaseGranulomasin8%-48%Culturepositivityin40%Combinationofhistology&culture

diagnosisin60%LaparoscopicFindingsThickenedperitoneumwithtubercles-Multiple,yellowishwhite,uniform(~4-5mm)tuberclesPeritoneumisthickened&hyperemicOmentum,liver,spleenalsostuddedwithtubercles.ThickenedperitoneumwithouttuberclesFibroadhesiveperitonitisMarkedlythickenedperitoneumandmultiplethickadhesions(Bhargavaetal)

DifferentialdiagnosisCDCancerLymphomaChroniccolitisManagementisoniazidrifampicinpyrazinamideethambutolSurgical

intervention

when

needed

atleast6monthsincluding2monthsofRif,INH,PzideandEthamHoweverinpracticet/toftengivenfor12to18monthsobstructinglesionsmayrelievewithMedalone HowevermostwillneedsurgeryTxdurationNewlydiagnosed:2HRZE/4HR、2SHRZ/4HRRelapsed:2HRZSE/4~6HRE

CDorTB???

Theultimatecourseofthesetwodisordersisdifferent.IntestinalTBisentirelycurable,providedthatthediagnosisismadeearlyenoughandappropriatetreatmentisinstituted.Incontrast,CDisaprogressiverelapsingillness.Unfortunately,itisdifficulttodifferentiateintestinalTBfromCDbecauseofsimilarclinical,pathological,radiological,andendoscopicfindings.Diagnosis:intestinalTBorCDTheycanpresentexactlywithsameclinicalpictures(sameagegroup,symptomsandsigns)SameradiologicalfindingsandsameendoscopicfindingsMostlywithsamepathologicalfindingsSohowcanwemakethediagnosis??OtherfeaturesHistoryofpreviousTBCXRfindingsofTBThetuberculinskintestislesshelpful,becauseapositivetestdoesnotnecessarilymeanactivedisease.PerianalfistulaeandextraintesitnalmanifestationsofCDIfallnegative:anyotherclues??Multipleattempts!!Endoscopicfindings?Laproscopicfindings?Histologicalfindings?PCR?EmpiricalTB?Endoscopicdiagnosis?CD(4parameters)Anorectallesions,longitudinalulcers,aphthousulcers,andcobblestoneappearanceIntestinalTB(4parameters)involvementoffewerthanfoursegments,apatulousileocecalvalve,transverseulcers,andscarsorpseudopolypsEndoscopy.2006Jun;38(6):592-7.Endoscopicdiagnosis?LeeetalhypothesizedthatadiagnosisofCrohn'sdiseasecouldbemadewhenthenumberofparameterscharacteristicofCrohn'sdiseasewashigherthanthenumberofparameterscharacteristicofintestinaltuberculosis,andviceversa.Endoscopy.2006Jun;38(6):592-7.Endoscopicfindings:TBIntuberculosispatients,transverseulcerswithsurroundinghypertrophicmucosaandmultipleerosionswereusualcolonoscopicfindings.AmJGastroenterol1998;93:606–609.GastrointestEndosc2004;59:362-8.TypicaltransverseulcerGastrointestEndosc2004;59:362-8.Radiologythickenedbowelwallwithdistortionofthemucosalfoldsandulcerations.CTmayshowpreferentialthickeningoftheileocecalvalveandmedialwallofthececumandmassivelymphadenopathywithcentralnecrosis.Calcifiedmesentericlymphnodesandanabnormalchestfilm