Gastrointestinal tuberculosis

Isolated hepatic tuberculosis associated with portal vein thrombosis and hepatitis B virus coinfection: A case report and review of the literature

BACKGROUND

While tuberculosis (TB) itself is a common disease, isolated TB of the liver is a rare entity. Tubercular involvement of the liver is more commonly a part of a disseminated disease of the hepatic parenchyma. In contrast, isolated hepatic TB spread through the portal vein from the gastrointestinal tract is seldom encountered in clinical practice, with only a few sporadic cases and short series available in the current literature. Vascular complications, such as portal vein thrombosis (PVT), have rarely been reported previously.

CASE SUMMARY

A 22-year-old man was hospitalized with complaints of a 3-mo history of fever and weight loss of approximately 10 kg. He had a 10-year hepatitis B virus (HBV) infection in his medical history. Contrast-enhanced computed tomography (CECT) confirmed hepatosplenomegaly, with hypodensity of the right lobe of the liver and 2.1 cm thrombosis of the right branch of the portal vein. A liver biopsy showed epithelioid granulomas with a background of caseating necrosis. Ziehl-Nelson staining showed acid-fast bacilli within the granulomas. The patient was diagnosed with isolated hepatic TB with PVT. Anti-TB therapy (ATT), including isoniazid, rifapentine, ethambutol, and pyrazinamide, was administered. Along with ATT, the patient was treated with entecavir as an antiviral medication against HBV and dabigatran as an anticoagulant. He remained asymptomatic, and follow-up sonography of the abdomen at 4 mo showed complete resolution of the PVT.

CONCLUSION

Upon diagnosis of hepatic TB associated with PVT and HBV coinfection, ATT and anticoagulants should be initiated to prevent subsequent portal hypertension. Antiviral therapy against HBV should also be administered to prevent severe hepatic injury.

Peritoneal thickening: It's not always carcinomatosis

The peritoneal pseudotumor localization of tuberculosis is a rare clinical form, representing 1 to 3% of extrapulmonary site of tuberculosis. It represents the sixth most common extra pulmonary site of tuberculosis. It is a great mimicker with major overlapping clinical and imaging features. Differentiating peritoneal tuberculosis and peritoneal carcinomatosis in imaging remains challenging. We present a case of a 37-year old woman complaining of chronic abdominal pain and distension who has been diagnosed to have peritoneal carcinomatosis based on CT findings, histopathological study then revealed necrotizing, granulomatous inflammation consistent with tuberculosis. This case showed the interest to be aware of the common and uncommon imaging features of tuberculosis by radiologists to better assess for alternative differential diagnosis.

TB or not TB: A comprehensive review of imaging manifestations of abdominal tuberculosis and its mimics

The ever-growing prevalence of tuberculosis is a cause for concern among both developing and developed countries. Abdominal tuberculosis is the most common site of extrapulmonary tuberculosis and involves almost all of the visceral organs. Clinical presentation of abdominal tuberculosis is often non-specific. Thus, having a high index of clinical suspicion is necessary to aide early diagnosis and guide prompt initiation of appropriate treatment. In this review, we focus on the entire spectrum of abdominal tuberculosis and other diseases mimicking it with an emphasis on their imaging findings.

Primary isolated hepatic tuberculosis mimicking small hepatocellular carcinoma: A case report

RATIONALE

Mycobacterium tuberculosis (TB) remains a serious threat in developing countries. Primary isolated hepatic tuberculosis is extremely rare. Because of its non-specific imaging features, noninvasive preoperative imaging diagnosis of isolated hepatic tuberculoma remains challenging.

PATIENT CONCERNS

A 48-year-old man was admitted to our hospital due for suspected liver neoplasm during health examination.

DIAGNOSES

The tests for blood, liver function, and tumor markers were within normal range. Preoperative ultrasonography (US) showed a hypoechoic lesion with a longitudinal diameter of 2.5 cm in segment six of liver. It exhibited early arterial phase hyperenhancement and late arterial phase rapid washout in contrast-enhanced US. It demonstrated hyperintensity in T2-weighted magnetic resonance imaging and partly restricted diffusion in diffusion-weighted imaging. For this nodule, the preoperative diagnosis was small hepatocellular carcinoma (HCC).

INTERVENTIONS

Laparoscopic hepatectomy was performed. Intraoperative extensive adhesion in the abdominal cavity and liver was found. The lesion had undergone expansive growth.

OUTCOMES

Microscopically, a granuloma with some necrosis was detected. With both acid-fast staining and TB fragment polymerase chain reaction showing positive results, TB was the final histology diagnosis. After surgery, the patient declined any anti-TB medication. During the follow-up, he had no symptoms. In the sixth month after surgery, he underwent an upper abdominal US. It showed no lesions in the liver.

LESSONS

Because of non-specific imaging findings and non-specific symptoms, a diagnosis of isolated hepatic TB is difficult to make, especially for small lesions. A diagnosis of HCC should be made cautiously when small isolated lesions in the liver are encountered, especially in patients without a history of hepatitis and with negative tumor markers.

Ultrasonography of peritoneal tuberculosis

Purpose

The objective of this work was to describe different presentations of peritoneal tuberculosis on ultrasound.

Materials and methods

This was a retrospective study conducted between 2008 and 2016 at the Main Hospital in Dakar, and including 38 cases of peritoneal tuberculosis. The tests were performed on Philips Envisor and Hitachi Preirus with 10 and 12 MHz linear transducers. The mean age was 26 years and the sex ratio was 0.8. The diagnosis of peritoneal tuberculosis was based on histological evidence (17 cases), isolation of BK from sputum (5 cases), positive adenosine deaminase in ascites fluid (4 cases) or a favorable clinical course after trial antituberculosis treatment (4 cases). The structures studied were the parietal peritoneum, the mesentery, the large omentum, as well as the characteristics of ascites, and extra-peritoneal lesions.

Results

Parietal peritoneal involvement was found in 89.4% of patients, including regular diffuse hypoechoic thickening in 70.5% and nodular thickening in 11.7%. Ascites was present in 84.2% of patients. The great omentum showed anomalies in 73.6% of cases in relation to 3 aspects: trilamellar thickening made up of a thick, hyperechoic central layer surrounded by 2 thin peripheral hypoechoic layers in 46.4% of cases; a single-layer hyperechoic thickening in 21.4% of cases; heterogeneous hyperechogenic thickening with hypoechoic nodules in 32.1% of cases. Mesentery abnormalities were noted in 63.1% of patients with hypoechoic thickening.

Conclusion

Ultrasound with the advantage of safety and accessibility is a reliable technique for the diagnosis of peritoneal tuberculosis. In some cases, it allows for a guided percutaneous biopsy to avoid the use of laparoscopy.

Peritoneal tuberculosis with elevated CA-125 mimicking ovarian cancer with carcinomatosis peritonei: Crucial CT findings

Preoperative diagnosis of peritoneal tuberculosis is often difficult because of confusion with ovarian cancer. A 56-year-old woman was admitted to our hospital with abdominal fullness. Ascites, prominent bilateral ovaries, and elevated CA-125 were noted. Computed tomography showed thickened peritoneum and strandings in the mesentery and omentum. Exploratory laparotomy was performed under the provisional diagnosis of ovarian cancer, but the final diagnosis was peritoneal tuberculosis. Careful evaluation of bilateral fallopian tubes and ovaries and peritoneum are helpful for correct diagnosis.

Imaging in extrapulmonary tuberculosis

Tuberculosis (TB) remains a major global public health problem, with 1.5 million deaths annually worldwide. One in five cases of TB present as extrapulmonary TB (EPTB), posing major diagnostic and management challenges. Mycobacterium tuberculosis adapts to a quiescent physiological state and is notable for its complex interaction with the host, producing poorly understood disease states ranging from latent infection to active clinical disease. New tools in the diagnostic armamentarium are urgently required for the rapid diagnosis of TB and monitoring of TB treatments, and to gain new insights into pathogenesis. The typical and atypical imaging features of EPTB are reviewed herein, and the roles of several imaging modalities for the diagnosis and management of EPTB are discussed.

Hepatic tuberculosis: a multimodality imaging review

OBJECTIVES

We aim to illustrate the multimodal imaging spectrum of hepatic involvement in tuberculosis (TB). Whilst disseminated tuberculosis on imaging typically manifests as multiple small nodular lesions scattered in the liver parenchyma, isolated hepatic tuberculosis remains a rare and intriguing entity.

METHODS

Indubitably, imaging is the mainstay for detection of tubercular hepatic lesions which display a broad spectrum of imaging manifestations on different modalities. While sonography and computed tomography (CT) findings have been described in some detail, there is a paucity of literature on magnetic resonance imaging (MRI) features. Due to a significant overlap with other commoner and similar appearing hepatic lesions, hepatic tuberculosis is often either misdiagnosed or labelled as indeterminate lesions. This article is a compendium of cases highlighting the spectrum of imaging patterns that can be encountered in patients with isolated primary hepatic tuberculosis as well as disseminated (secondary) disease. Rare patterns of primary disease such as tubercular cholangitis, hypervascular liver masses, and those with vascular complications are also illustrated and discussed.

CONCLUSIONS

Imaging plays a valuable role in the detection of tubercular hepatic lesions. Also, imaging can be helpful in their characterisation and for assessing associated complications.

TEACHING POINTS

• Hepatic TB has myriad imaging manifestations and is often confounded with neoplastic lesions. • Imaging patterns include miliary TB, macronodular TB, serohepatic TB and tubercular cholangitis. • Concurrent splenic, nodal or pulmonary involvements are helpful pointers towards the diagnosis. • Miliary calcifications along the bile ducts are characteristic of tubercular cholangitis. • Histological/microbiological confirmation is often necessary to confirm the diagnosis.

Intraperitoneal tuberculous abscess: Computed tomography features

AIM: To evaluate the computed tomography (CT) features of intraperitoneal tuberculous abscess (IPTA).

METHODS: Eight patients with IPTA confirmed by pathology were analyzed retrospectively. The clinical symptoms, medical images, and surgical findings were evaluated. Involvement of the intestine, peritoneum, viscera, and lymph nodes was also assessed.

RESULTS: All 8 patients had a history of abdominal discomfort for 1 to 6 mo. Physical examination revealed a palpable abdominal mass in 6 patients. Three patients had no evidence of pulmonary tuberculosis (TB). All IPTAs (11 abscesses) were seen as a multiseptated, peripherally enhanced, hypodense mass with enlarged, rim-enhanced lymph nodes. The largest abscess diameter ranged from 4.5 cm to 12.2 cm. CT showed 2 types of IPTA: Lymph node fusion and encapsulation. Of the 8 patients, one had liver tuberculosis and one had splenic and ovarian tuberculosis. Two cases showed involvement of the terminal ileum and ileocecal junction. Ascites were found in 4 cases. Three patients had peritonitis and mesenteritis. Three patients showed involvement of the omentum. Three patients had histological evidence of caseating granuloma, and 5 had histological evidence of acid-fast bacilli.

CONCLUSION: CT is crucial in the detection and characterization of IPTA. Certain CT findings are necessary for correct diagnosis.

Imaging in tuberculosis

Despite many advances in both diagnosis and treatment, tuberculosis still remains one of commonest causes of morbidity and mortality from any infectious cause in the world. Although the overall incidence and mortality rate for tuberculosis has decreased over the years, timely and accurate diagnosis of tuberculosis is essential for the health of the patient as well as the public. For the diagnosis of tuberculosis, a high degree of clinical suspicion is required, and this becomes much more important in high-risk populations. Tuberculosis may masquerade as any disease; therefore, tissue and microbiological assessment is sometimes important for establishing the diagnosis. However, in daily practice, the clinician and radiologist should be familiar with the imaging features of pulmonary and extrapulmonary tuberculosis, as well as manifestations of tuberculosis in immunocompromised patients. Imaging provides a very important role in the diagnosis and management of tuberculosis. Although chest X rays remain the basic imaging modality for pulmonary tuberculosis, computed tomography, magnetic resonance imaging, and nuclear medicine techniques, including positron emission tomography/computed tomography, are extremely helpful in the assessment of both pulmonary and extrapulmonary tuberculosis.

Computed tomography of the spleen: how to interpret the hypodense lesion

Background

As the largest single lymphatic organ in the human body, the spleen is responsible for central immunological and haematological tasks. Therefore, the spleen can be subject to a wide range of pathologic disorders. Computed tomography (CT) represents the most widely applied cross-sectional abdominal imaging technique and is considered the imaging modality of choice for the evaluation of numerous abdominal pathological conditions. Hypodense splenic lesions are frequently encountered on abdominal CT images. Although most hypodense lesions of the spleen can be considered benign, some findings and clinical conditions warrant closer attention to the lesion. CT offers a number of morphological criteria that can be applied to differentiate hypodense lesions of the spleen, such as a the appearance of a lesion’s borders, its attenuation, as well as the presence of calcifications or solid components.

Methods

This article reviews the most common splenic pathologies leading to hypodense appearances on CT images and illustrates the key CT imaging findings in the context of the clinical history of the patients.

Conclusion

The key imaging findings of hypodense splenic lesions are presented in order to aid interpretation during routine evaluation of abdominal CT images.

Teaching Points

• Haemangiomas, congenital in origin, represent the most common benign lesions of the spleen.

• Lymphoma represents the most common malignant tumour of the, usually secondarily involved, spleen.

• Most hypodense splenic lesions on CT represent benign lesions that require no further work-up.

• For correct interpretation, hypodense splenic lesions need to be evaluated in the clinical context.

Infections and infestations of the gastrointestinal tract. Part 1: bacterial, viral and fungal infections

The purpose of this article is to review the imaging findings of various infections affecting the gastrointestinal tract. Barium examinations, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography all play an important role in the diagnostic workup of gastrointestinal tract infections. Knowledge of differential diagnosis, sites of involvement, and typical imaging features of different infections can help in accurate diagnosis and guide treatment.

Primary gastric tuberculosis presenting as non-healing ulcer and mimicking Crohn's disease

A 39-year-old woman was referred to our hospital for treatment of a non-healing gastric ulcer. Esophagogastroduodenoscopy (EGD) revealed an erosion in the pyloric antrum and a longitudinal ulcer on the lesser curvature of the gastric body. The histopathologic examination of biopsy specimens revealed non-caseating epithelioid granulomas. Acid-fast staining did not reveal bacilli. The differential diagnosis included gastric tuberculosis, Crohn's disease, and sarcoidosis and empiric antituberculous therapy consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide was initiated. Gastric lesions were subsequently resolved and non-caseating epithelioid granulomas were not demonstrated on the post-treatment examination. Recurrence was not observed during the follow-up period of 53 months.

Miliary tuberculosis associated with chronic neutrophilic leukemia

We report a case of miliary tuberculosis associated with chronic neutrophilic leukemia (CNL). A 70-year-old woman was referred to our hospital complaining of a 1-month history of persistent fever and anorexia. Chest and abdominal computed tomography images revealed diffuse small nodular lesions in the bilateral lung fields and extreme splenomegaly. Sputum cultures isolated Mycobacterium tuberculosis. After anti-tuberculous therapy for 1 year, the patient underwent splenectomy for massive splenomegaly and progressive leukocytosis. The presence of the homozygous JAK2 V617F tyrosine kinase mutation was also demonstrated in the peripheral blood. She was finally diagnosed as having miliary tuberculosis associated with CNL based on the histopathological examination of spleen. The patient was treated with a daily dose of 500 mg of hydroxyurea. As a result, 18 months after the splenectomy, her leukocyte count was decreased and her clinical condition was markedly improved; there was no relapse of the CNL.

Tuberculoma of the liver

We report an isolated giant solid macronodular tuberculoma in an 8-year-old boy. A large-space-occupying lesion in the right lobe with nodular surface and hard consistency mimicked liver malignancy. This case is unusual as the ultrasonography, computed tomography scan, and aspiration cytology were all suggestive of a malignant tumor. Laparotomy confirmed a 15 × 10 cm nodular tumor present in the right lobe of liver. The segments 5, 6, 7, and 8 were excised. The histopathology revealed tuberculosis.

Intra-abdominal and gastrointestinal tuberculosis

OBJECTIVE

Reports suggest that the rates of tuberculosis (TB) continue to rise in the UK and throughout the world. The spread of the disease is aided by poverty, overcrowding, co-infection with human immunodeficiency virus and drug resistance. Consistent with the overall trend, intra-abdominal and gastrointestinal (GI) TB rates are rising. Tuberculosis is a treatable disease, whether occurring in the lungs or at extra-pulmonary sites but the nonspecific features of the disease result in difficulty in establishing a diagnosis. In this report, we have concentrated on the benefits and potential pitfalls of diagnostic methods.

METHOD

A literature review was performed using the National Library of Medicine's Pubmed Database using the keywords diagnosis, management, abdominal and GI TB.

RESULTS

Abdominal TB presents a particular challenge, as the diverse features of the disease do not readily suggest a particular diagnosis and diagnostic delays lead to significant morbidity and mortality. A number of investigative methods have been used to aid in the diagnosis of abdominal and GI TB.

CONCLUSION

The nonspecific presentation of abdominal and GI TB present challenges in the diagnosis of this increasingly common disease. A high index of suspicion is an important factor in early diagnosis. After a diagnosis has been established, prompt initiation of treatment helps prevent morbidity and mortality.

Unusual presentation of tuberculosis as a splenic mass

Tuberculosis is an important health problem in developing countries, with varying clinical presentations depending on the organs/systems involved. Tuberculosis is mostly seen in immuno-compromised individuals, such as those with acquired immune deficiency syndrome or malignancies. Here we report a case of a spleen tuberculoma in a 29-year-old male patient with no known immune deficiency. He first presented with abdominal pain, and subsequent ultrasonographic examination revealed a splenic lesion of 10 cm in diameter. A computerized tomography scan of the abdomen confirmed the presence of a solitary, hypodense, septated cystic lesion. Lack of evidence supporting the presence of a splenic infection or a primary/metastatic malignancy prompted explorative surgery where a septated abscess formation was discovered and splenectomy was performed. Histopathological examination revealed granulomatous inflammatory changes with Langerhans-type giant cells, which are consistent with tuberculosis. For a period of two months, antituberculosis therapy with four drugs, isoniazid, rifampicin, pyrazinamide, and ethambutol, was carried out. Pyrazinamide and ethambutol were quitted at the end of two months. Therapy with isoniazid and rifampicin was planned for an additional 10 months. We would like to call attention to yet another atypical presentation of extrapulmonary tuberculosis.

CT imaging of colitis

Computed tomography (CT) is widely used to assess patients with nonspecific abdominal pain or who are suspected of having colitis. The authors recommend multidetector CT with oral, rectal, and intravenous contrast material and thin sections, which can accurately demonstrate inflammatory changes in the colonic wall and help assess the extent of disease. In most cases, the final diagnosis of the type of colitis is based on clinical and laboratory data and colonoscopic and biopsy findings, but specific CT features help narrow the differential diagnosis. Ulcerative colitis is distinguished from granulomatous colitis (Crohn disease) in terms of location of involvement, extent and appearance of colonic wall thickening, and type of complications. Ulcerative colitis and Crohn disease (granulomatous colitis) are rarely associated with ascites, which is often seen in infectious, ischemic, and pseudomembranous colitis. Pseudomembranous colitis also demonstrates marked wall thickening and, occasionally, skip areas but is associated with broad-spectrum antibiotic treatment or chemotherapy. Neutropenic colitis is characterized by right-sided colonic and ileal involvement, whereas ischemic colitis is characterized by vascular distribution pattern and history. Diverticulitis is a focal asymmetric process with fascial thickening and inflamed diverticula. Dilatation of a thick-walled appendix with increased enhancement and adjacent stranding suggests appendicitis, but inflammatory changes may extend to the cecum and terminal ileum. Epiploic appendagitis is a focal rim-enhancing area next to the colon, usually without any substantial colonic wall thickening.

Imaging of hepatic infections

Imaging plays a significant role in the detection, characterization and treatment of hepatic infections. Infectious diseases of the liver include pyogenic and amoebic abscesses and parasitic, fungal, viral and granulomatous infections. With increases in worldwide travel, immunosuppression and changing population demographics, identification of cases of hepatic infection is becoming more common in daily practice. Knowledge of the imaging features seen with hepatic infections can assist in early diagnosis and timely initiation of appropriate therapy. This review presents the imaging appearances of hepatic infections, emphasizing specific features that may contribute to the diagnosis. Examples of the imaging findings seen with pyogenic and amoebic abscesses, infection with Echinococcus granulosus (Hydatid), schistosomiasis, candidiasis and tuberculosis (TB) are presented.

Abdominal tuberculosis: imaging features

LEARNING OBJECTIVES

Radiological findings of abdominal tuberculosis can mimic those of many different diseases. A high level of suspicion is required, especially in high-risk population. In this article, we will describe barium studies, ultrasound (US) and computed tomography (CT) findings of abdominal tuberculosis (TB), with emphasis in the latest. We will illustrate CT findings that can help in the diagnosis of abdominal tuberculosis and describe imaging features that differentiate it from other inflammatory and neoplastic diseases, particularly lymphoma and Crohn's disease. As tuberculosis can affect any organ in the abdomen, emphasis is placed to ileocecal involvement, lymphadenopathy, peritonitis and solid organ disease (liver, spleen and pancreas). A positive culture or hystologic analysis of biopsy is still required in many patients for definitive diagnosis.

Imaging diagnosis of 12 patients with hepatic tuberculosis

AIM

To assess CT, MR manifestations and their diagnostic value in hepatic tuberculosis.

METHODS

CT findings in 12 cases and MR findings in 4 cases of hepatic tuberculosis proved by surgery or biopsy were retrospectively analyzed.

RESULTS

(1) CT findings: One case of serohepatic type of hepatic tuberculosis had multiple-nodular lesions in the subcapsule of liver. Parenchymal type was found in 10 cases, including multiple, miliary, micronodular and low-density lesions with miliary calcifications in 2 cases; singular, low-density mass with multiple flecked calcifications in 3 cases; multiple cystic lesions in 1 case; multiple micronodular and low-density lesions fusing into multiloculated cystic mass or "cluster" sign in 3 cases; and singular, macronodular and low-density lesion with multiple miliary calcifications in 1 case. One case of tuberculous cholangitis showed marked dilated intrahepatic ducts with multiple flecked calcifications in the porta hepatis. (2) MR findings in 4 cases were hypointense on both T1-weighted imagings and T2-weighted imagings in one case, hypointense on T1-weighted imagings and hyperintense on T2-weighted imagings in 3 cases. Enhanced MR in 3 cases was slightly shown peripheral enhancement or with multilocular enhancement.

CONCLUSION

Various types of hepatic tuberculosis have different imaging findings, and typical CT and MR findings can suggest the diagnosis.

Colorectal tuberculosis

Our objective was to evaluate the incidence of colorectal tuberculosis in our series and to study its radiological spectrum. A total of 684 cases of proven gastrointestinal tuberculosis with positive barium contrast findings seen over a period of more than one decade were evaluated. The study did not include cases where colon was involved in direct contiguity with ileo-caecal tuberculosis. Seventy-four patients (10.8%) had colorectal tuberculosis. Commonest site involved was transverse colon, closely followed by rectum and ascending colon. Radiological findings observed were in the form of strictures (54%), colitis (39%) and polypoid lesions (7%). Complications noted were in the form of perforations and fistulae in 18.9% of cases. Colorectal tuberculosis is a very common site for gastrointestinal tuberculosis. Typical findings of colorectal tuberculosis are strictures, signs of colitis and polypoid lesions. Common complications are perforation and fistulae.

Tuberculous peritonitis in an endemic area

BACKGROUND

Tuberculous peritonitis is a fatal disease if not diagnosed in time.

AIMS

To identify the clinical, laboratory, and diagnostic features of tuberculous peritonitis in Iranian patients.

PATIENTS

Included in the study were all cases of tuberculous peritonitis with a definite diagnosis confirmed by pathology in four referral University Hospitals in Tehran between 1989 and 1999.

METHODS

All clinical, laboratory, and radiological findings as well as invasive procedures were reviewed.

RESULTS

A total of 50 patients (30 female, 20 male), mean age 33.5 years were studied. Main presenting symptoms included abdominal pain (84%), weight loss (72%) and fever (50%). In 24% of patients a positive tuberculin test was found. Erythrocyte sedimentation rate >50 mm/h was detected in 60% of patients and 4.4% had an Erythrocyte sedimentation rate >100 mm/h. Laparoscopy or laparotomy showed peritoneal seeding in 74% of patients.

CONCLUSIONS

Exudative ascites should give rise to clinical suspicion of tuberculous peritonitis in endemic areas or in immigrants from endemic areas. Laparoscopy is the most sensitive and specific diagnostic method.

CT features in abdominal tuberculosis: 20 years experience

BACKGROUND: Abdominal tuberculosis (TB) is endemic in the developing world and is reemerging in the West. Since computed tomography (CT) has the ability to demonstrate changes in the peritonium, mesentry, lymphnodes, bowel and solid organs and is being increasingly used for primary evaluation of abdominal conditions, it is important to be familiar with the CT features of the disease. METHODS: CT findings were retrospectively analysed in 49 patients with proved abdominal TB. Patients with genitourinary TB and with AIDS/HIV were not included in the study. RESULTS: Peritoneal involvement was the most common feature (77.5%) with ascites (wet peritonitis) seen in more than half the cases (55.2%). The rest showed peritoneal, mesenteric or omental thickening or mass formation but no ascites (dry peritonitis). Other findings included lymphadenopathy (46.9% mainly of diffuse nature, bowel wall thickening (38%) and solid organ involvement (20.4%). CONCLUSIONS: CT reliably demonstrates the entire range of findings which need interpretation in the light of clinical and laboratory data.

Tuberculous peritonitis defying diagnosis: report of a case

A case of tuberculous peritonitis, which has been scarcely encountered in clinical practice in recent years, is reported. A 32-year-old man was admitted to our hospital complaining of abdominal fullness, anorexia, and a 15 kg weight loss. His abdomen was distended. There was neither any previous history nor recent contact with tuberculosis. The laboratory data indicated increased C-reactive protein and erythrocyte sedimentation rate, but the white blood cell count was normal. A chest X-ray examination revealed no abnormalities. Abdominal X-ray showed scattered, small-intestinal gas shadows. Abdominal computed tomography scanning revealed a diffuse thickening of the dilated bowel wall, mainly adjacent to the mesentery. After a detailed examination a diagnosis of peritonitis carcinomatosa of unknown origin was suspected, and an exploratory laparotomy was done. Severe adhesions between the parietal peritoneum and the bowel were found. An excisional biopsy specimen was taken from the peritoneum, and a diagnosis of tuberculosis was thus made. Triple therapy with isoniazid, rifampicin, and kanamycin was started, and both the intestinal obstruction and anorexia were thus resolved.

A meta-analysis of antimycobacterial therapy for Crohn's disease

OBJECTIVE

Various therapies have been studied for the treatment of Crohn's disease, including antimycobacterial therapy. Meta-analysis was used to evaluate the effect of antimycobacterial therapy in patients with Crohn's disease.

METHODS

Randomized, controlled trials comparing antimycobacterial therapy with placebo were identified. Key outcome data were abstracted and the results were pooled to yield odds ratios for maintenance of remission in treated versus control groups.

RESULTS

A total of eight randomized trials were identified. Six trials were fully published and were included in the primary analysis. Two trials used antimycobacterial therapy in combination with corticosteroids to induce remission in patients with active Crohn's disease, followed by maintenance therapy with antimycobacterial agents. In these trials, control patients received corticosteroids to induce remission but no antimycobacterial therapy. Pooling of these trials yielded an odds ratio of maintenance of remission in treatment versus control of 3.37 (95% confidence interval [CI], 1.38-8.24) in favor of antimycobacterial therapy. The remaining four trials used antimycobacterial therapy combined with standard therapy in patients with Crohn's disease. In these trials, control patients received standard therapy alone. Pooling of these trials yielded an odds ratio of maintenance of remission in treatment versus control of 0.69 (95% CI, 0.39-1.21) in favor of standard therapy.

CONCLUSIONS

These results suggest that antimycobacterial therapy is effective in maintaining remission in patients with Crohn's disease after a course of corticosteroids combined with antimycobacterial therapy to induce remission. Treatment of Crohn's disease with antimycobacterial therapy does not seem to be effective without a course of corticosteroids to induce remission. Because of the small number of studies included in this meta-analysis, the results should be interpreted with caution.

Tuberculosis from head to toe

Tuberculosis can affect virtually any organ system in the body and can be devastating if left untreated. The increasing prevalence of tuberculosis in both immunocompetent and immunocompromised individuals in recent years makes this disease a topic of universal concern. Because tuberculosis demonstrates a variety of clinical and radiologic findings and has a known propensity for dissemination from its primary site, it can mimic numerous other disease entities. Primary pulmonary tuberculosis typically manifests radiologically as parenchymal disease, lymphadenopathy, pleural effusion, miliary disease, or lobar or segmental atelectasis. In postprimary tuberculosis, the earliest radiologic finding is the development of patchy, ill-defined segmental consolidation. Both computed tomography (CT) and magnetic resonance (MR) imaging are helpful in diagnosing tuberculous spondylitis and tuberculous arthritis. CT is especially useful in depicting gastrointestinal and genitourinary tuberculosis. In tuberculosis involving the central nervous system, CT and MR imaging findings vary depending on the stage of disease and the character of the lesion. A high degree of clinical suspicion and familiarity with the various radiologic manifestations of tuberculosis allow early diagnosis and timely initiation of appropriate therapy, thereby reducing patient morbidity.

CT appearances in abdominal tuberculosis. A pictorial essay

Abdominal tuberculosis continues to be endemic in the developing world and has shown a resurgence in the West. Computed tomography (CT) evaluation is singularly informative as it demonstrates involvement of the bowel, peritoneum, lymph nodes, and solid organs in a single examination. A spectrum of CT findings in an immunocompetent population is presented, ranging from subtle to advanced and common to rare. Genitourinary tuberculosis and tuberculosis in AIDS are excluded as they merit separate discussions.

Is it Crohn's disease or intestinal tuberculosis? CT analysis

A computed tomographic (CT) analysis of 36 patients with differential diagnosis of intestinal tuberculosis (IT) or Crohn's disease (CD) in barium gastrointestinal studies was undertaken to identify distinguishing bowel wall or mesenteric features which could provide a radiological definitive diagnosis. Final diagnoses obtained in 32 cases were tuberculosis (N = 18), CD (N = 9), carcinoid (N = 2), chronic appendicitis (N = 2) and bowel infarction (N = 1). In IT, the bowel wall changes were varied: absence of wall thickening (N = 6), minimal asymmetric wall thickening with and without mucosal tethering (N = 8), minimal symmetric wall thickening often with mild peritonitis (N = 3), exophytic mass encircling bowel lumen (N = 4). Mural stratification (target sign) was not found. CD showed concentric or symmetrical wall thickening ranging from 0.6 to 1.5 mm and mural stratification occurred in about a half of the cases. Lymphadenopathy was the commonest associated feature in both but in IT, the nodes were larger and a third had necrotic centers. Displacement of bowel loops was more often due to enlarged lymphadenopathy in IT while in CD it was frequently due to fibrofatty change. CT was able to provide the correct diagnosis in 26 out of these 32 (81%) cases of indeterminate barium studies. CT is recommended when barium gastrointestinal studies are unable to differentiate between intestinal tuberculosis and Crohn's disease.

Abdominal tuberculosis in Ahmadi, Kuwait: a clinico-pathological review

For studying abdominal tuberculosis (TB) in Ahmadi, files off all patients admitted to our hospital with abdominal TB over 15 years (1981-1996) were reviewed. Nineteen patients are reported here. Young adults were predominant in our study. The non-Arab Asians were the most frequently affected group in relation to their population in Ahmadi, and Kuwaitis were the least frequently affected group. Abdominal pain, sweating, anorexia and fever were the most frequent presenting symptoms. Ascites and intestinal obstruction were the most frequent clinical presentations. Two patients presented with acute appendicitis and one patient had tuberculous pancreatitis. Abdominal lymph nodes, peritoneum, ileum and and caecum were the most frequently affected abdominal structures. We found laparoscopy very helpful in diagnosis of abdominal TB and we recommend it as the diagnostic method of choice. All our patients responded well to antituberculous chemotherapy. It should be kept in mind that abdominal TB still affects the indigenous and expatriate population of Kuwait.

Intestinal tuberculosis: return of an old disease

OBJECTIVE

Tuberculosis (TB) can no longer be considered a rare disease in the United States due, in part, to the AIDS epidemic. Because the signs and symptoms of intestinal TB are nonspecific, a high index of suspicion must be maintained to ensure a timely diagnosis. The aim of this article is to review the history, epidemiology, pathophysiology, and treatment of TB.

METHODS

This review is based on an examination of the world literature.

RESULTS

In only 20% of TB patients is there associated active pulmonary TB. Areas most commonly affected are the jejunoileum and ileocecum, which comprise >75% of gastrointestinal TB sites. Diagnosis requires colonoscopy with multiple biopsies at the ulcer margins and tissue sent for routine histology, smear, and culture. If intestinal TB is suspected, empiric treatment is warranted despite negative histology, smear, and culture results. Treatment is medical, and all patients should receive a full course of antituberculous chemotherapy. Exploratory laparotomy is necessary if the diagnosis is in doubt, in cases in which there is concern about a neoplasm, or for complications that include perforation, obstruction, hemorrhage, or fistulization.

CONCLUSIONS

This review draws attention to the resurgence of tuberculosis in the United States. An increased awareness of intestinal tuberculosis, coupled with knowledge of the pathophysiology, diagnostic methods, and treatment should increase the number of cases diagnosed, thus improving the outcome for patients with this disease.

Radiological evaluation of complications of intestinal tuberculosis

Complications of intestinal tuberculosis may be masked. This study aims to heighten awareness of these unusual clinical complications and the radiological findings in such cases. Over a period of 5 years, 21 patients with proven intestinal tuberculosis, 13 of whom presented with complications, are presented in this report. Radiological diagnosis was by barium gastrointestinal studies and computed tomographic (CT) evaluation. Surgical specimens and histopathology confirmed the diagnosis. The commonest complication was intestinal obstruction (N = 6). Others were esophagobronchial and duodenocolic fistulas (N = 2), significant gastrointestinal hemorrhage (N = 3) caused by ulcers in the small bowel and colon, and malabsorption syndrome (N = 3) caused by diffuse small bowel infiltration in 2 cases and duodenocolic fistula in the third case. None of the patients presented were immunocompromised. Though uncommon, tuberculosis should be considered in patients presenting clinically with intestinal obstruction, significant gastrointestinal hemorrhage and malabsorption state.

Imaging of tuberculosis. II. Abdominal manifestations in 112 patients

PURPOSE

To describe the radiological findings of tuberculosis (TB) of the abdomen as reflected at our hospital.

MATERIAL AND METHODS

The radiological files of 503 patients (referred to our institution mainly because of a clinical suspicion of malignancy, and found to have culture- or biopsy-proven TB) were reviewed in order to analyze the spectrum of the TB manifestations in this group of patients.

RESULTS

Abdominal manifestations were found in 112 patients, in 1/3 abdominal disease was the only evidence of TB. More than half of the patients also had chest TB. The most common abdominal TB manifestations were peritonitis and lymph node enlargement, each occurring in about 1/3 of the patients. Also 1/3 had genitourinary TB manifestations. About 1/5 had TB of the liver, spleen or pancreas or in the gastrointestinal tract, respectively. Multiple organ involvement was common.

CONCLUSION

The need to consider TB in the differential diagnosis in patients with obscure abdominal symptoms, especially with multiple organ involvement, is stressed.

Abdominal tuberculosis in children: review of 26 cases

The protean clinical manifestations and varied complications of abdominal tuberculosis continue to challenge the diagnostic acumen and therapeutic skills of all physicians. Although abdominal tuberculosis in children has not been common in the United States over the past 2 decades, the authors found 26 case reports for the period 1980-1993. Three clinical patterns were evident: intestinal (13) peritoneal (9), and asymptomatic with incidental calcifications apparent on abdominal radiographs (4). The diagnosis was suspected for only 23% of these cases, which emphasizes the nonspecific symptomatology caused by this extrapulmonary manifestation and the need for a high index of suspicion to make a prompt diagnosis. In this study, 24 of the 26 (91%) were of Hispanic origin; the other two were indo-Chinese, another high-risk group. Most patients (88%) had a positive PPD skin test result. Mycobacteria were isolated from 15 of 21 (71.4%) cultures, with M bovis in 80% and M tuberculosis in 20%. Antituberculous chemotherapy is the mainstay of treatment; surgery is reserved for tissue diagnosis in cases of peritoneal tuberculosis and for the management of complications of intestinal tuberculosis. The response to chemotherapy usually is excellent, and long-term sequelae are uncommon. It appears that steroids do not decrease the incidence or degree of fibrosis in intestinal tuberculosis.

Update: abdominal tuberculosis--unusual findings on CT

To update our knowledge of abdominal tuberculosis as manifested on computed tomography (CT), we reviewed the CT scans of 12 patients with proven abdominal tuberculosis. The nature, range and extent of abdominal involvement was determined. The CT findings were compared to those reported in the literature. The aetiologic agent was Mycobacterium tuberculosis in all patients. One patient had an increased risk because of AIDS. In nine patients, tuberculosis was limited to the abdomen, and three patients had previously unknown thoracic tuberculous disease. Characteristic features in our patients included low density ascites and uncommon patterns of adenopathy. Findings reported to be typical in abdominal tuberculosis were present in only five of our 12 patients. Unusual findings in our patients included solitary and multiple pelvic, adrenal, splenic and hepatic lesions. In six of 12 patients, those findings mimicked malignancy. We conclude that knowledge and early recognition of these unusual manifestations of abdominal tuberculosis should help to optimize clinical management of the disease and avoid misdiagnosis.

Abdominal tuberculosis in Taiwan: a report from Veterans' General Hospital, Taipei

SETTING

From 1986 to 1992, 27 cases of abdominal tuberculosis were diagnosed in Veterans General Hospital-Taipei, Taiwan, including 21 cases of intestinal tuberculosis and 6 cases of peritoneal tuberculosis.

OBJECTIVE

To ascertain the clinical characteristics of abdominal tuberculosis in Chinese patients and the possibility of early clinical diagnosis of abdominal tuberculosis.

DESIGN

Clinical features, diagnosis and treatment modality of these 27 cases were reviewed.

RESULTS

22 of the patients (81.5%) had chest X-ray evidence of pulmonary tuberculosis. Only 2 had normal chest X-ray findings. Sputum mycobacterium culture was positive in 14 of 27 patients (51.9%). 20 patients received exploratory laparotomy for the diagnosis and all of the preoperative diagnoses were wrong. The diagnosis was still incorrect or uncertain in 9 cases after laparotomy if no pathological examination was done. Ileocecal area was the most common site of intestinal tuberculosis in our series and 3 of 11 ulcerative types of intestinal tuberculosis died later.

CONCLUSION

Due to protean manifestations, the diagnosis of abdominal tuberculosis was frequently misdiagnosed, and particularly as carcinomatosis. The diagnosis should be considered when patients with pulmonary tuberculosis suffer from abdominal discomfort. Exploratory laparotomy is needed in cases suspected of abdominal carcinomatosis without definite diagnosis.

Sonographic findings in gastrointestinal and peritoneal tuberculosis

The various ultrasound (US) findings in 90 patients with abdominal (gastrointestinal, peritoneal, mesenteric and lymph node) tuberculosis (TB) studied in an area of high incidence of TB over a 1 year period were analysed. The lesions encountered were intestinal (n = 31), extraintestinal (n = 39), or a combination (n = 20). The extraintestinal lesions included free and loculated ascites (n = 36), localized ascites ('Club Sandwich sign') (n = 4), adhesions (n = 14), peritoneal thickening (n = 14), peritoneal nodules (n = 3), lymphadenopathy (n = 23) and cold abscesses (n = 10)-of these, the presence of fine fibrinous strands in the ascetic fluid, localized ascites and caseous or calcified lymph nodes were highly suspicious of a diagnosis of TB in appropriate clinical settings. The bowel lesions were characterized by concentric bowel wall thickening (n = 31) with ulceration in six. Bowel thickening, when present in the ileocaecal junction and especially when situated in the subhepatic position, was suggestive of a tuberculous etiology. Complex masses in the abdomen pointed to an advanced stage of the disease. US is a useful imaging modality in patients clinically suspected of having abdominal TB for diagnosis and follow-up, although in a few cases differentiation of it from metastatic disease is difficult. When bowel involvement is suspected, barium studies should be performed.

Abdominal tuberculosis in children

Four boys with abdominal tuberculosis, one of whom had acquired immunodeficiency syndrome, are presented. Abdominal imaging findings on plain radiography, ultrasonography, computed tomography, and gastrointestinal contrast studies included tuberculous peritonitis and ascites in all patients, tuberculous adenopathy in two, gastrointestinal tuberculosis in two, and omental tuberculosis in two. The radiographic features particularly characteristic of abdominal tuberculosis were: (1) low attenuating adenopathy with rim enhancement, (2) omental or ileocecal inflammatory mass, (3) high density ascites, and (4) gastrointestinal enteritis involving the ileocecal region. All patients had acid-fast bacilli identified in cultures of bodily fluids and/or pathologic specimens and three patients had cultures positive for Mycobacterium tuberculosis. The patient with a negative culture had a positive PPD skin test and a surgical specimen showing caseating granulomata and acid-fast bacilli in the omentum. The radiologist must maintain a high degree of suspicion for abdominal tuberculosis particularly in normal or immunosuppressed children with acquired immunodeficiency syndrome. Fine needle aspiration and biopsy of abdominal adenopathy, inflammatory mass or ascites may be necessary for diagnosis.