Gi Tuberculosis Shokry Hunter

INTRODUCTION
x Tuberculosis (T.B.) has existed from the
very dawn of civilization.
x Records of TB in mummies were found in
Egypt as far as 5000 years ago.
(Cave, 1935)

x Extrapulmonary tuberculosis was
also known since antiquity.
x Pott’s disease was described in
paints and statues of ancient
Egyptians.
(Ghalioungy, 1958)

GASTROINTESTINAL TUBERCULOSIS
Tuberculous enteritis as a complication of
pulmonary T.B. was appreciated by Hippocrates in
the 5th century B.C.

Diarrhea attacking a
person with phthisis is a
mortal symptom

(Walsh, 1909)


Ebn Sina
The Famous Arab Scientist (980-1037)
in his book “Al-Kanoun”
described tuberculosis (Al-Sol) in details.
He described
q Abdominal distention

q Diarrhea

q Borborygmi

In late stages of the disease.
(Hunter, 1999)


PATHOGENESIS

x Mycobacterium tuberculosis is the pathogen in
most cases.
x Mycobacterium bovis in some parts of the world
with no pasteurization of milk.
x Mycobacterium avium intracellulare has become a
major pathogen in HIV patients.
(Nial et al., 1997)

PATHOLOGY
Most active inflammation in submucosa.
Bacill in depth of mucosal glands

Inflammatory reaction

Phagocytes carry bacilli to Peyers Patches

Formation of tubercle

Tubercles undergo necrosis

Portis (1953)

PATHOLOGY
Submucosal tubercles enlarge

Endarteritis & edema

Sloughing

Ulcer formation

Accumulation of collagenous tissue

Thickening & Stenosis

(Howell & Knapton, 1964)

PATHOLOGY
Inflammatory process in submucosa penetrates to serosa

Tubercles on serosal surface

Bacilli reach lymphatics

Bacilli via lymphatics

Lymphatic obstruction Regional lymph nodes
of mesentery and bowel • Hyperplasia
→ Thick fixed mass • Caseation necrosis
• Calcification
(Boyed, 1943)

FORMS OF GI TB

Ulceroconstrictive Hypertrophic
60% of patients 10% of patients

Highly virulent Chronic
Mostly small Intestinal Mostly Ileocoecal

Mixed 30% of patients
(Howell & Knapton, 1964)

T.B. Bacilli, Z.N. stain
Maha Hasaballa, Cairo University

T.B. stenotic surgical segment with involvement of
mesenteric fat
Makram Milad, Cairo University
T.B. transverse girdle ulcer small
intestine

Pathology of the previous ulcer
Sub mucosal muscular and
subserous granulomas

T.B. Lymphadenitis

GASTROINTESTINAL TUBERCULOSIS POSES A
DIAGNOSTIC PROBLEM

x The disease is not common.
x Not familiar to clinicians.
x Involves inaccessible sites.
x May be associated with other serious disorders, the
manifestations of which obscure or modify those of
T.B.:
HIV, Chronic Renal Failure, Diabetes Mellitus,
Liver Cirrhosis, Neoplastic disease.
(Kramer et al., 1990)

The approach to the subject
was directed to these main points.

x Country and continent of origin.
x Age
x Gender
x Associated HIV infection
x Associated pulmonary disease
x Constitutional signs and symptoms
x Signs and symptoms related to the site of
involvement in the G.I. tract

To achieve this aim
The following was carried on
x Search on the Pubmed was done for all abstracts since
1965.
x Original articles tackling the subject and available in
Egyptian libraries were collected
x Abstracts and original articles that describe symptoms
and signs related to gastrointestinal tuberculosis were
selected.
x Abstracts and articles were classified according to
organ involvement in the gastrointestinal tract.
x Retrieved data were pooled, tabulated and statistically
analyzed.

Demonstration photos were kindly
provided by colleagues; staff members of
Faculty of Medicine, Cairo University

700

600

500

400
Count

300

200

100

0
1960 - 1965 1965 - 1970 1970 - 1975 1975 - 1980 1980 - 1985 1985 - 1990 1990 - 1995 1995 - 2000

Year

Gastro-intestinal tuberculosis cases as
reported by publication year (n = 2204)

Distribution of gastrointestinal tuberculosis

r
d de
b la y
ll r
ga lia
o bi
ic
at
re
nc
pa r y
lia
bi
he
pa
to
cases (n=2204) by site
m
3

u
ie
on
rit
pe
39

l
ta
r ec
lo
co
21

Site
n
lo
o co
ile e
tin
24

es
nt
li
al
sm

5
h
ac
om
st
s
gu
ha
op
es

4
0
50

40

30

20

10
Percent

India
23.9% Malaysia
6.5%
S. Africa
11.6%

USA
8.5%

Saudi Arabia
Others 11.7%
37.8%

Distribution of gastrointestinal
tuberculosis cases by country

S. America
1.1%
Australia
5.0% Asia
Europe 57.0%
13.9%

Africa
23.0%

tuberculosis cases by continent

Children
2.0%

Adults
98.0%

tuberculosis cases by age group

Male
41.8%

Female
58.2%

tuberculosis cases by sex

Present
55.9%

Absent
44.1%

cases reporting associated HIV

120%

100%

80%

60%

40%

20%

0%

ry
n

l
h

ry
us

ta
lo
ac

ilia

ilia
ec
g

co
om
ha

ob
or

ob
o
op

Ile

ol
St

at

tic
C
Es

p

a
He

re
nc
Pa
cases reporting associated HIV by site

Present
56.5%

Absent
43.5%

Distribution gastrointestinal tuberculosis cases
reporting associated pulmonary tuberculosis

120%

100%

80%

60%

40%

20%

0%
n

ry
l
h

um

ry
us

ta
lo
ac

ilia

ilia
ec
g

co

ni
om
ha

ob
or

ob
o
o

rit
op

Ile

ol
St

at

tic
Pe
C
Es

p

a
He

re
nc
Pa
cases reporting associated pulmonary
tuberculosis by site

0% 5% 10% 15% 20% 25% 30% 35% 40%

Fever 35.6%

Wt. loss 34.1%

Anorexia 35.0%

Night sweats 5.0%

Distribution of gastrointestinal tuberculosis cases
reporting for associated general manifestations

0% 10% 20% 30% 40% 50% 60%

Dysphagia 57.0%

Fistula 32.6%

Haematemesis 12.8%

Esophageal diverticula 2.3%

Epigastric pain 1.2%

Free mediastinal air 1.2%

Mediastinitis 1.2%

Local manifestations of esophagus cases
(n= 86)

Esophageal Tuberculous Nodules
Abdel Magid Kasem
Cairo University

Caseating Granuloma of the esophagus
Makram Milad
Cairo University

0% 10% 20% 30% 40% 50% 60%

Ulcer dyspepsia 52.4%

Outlet obstruction 26.2%

Mass 19.0%

Haematemesis 11.9%

Fistula 2.4%

Local manifestations of gastroduedenal
cases (n= 42)

Diffuse narrowing of the body of the stomach
Calcified Lymph node.
Ba. Meal
Yehia Aly
Cairo University

Tuberculous mass in the stomach
Abdel Magid Kasem
Cairo University

Mucosal T.B. granuloma of the stomach,
Endoscopic biopsy
Makram Milad
Cairo University
Duodenal T.B. ulceration with narrow lumen
Mazen Naga
Cairo, University

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Perforation 81.3%

Ascitis 20.5%

Obstruction 11.6%

Abd.pain 6.3%

Ulcer 4.5%

Abd.mass 1.8%

Hge 0.9%

Fistula 0.9%

Local manifestations of small intestinal cases
(n= 112)

Small intestinal T.B.
Ileoscopy
Multiple tuberculous strictures small intestine
Waheed Doss, Cairo University
Ba. Meal follow-through
Yehia Aly, Cairo University

0% 5% 10% 15% 20% 25% 30% 35%

pain 30.8%

diarrhea 16.7%

distention 9.2%

mass 8.5%

malabsorption 2.0%

Local manifestations of ileocoecal cases
(n= 520)

Tuberculous ulcerated coecal
Ileocoecol T.B. mass Colonoscopy
Ba. Enema Hunter, Cairo University
Yehya Aly
Cairo University

0% 5% 10% 15% 20% 25% 30% 35% 40% 45%

pain 39.1%

rectal bleeding 21.8%

mass 12.1%

distention 9.0%

Local manifestations of colorectal cases
(n= 463)

Colonic T.B. polypoid mass. Colonic T.B. polypoid mass.
Colonoscopy Colonoscopy
Mazen Naga, Cairo, University Hunter, Cairo, University

0% 20% 40% 60% 80% 100%

ascitis 90.6%

pain 59.9%

mass 23.7%

lymphadenopathy 3.4%

jaundice 3.4%

distention 2.0%

diarrhoea 1.0%

Local manifestations of peritonitis cases
(n= 881)

Peritoneal T.B.
Laparoscopy
Hunter, Cairo University
T.B. peritonitis
granulomata with fibrosis in
the omentum
Makram Milad

T.B. Peritoneal adhesions
Peritoneal T.B with adhesions Ultrasonography
Laparoscopy Zakareya Salama
Hunter, Cairo, University Cairo University

Calcified T.B lymph nodes
C.T. scan
Yehia Ali, Cairo, University

0% 20% 40% 60% 80% 100%

jaundice 94.4%

pain 64.8%

Local manifestations of hepatobiliary cases

(n= 71)

T.B. adhesion around the gall bladder T.B. Liver abscess
Laparoscopy, C.T. scan
Hunter, Cairo University Yehia Aly, Cairo University

Hilar stricture due to porta hepatis
lymphadenopathy

0% 10% 20% 30% 40% 50% 60% 70%

Abd.pain 60.9%

jaundice 17.4%

Local manifestations of pancreaticobiliary cases
(n= 86)

Tuberculous distal common bile duct stricture
(Tuberculous Pancreatic Mass)

SUMMARY
x Most publications on GI tuberculosis were in
the last decade.
x The publications were mainly from Asia.
x In the Western hemisphere, the disease is
mainly in emigrants from endemic areas.

SUMMARY
x Adults represent the majority of G.I. T.B. cases.
x The disease is slightly more prevalent in
females.
x HIV infection is a main risk factor.
x Pulmonary T.B. is a frequent but not an
essential association.

SUMMARY
x Patients present with nonspecific constitutional symptoms,
pyrexia and weight loss are the most common.
x Local manifestations depend on the site of G.I. tract affection:
q The esophagus: Dysphagia, fistula and haematemesis.

q The stomach and duedenum: ulcer-dyspepsia, outlet
obstruction and abdominal mass.
q The intestine: pain, diarrhea, perforation & abdominal mass

q The colon: pain and rectal bleeding.

q The peritoneum: ascites and abdominal distension.

q Hepato-pancreaticobiliary: pain and jaundice.

Gastrointestinal T.B.
Differential Diagnosis
Gastrointestinal T.B. should be considered in the
differential diagnosis of :
x Chronic diarrhea
x Malabsorption syndrome
x Abdominal masses
x Ascitis
x Inflammatory bowel disease particularly Crohn’s
disease.
x Gastrointestinal lymphomas
x Other GIT malignancies.

CONCLUSION
x Since 1980s, a resurgence of tuberculosis has
occurred.
x The disease is still and will remain a serious
public health threat worldwide
x Still the great mimicker, gastro intestinal
tuberculosis.
(Jadvar, 1997)

Do not fear to repeat what has already been said.
Men need most things dinned into
their ears many times and from all sides

mak THE FI
es th R
em p ST RUM
rick
up th OR
eir e
ars
THE SECOND registers

s
D enter
THIR
THE

(Rene Laennec, 1781-1826)

G.I. TUBERCULOSIS, A FINAL WORD

Be aware
of Abdominal Tuberculosis

(Bouma et al., 1997)

Gi Tuberculosis Shokry Hunter

Gi Tuberculosis Shokry Hunter

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Gi Tuberculosis Shokry Hunter