1. Intestinal Tuberculosis Second Affiliated hospital Yan Chen Second Affiliated hospital Yan Chen

2. Intestinal tuberculosis General situation Etiology and pathogenesis Pathology Clinical manifestation lab & other examination Diagnosis and differential diagnosis Treatment, prognosis and prevention

3. General ideas Developing countries (95%), especially poverty, malnutrition, overcrowding and HIV coinfection. Involvement of intestine is usually secondary to pulmonary tuberculosis.

4.  The ileocecal region is the most common area of involvement in the intestinal tract. Why ?  The abundance of lymphoid tissue  Long residence time of bactera in ileocucum  The ileocecal region is the most common area of involvement in the intestinal tract. Why ?  The abundance of lymphoid tissue  Long residence time of bactera in ileocucum

5. Predisposing factors Fatigue poor sanitation malnutrition lowered resistance etc.

6. Pathogenic organism---- tubercle bacillus tubercle bacillus maybe either the human type or bovine type human type----90% bovine type----10%

7. Etiology and pathogenesis Route of transmission Propagation by mouth: Hemotogenous dissemination: miliary TB Spread straightly:

8. Bacilium: number, virulence Decreased immunity of human Weakening of intestinal resistance Etiology and pathogenesis

9. Caseation

10. Langhan’s giant cells

11. Clinical manifestation Systemic symptoms ● Fatigue ● low-grade fever ● Night sweats ● Loss of weight ● poor appetite ● anemia Local symptoms ● abdominal distension ● ascites ● mass ● abdominal pain ● diarrhea & constipation ● complication Local symptoms ● abdominal distension ● ascites ● mass ● abdominal pain ● diarrhea & constipation ● complication Extraintestinal tuberculosis manifestation : pulmanory TB

12. Cachexia

13. laboratory findings erythrocyte sedimentation rate, ESR ● ESR typically elevated in the active stage ● Stool routine test : occult blood

14. laboratory findings  PPD test purified protein derivative tuberculin skin test  culture or histological examination of specimen  biopsy-microscopic tissue exam revealed tubercular histological feature of TB  PPD test purified protein derivative tuberculin skin test  culture or histological examination of specimen  biopsy-microscopic tissue exam revealed tubercular histological feature of TB

15. Straight arrow show Conical and shrunken cecum;curved arrow show the narrowing of the terminal ileum Radiography  In advanced cases, symmetric annular stenosis and obstruction associated with shortening, retraction, and pouch formation may be seen. The cecum becomes conical, shrunken, and retracted out of the iliac fossa due to fibrosis within the mesocolon, Ileocecal valve becomes fixed, irregular, gaping, and incompeten

16. TB Colonoscopy

17. Ulceration

18. TB

20. Imaging features Ultrasonography, CT, MRI Asymmetric bowel wall thickening Ascites Inflammatory mass of bowel wall Narrowing of the terminal ileum with thickening and gaping of the iliocaecal valve Fluid surrounding bowel caused by inflammation of the bowel wall

21. Other examinations Laparoscopic biopsy of tubercles found in the peritoneum or other parts Laparotomy Capsule endoscopy enteroscopy

22. Diagnosis & differential diagnosis Younger patients presented with extraintestinal TB Symptom: toxic symptom diarrhea, abdominal pain, abdominal mass X-ray: sterlin sign, stricture of bowel, deformation Colonoscopy and biopsy: inflammation,ulcer,polyp,striction caseating granuloma, bacterium(+) PPD test :strongly positive Exploratory laparotomy for patients difficult to be diagnosed Experimental treatment :2-8 weeks Diagnostic criteria

23. Diagnosis & differential diagnosis Differential diagnosis  Crohn’s disease: The major diagnostic dilemma of ITB is to differentiate it from CD.  Right-sided colonic carcinoma  Amoebiasis or schistosomic granuloma  Chronic bacillary Dysentery or cholera  Malignant lymphoma  FGID:IBS, functional diarrhea Differential diagnosis  Crohn’s disease: The major diagnostic dilemma of ITB is to differentiate it from CD.  Right-sided colonic carcinoma  Amoebiasis or schistosomic granuloma  Chronic bacillary Dysentery or cholera  Malignant lymphoma  FGID:IBS, functional diarrhea

24. TB & CD TB CD  Extraintestinal TB √  Course(relief and relapse) √  Fistula/abscess/peri-anal lesion √  Segmental appearance √  Form of ulcer transverse longitudinal  Caseating granuloma by biopsy √  PPD test with strong positive √  Effective Anti-TB treatment √ TB CD  Extraintestinal TB √  Course(relief and relapse) √  Fistula/abscess/peri-anal lesion √  Segmental appearance √  Form of ulcer transverse longitudinal  Caseating granuloma by biopsy √  PPD test with strong positive √  Effective Anti-TB treatment √

25. Female 19years old Right lower quadrant pain and fever The ileocecal region Sigmoid and Rectom

26. After treatment

28. Treatment purpose: resolve symptom, improve constitutional condition, promote curing, prevent complication Measures: rest nutritional support anti-TB chemotherapy relieve symptom surgery

29. tuberculous peritonitis Same as tuberculous pleurisy