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Abdominal tuberculosis

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					CLINICAL PRESENTATION:

Abdominal tuberculosis



Author?
    HISTORY
   A 12 year old girl first presented with
    acute abdominal pain and vomiting for
    a day
   For 4 months she had had
       severe weight loss (from 35kg to 24kg)
       Loss of appetite
       Intermittent lower abdominal pain
       Low grade fever
DURING THIS PERIOD,
INVESTIGATED 3 TIMES IN HOSPITAL
INVESTIGATIONS
  Chest X -Ray
  Ultrasound of abdomen
  Barium meal and follow through
  CT of abdomen
  Gastroscopy, biopsies
  Liver biopsy
  Bone marrow biopsy
This was the chest X-ray
What does it show?
CT ABDOMEN
 Hepatomegaly with fatty infiltration
 Ascites
 No lymph nodes
 Cannot exclude terminal ileum wall
  thickening due to ascites
 No masses or omental calcification
 No definitive features of abdominal
  TB
INVESTIGATIONS
   Bloods
    hematology,biochemistry,immunology,
    microbiology
   Urine
   Liver biopsy
   Duodenal biopsy
   Bone marrow biopsy
   Sputums
   Stools
POSITIVE FINDINGS:
 Raised CRP
 Fe deficient anaemia
 Ulcerating Mantoux
 Hypo-albuminaemia


   Bone marrow : Granulomas and
    acid-fast bacilli seen
TREATMENT
 She was started on treatment for
  disseminated tuberculosis,
  December 2002
 Rifafour , with
 Prednisone, for the inflammatory
  response
 High calorie, high protein diet
TREATMENT
 Tb treatment 18/12/2002
 Prednisone started – inflammatory
  response
 Diet
PRESENT ADMISSION (FEBRUARY
2003)


EXAMINATION
 wasted
 tachycardia
 acute abdomen
  Maximally tender right iliac fossa
  mass palpable
INVESTIGATIONS
 WCC 34 X 10^9/L
 ALBUMIN 29 G/DL
 Abdominal X Ray
TREATMENT

   Prepared for theatre

   IV fluids , antibiotics
OPERATIVE FINDINGS
 Fixed mass in right iliac fossa ,
  matted bowel
 Sealed off with omentum
 Granulomas
 Multiple perforations
These are the operative
findings
PROCEDURE
   Resection of affected bowel

   Primary anastomosis

   Left with 233 cm jejunum, 20 cm
    terminal ileum
HISTOLOGY
 Matted bowel ,multiple perforations ,
  multiple circumferential ulcers seen
 Focal caseating granulomas
 Focal sloughing of mucosa , areas of
  transmural necrosis
 Resection lines showed no
  granulomas
POST OPERATIVE COURSE
   TB treatment continued

   Hyperalimentation for one week

   Discharged Day 9

   At follow-up - gained 2 kg
HOW DOES ABDOMINAL TB
COME ABOUT?
HOW ABDOMINAL TB COMES
ABOUT
 Along lymphatics from mediastinal
  nodes to abdominal nodes
 Blood spread
 Possibly from swallowed sputum ->
  ileum
 Rarely, primary in bowel from
   M bovis
ABDOMINAL
TUBERCULOSIS
 Increased incidence of pulmonary TB
  has led to a corresponding increase
  in abdominal TB.
 Extremely difficult disease to
  diagnose outside operating room
 50% of patients are HIV positive
SYMPTOMS
 Abdominal pain
 Fever
 Significant weight loss
 Nausea, vomiting
 Abdominal distention
 Long duration of symptoms
PHYSICAL EXAMINATION

 ABDOMINAL TENDERNESS
 PALPABLE MASS
 ASCITES, or
 DOUGHY ABDOMEN
SPECIAL INVESTIGATIONS
 CXR
 AXR
 CONTRAST ENEMAS
 CT ABDOMEN : Thickening
  parietal/visceral peritoneum, bowel
  wall thickening,
  irregularity,mesenteric
  lymphadenopathy
LAPAROSCOPY : FINDINGS
   PERITONEAL STUDDING WHITISH-
    YELLOW PLAQUES
   MATTING OF THICKENED BOWEL WALLS
    WITH DENSE ADHESIONS
   PUNCTATE LESIONS OF CASEATING
    GRANULATION TISSUE
   PERITONEAL/RETROPERITONEAL
    LYMPHADENOPATHY WITH FLUCTUANCE
    AND CENTRAL NECROSIS
DIAGNOSIS
 ACID FAST BACILLI STAIN AND /OR,
 POSITIVE CULTURE RESULTS
 ? PLACE FOR FINE NEEDLE
  ASPIRATION
TREATMENT
 Four drug regimen
 Isoniazid,rifampin,pyrazinamide,
   either ethambutol or streptomycin
 Corticosteroid administration to
  reduce complications with peritoneal
  tuberculosis
 Surgery reserved for complications
ABDOMINAL TB
 Non-specific presentation delays
  diagnosis
 Diagnosis intraoperatively start
  treatment promptly
 Appropriate surgical operations and
  prompt initiation of treatment
  successfully treats abdominal TB
THE END

				
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posted:4/7/2008
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