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  1. INTRODUCTION • Declared as a global emergency by the WHO • Most common communicable disease in the developing countries like India. • It accounts for 3 million deaths every year • Accounts for 12% of extrapulmonary tuberculosis
  2. Causative organism  Mycobacterium tuberculosis in immunocompetant individuals  Mycobacterium bovis  Atypical mycobacteria ( Mycobacterium avium intercellulare) in immunosuppressed individuals
  3.  Tuberculosis has a varied spectrum of presentation  Hence it is a great mimicker of neoplastic diseases like lymphoma and inflammatory diseases like ulcerative colitis and crohn’s disease.
  5. GASTROINTESTINAL TUBERCULOSIS  Tuberculosis of the GIT is the sixth most common site of extrapulmonary tuberculosis.  It is a common form of abdominal tuberculosis.  Accounts for up to 90% of patients with abdominal tuberculosis.  Most common site – terminal ileum & ileocaecal region .  Rarely found in stomach, duodenum & esophagus.  Patients with gastrointestinal tuberculosis present with diarrhea, abdominal pain and distension, anorexia, wt. loss.
  6. The most frequent region of involvement in descending order of frequency  Ileocecal junction  Ileum  Cecum,  Ascending colon,  Jejunum  Rest of the colon, rectum,  Duodenum and stomach.
  7. COMPLICATIONS :  Obstruction,  Perforation,  Perianal fistula,  Enterolithiasis formation proximal to the stricture,  Hemorrhage.
  8. MORPHOLOGICAL TYPES  ULCERATIVE  HYPERTROPHIC  STRICTUROUS  A combination of these types can also occur.
  9. site Type Clinical features Small intestine Ulcerative Diarrhoea, malabsorption Stricturous obstruction Large intestine Ulcerative Rectal bleeding Hypertrophic Lump, obstruction Peritoneum Ascitis Adhesive Pain, distension obstruction Lymph node Lump, obstruction
  10. IMAGING IN GASTROINTESTINAL TUBERCULOSIS  Plain Xray  Barium study (for demonstration of mucosal details)  Enteroclysis  Ultrasonography  CT  MRI  Small bowel enteroscopy  Capsule endoscopy
  11. Oesophageal tuberculosis • Very rare • Usually secondary to advanced pulmonary or mediastinal disease • Primary disease involves most commonly the tracheal bifurcation  Spread : From tubercular laryngitis, Adjacent caseating lymph nodes, Vertebral body, Lymphatics and Hematogeneous route
  12.  Patients usually presents with dysphagia, odynophagia, chest pain or cough. • Barium studies shows extrinsic compression by enlarged lymph nodes , smooth strictures, ulceration, mucosal irregularity & traction diverticulum.  Sinus tracts and fistulous communication may develop with the mediastinum or tracheobronchial tree. • CT is more reliable • In HIV patients it manifests as deep ulceration, transmural inflammation with fistula & sinus formation .
  13. Barium Swallow- esophageal stricture with ulceration and periesophageal leak - Tubercular
  14. CT Concentric mural, esophageal wall thickening with periesophageal leak with mediastinal adenopalthy
  15. GASTRIC TUBERCULOSIS • SYMPTOMS : Epigastric discomfort, vomiting, weight loss , fever & haemorrhage • Palpable lump may be present • Pathological types: 1. Ulcerative (commonest) 2. Hypertrophic 3. Miliary tubercles 4. Tubercular pyloric stenosis 5. Solitary tuberculoma 6. Tubercular lymphadenitis
  16. GASTRIC TUBERCULOSIS  Charecterised by multiple large & deep ulcers mostly involving the lesser curvature of the antrum or pyloric region. Scarring may lead to stricture of the antrum & causing gastric outlet obstruction.
  17. DUODENAL TUBERCULOSIS • Intrinsic involvement may be ulcerative or hyperplastic lesions. • Incompetance of sphincter of oddi leads to reflux of air into biliary tract • Barium study shows lymphadenopathy leading on to widening or impressions on the medial aspect of C loop • Healing causes contraction & stenosis leading to duodenal obstruction
  18. LONG STRICTURE OF DUODENUM CAUSED BY TUBERCULOSIS  Can present as diffuse mucosal fold thickening, ulcers or stricture formation & is complicated by fistula formation
  19. Ba MUGIT in a case of duodenal tuberculosis with both extrinsic and intrinsic involvement
  20. TUBERCULOUS ENTERITIS Most common cause of small bowel obstruction in India Ulcerative type is the most common form . Ulcers are stellate or linear shape Stellate ulcers are characterised by barium speck with converging folds. Linear ulcers are perpendicular to long axis resulting in spasm & strictures.
  21.  Hypertrophic form is less common  Bowel loops are matted & fixed by adhesion & fibrosis.  Small bowel enteroclysis provides better mucosal details  Early & incomplete strictures can be detected as evidenced by prestenotic dilatation
  22. Imaging in pathological state of disease First stage: Superficial invasion of the mucosa Imaging reveals: • An accelerated transit time. • Disturbances in tone & peristaltic contractions results in hypersegmentation of barium column called as ‘chicken intestine’ • Disturbances in secretion, results in precipitation, flocculation or dilution of barium. • Changes in intestinal contour are irregular & crenated • Changes in mucosal pattern is seen as softened & thickened folds.
  23. Ba MFT: Accelerated transit time is seen with barium reaching large bowel in Ist film
  24. Ba MFT. Early TB with mucosal irregularity and spiculation
  25. • Second stage : Comprise of ulcerations seen as a barium fleck surrounded by either a thickened wall or converging walls. • Third stage: Has sclerosis, hypertrophy & stenosis. Leads to ‘hour glass stenosis’ with smooth but stiff contours. Mucosal relief will disappear. Multiple strictures with segmental dilatation can occur .
  27. BaMFT - Fixed matted and dilated small bowel loops with mucosal thickening
  29. Ileocaecal region is most commonly affected in small bowel TB . Why? 1) Physiological stasis, 2) Abundant lymphoid tissue (payers patch), 3) Increased rate of absorption in the region 4) close contact of the bacilli with the mucosa.
  30. The lesion may be: i. Hyperplastic with long segments of narrowing, rigidity and loss of distensibility, i.e., the 'pipe stem colon', commonest, ii. Ulcerative iii. Ulcerohyperplastic, and iv. Carcinoma type with a short annular defect and overhanging edges.
  31. Early stages of ileocaecal TB manifest as spasm and hypermotility with edema of the valve. Radiological features: Thickening of the ileocaecal valve lips, Wide gaping of the valve, Narrowing of the terminal ileum ('Fleischner or inverted umbrella' sign).
  32. Fleischner or inverted umbrella sign  Wide gaping of the ileocaecal valve & narrowing of the terminal ileum
  33. Ba MFT - Thickening of ileocecal valve with narrowing of terminal ileum FLEISCHNER SIGN
  34. CT - narrowing of terminal ileum with thickening in region of I.C Valve
  35. Double contrast barium enema may show shallow ulcers that are linear or stellate with characteristic elevated margins Advanced disease shows  symmetric,annular, napkin ring stenoses.  obstruction or shortening,  retraction & pouch formation  Caecum classically becomes conical, shrunken and retracted out of the iliac fossa due to contraction of the mesocolon and appears amputated.
  36. Hepatic flexure may also be pulled down. Loss of the normal ileocecal angle, Dilated terminal ileum may appear suspended and hanging from a retracted, shortened cecum (goose neck deformity)
  37. BARIUM STUDIES • Demonstrate multiple strictures • Distended caecum or terminal ileum • Mucosal irregularity • Flocculation & fragmentation of barium
  39. BaMFT-Retracted and contracted caecum with terminal ileum appearing suspended with loss of I-C angle. GOOSE NECK DEFORMITY
  40. STERLING SIGN Narrowed terminal ileum with rapid emptying of the diseased segment through a gaping ileocaecal valve into a shortened, rigid obliterated caecum. STRING SIGN A persistent narrow stream of barium in the bowel indicates stenosis. Both Stierlin's sign and string sign are also noted in Crohn's disease and cannot be considered specific for tuberculosis.
  41. BaMFT : Persistent narrow stream of barium in bowel indicating stenosis String sign :
  42. BaMFT - Advanced IC Koch's with symmetric annular napkin ring stenosis with conical shrunken and caecum
  43. Multiple stenotic segments of the colon in double contrast barium enema with colonic fistula
  44. Ultrasonography  Dilated small bowel loops & bowel wall thickening  Non-specific bowel wall thickening with a hypoechoic halo of >5mm
  45. •Circumferential thickening of the terminal ileum and caecum ( Club sign). Pseudokidney sign – TB involvement of the ileocaecal region which is pulled up to a subhepatic position
  46. USG-Retracted and pulled up caecum wall with thickening in the subhepatic region
  47. CT in gatrointestinal TB • Bowel wall thickening is a non specific manifestation • Mural thickening affecting the ileocaecal junction is the most common finding • Caecal involvement is concentric ;may be eccentric involving medial caecal wall.
  48. TUBERCULOSIS CROHN’S DISEASE Asymmetric and irregular wall thickening ; Circumferential bowel wall thickening ; ulceration on mesentric surface Fleischner sign on barium Cobble stone appearance on barium No creeping fat Creeping fat (abnormal quantity of mesentric fat) present Positive chest film Negative chest film Omental & peritoneal thickening Normal omentum & peritoneum Enlarged lymph nodes with low density centres Enlarged soft tissue density lymphnodes
  49. Cobblestone appearance
  50. APPENDICEAL TB  Isolated appendicular involvement is rare CHRONIC APPENDICITIS  Due to intrinsic disease of appendix  Involvement by surrounding lymphnodes  Occlusion of lumen by a caecal mass
  51. ANORECTAL TUBERCULOSIS  May rarely present as ulcerating proctitis.  Fistulas , strictures & chronic ischiorectal abscess may occur.  DD: LGV, Amoebiasis, Actinomycosis & Schistosomiasis
  52. TUBERCULOUS PERITONITIS  Peritoneum and its reflections are common sites of tuberculous involvement of the abdomen.  Most cases are as a result of reactivation of latent tuberculous foci in the peritoneum or due to tubercular salpingitis or discharge of caseous material from diseased lymph nodes.  Mode of spread:  Haematogenous spread  Secondary to lymph node rupture  Perforated gastrointestinal tract  Perforated fallopian tubes
  53. Three forms of tuberculous peritonitis  i. Wet ascitic type-seen in 90% cases characterized by large amounts of free or loculated ascitic fluid.  ii. Fibrotic fixed type-characterized by mesenteric and omental thickening and masses, matted bowel loops and occasionally loculated ascitis.  iii. Dry or 'plastic' type-unusual caseous nodules, fibrous peritoneal reaction and dense adhesions
  54. USG: Voluminous free fluid with floating bowel loops in a case of peritoneal TB
  55. USG. Complex ascitis with loculations and septae seen in perihepatic pouch
  56. On CT, High density (25-45 HU) of fluid due to high fibrin content and cellular debris is characteristic of TB. In earlier transudative stage of immune reaction the ascitis may be near water density. Fat fluid level, a feature of chylous ascitis with supportive evidence of mesenteric adenopathy has been described in tuberculosis. CT fails to show multiple, thin interlacing septa in most patients, especially in sub diaphragmatic and pelvic regions.
  57. CT: Ascitis with omental thickening and spread out bowel loops
  58. Barium Meal FT-Mildly dilated small bowel loops with increased interloop distance in tubercular peritonitis
  59. TB peritonitis Vs carcinomatosis Smooth peritoneum with minimal thickening and marked enhancement Nodular and irregular peritoneal thickening
  60. Abdominal cocoon -sclerosing encapsulating peritonitis CT showing small bowel loops congregated at the centre of the abdomen encased by a sac like soft tissue density mantle
  61. OMENTUM • Omental thickening is present in both tuberculosis & peritoneal carcinomatosis, Nodular, Smudged (Infiltration with ill-defined lesions) Caked appearance (Soft tissue replacement). • The smudged type is the most common type • Nodular type is not seen in tuberculosis • Omental caking is seen in both
  62. USG -smooth omental thickening and ascitis
  63. Mesenteric tuberculosis • Micro (<5mm) or macro (>5mm) mesentric nodules are present • Mesentric thickening of >15mm is found abnormal • Thickening is a result of lymphadenopathy , fat deposition & edema due to lymphatic obstruction that makes it more echogenic on USG.
  64. Arbitrary value of 15 mm is considered as a threshold for disease. Mesentery becomes echogenic as a result of increased fat deposition due to lymphatic obstruction. Presence of enlarged lymph nodes adds to the diagnosis of early tuberculosis. Other conditions like portal hypertension and lymphoma can also give rise to mesenteric thickening. Fixed loops of bowel and mesentery standing out as spokes radiating out from the mesenteric root are described as US 'stellate' sign. CT demonstrates thickened mesentery by its increased vascularity and thickened strands, tethering of bowel loops, forming an abdominal mass.
  65. USG-echogenic and thickened mesentry
  66. CT-Ascitis with omental thickening
  67. Club sandwich sign or sliced bread appearance  Localised or focal ascites between radially oriented bowel loops as a result of local exudation from inflamed bowel loops or ruptured lymph nodes. USG- Mesenteric thickening seen between loops- "club sandwich"appearance
  68. Nodal Involvement • Mesentric or retroperitoneal involvement • With or without calcification or caesation. • Nodes involved are mesentric, peri pancreatic periportal or para-aortic groups of lymph nodes. • Reflects the lymphatic drainage of sites in the small bowel and liver that are seeded haematogenously.
  69. Plain x ray  Erect & supine films  Calcification of the nodes
  70. Ultrasonography Multiple hypoechoic enlarged discrete nodes in periportal and peripancreatic region
  71. USG-Multiple enlarged hypoechoic mesenteric nodes, with foci of calcification
  72. CT OF NODES • Most common manifestation on CT • Contrast enhancement patterns 1. Peripheral rim enhancement 2. Non-homogenous enhancement 3. Homogenous enhancement 4. Non-enhancement
  73. CT scan at the level of porta showing multiple hypodense nodes showing peripheral rim enhancement in tuberculous lymphadenitis.
  74. CT- Large conglomerate hypodense nodal mass in periportal and peripancreatic region
  75. Peripheral rim enhancement is highly suggestive of tuberculosis  Differential diagnosis: Malignant adenopathy Metastases from testicular tumours Whipples disease Lymphoma after radiotherapy
  76. Non contrast axial CT shows lymphadenopathy with central caeseus necrosis
  77. TUBERCULOSIS LYMPHOMA Distribution- Mesenteric,lesser omental,anterior pararenal or upper para-aortic nodes. Predominantly lower para-aortic, retrocural nodes. . Enhancement pattern- Peripheral and multiloculated Homogenous enhancement Others finding. Mesenteric thickening, I-C region and ascites present. Absent
  78. HEPATOSPLENIC TUBERCULOSIS  Part of disseminated or miliary tuberculosis  Appear as tiny low density masses scattered throughout the organ on CT
  81. MACRONODULAR TUBERCULOSIS  Macronodular form is an uncommon manifestation  It appears as multiple low attenuation (15-50HU) 1-3 cm round lesions or simple tumour like lesions.
  82. MRI  Coronal T1 weighted image shows hypointense masses within the liver.  May show peripheral enhancement with honey combing appearance
  83. MRI • Coronal T1 weighted image shows peripheral rim enhancement with Honey comb appearance within the mass Diagnosis of tuberculosis was confirmed on USG guided biopsy
  84.  Coronal T2 weighted image shows hyperintense lesion with perihepatic fluid collection
  85. PANCREATIC TUBERCULOSIS • May present as pancreatitis • Usually localised to head but can also involve body & tail • USG may show well defined hypoechoic areas • CT may show hypodense necrotic lesions within the enlarged pancreas • Peripancreatic nodes are involved • Calcifications can be present
  87. HIV & TUBERCULOSIS • Extrapulmonary dissemination with atypical presentations are common • Infection is commonly by atypical mycobacteria MAC • In 25% of cases , large nodes with low attenuation with no peripheral enhancement is seen • Large bulky retroperitoneal or mesentric lymphadenopathy can occur simulating lymphoma or kaposi’s sarcoma
  88. • Hepatosplenic involvement is more frequent • Also causes hepatosplenomegaly in 15% of the cases • MAC produces intrahepatic & extrahepatic stenosis & dilatation leading to cholangitis • Ileocaecal involvement is same as non- HIV patients
  92. A high degree of clinical suspicion & familiarity with various radiological manifestations of the disease allow early diagnosis & timely initiatiation of appropriate therapy to reduce patient mortality & morbidity
  93. `