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PRESENTED BY : Sabita Poudel B.sc nursing 2nd year BPKIHS, DHARAN , NEPAL

CONTENTS
Introduction to tuberculosis Global burden Brief Description of the disease Pathogenesis Routes of G.I tract infection Clinical presentation Differential diagnosis Investigation Medical management Nursing management Potential complications

INTRODUCTION
Tuberculosis is a specific infectious disease caused by Mycobacterium tuberculosis. Tuberculosis(TB) is an infectious disease that primarily affects the lung parenchyma.

The disease also affects animals/ cattle and known as Bovine tuberculosis which may be sometimes transmitted to men. However it can also affect intestine meninges bones joints, lymph glands .

GLOBAL BURDEN
The annual incidence of tuberculosis is nearly 8 million,with 2 million deaths worldwide . The total disease burden in India is estimated to be more than 40% of the population It may involve the gastrointestinal tract, peritoneum, lymph nodes or solid viscera, and constitutes up to 12% of extrapulmonary TB and 1%3% of the total TB cases

Definition Abdominal Tuberculosis is a condition in which there is tuberculous infection of the peritoneum or other organs in the abdomen

Robert Koch, a German Scientist who found out the causative organism for consumption and revealed his invention in1882

Gram negative bacillus Mycobacterium tuberculosis

Abdominal tuberculosis is predominantly a diseaseof young adults. Two-thirds of the patients are 21-40 yr old and the sex incidence is equal, although some Indian studies have suggested a slight female predominance.

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The spectrum of disease in children is different from adults, in whom adhesive peritoneal and lymph nodal involvement is more common than the gastrointestinal.

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Tuberculosis can involve any part of the gastrointestinal tract. Gastro intestinal tract is the sixth most frequent site of extrapulmonary involvement.

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The common site of involvement in the GI tract are the ileum and the ileocaecal region, possibly because of the increased physiological stasis, increased rate of fluid and electrolyte absorption, minimal digestive activity and an abundance of lymphoid tissue at this site, followed by the colon and jejunum.

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PATHOGENESIS
. When the bacilli enter a suitable host, they are transmitted through the airways to alveoli, where they get deposited and start to multiply The body immune system initiates tissue reaction resulting in the accumulation of exudates in alveoli causing bronchopneumonia. This occurs 2 to 10 weeks after exposure

Furthermore, the granulomas thus formed are surrounded by macrophages and later get fibroid with central soft portion called as Ghons Tubercle.

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ROUTES OF G.I TRACT INFECTION

1.Hematogeneous spread from primary lung focus in the childhood with later reactivation

2.Ingestion of bacilli in sputum from active pulmonary focus

3.Direct spread from adjacent organs and through lymph channel from infected nodes.

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The clinical presentation of abdominal tuberculosis can be acute, chronic or acute on chronic. Most patients have constitutional symptoms of fever (40-70%)pain (80-95%), diarrhoea (11-20%), constipation, alternating constipation and diarrhoea, weight loss (4090%),anorexia and malaise.

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Complication are: Perforation Fistula formation Obstructive jaundice by compression of the common bile duct.

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OESOPHAGEAL TUBERCULOSIS
Oesophageal tuberculosis is a rare entity,constituting only 0.2 per cent of cases of abdominal tuberculosis. Oesophageal involvement occurs mainly by extension of disease from adjacent lymph nodes. The patient usually presents with low grade fever, dysphagia,odynophagia and an ulcer, most commonly midoesophageal.

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GASTRODUODENAL TUBERCULOSIS
Stomach and duodenal tuberculosis each constitute around 1 per cent of cases of abdominal tuberculosis. Gastroduodenal tuberculosis may mimic peptic ulcer.

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Symptoms Abdominal pain Fever Weight loss Abdominal distension Anorexia Alteration of bowel habits Vomiting Cough

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Signs

Distension of abdomen Doughy abdomen Abdominal lump Mixed type (ascites, lump and diffuse peritonitis) Ascites Hepatomegaly Splenomegaly Hepatosplenomegaly Jaundice Pedal oedema

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Complications:

perforation fistulae (pyeloduodenal, duodenocutaneous, blind),excavating ulcers extending into pancreas and obstructive jaundice by compression of the common bile duct.

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GASTROINTESTINAL TUBERCULOSIS
Abdominal tuberculosis is usually secondary to pulmonary tuberculosis, radiologic evaluation often shows no evidence of lung disease The ileocecal region is the most common area of involvement in the gastrointestinal tract due to the abundance of lymphoid tissue. The natural course of gastrointestinal tuberculosis may be ulcerative hypertrophic or ulcerohypertrophic.

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SEGMENTAL COLONIC TUBERCULOSIS

Segmental or isolated colonic tuberculosis refers to involvement of the colon without ileocaecal region, and constitutes 9.2 per cent of all case as of abdominal tuberculosis. It commonly involves the sigmoid, ascending and transverse colon.

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RECTAL COLONIC TUBERCULOSIS

Clinical presentation of rectal tuberculosis is different from more proximal disease. Haematochezia is the most common symptom 88%) followed by constitutional symptoms (75%) and constipation(37%). The high frequency of rectal bleeding may be because of mucosal trauma caused by scybalous stool traversing the strictured segment.

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Other manifestations of colonic tuberculosis include fever, anorexia, weight loss and change in bowel habits. The diagnosis is suggested by barium enema or colonoscopy.

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DIFFERENTIAL DIAGNOSIS
Crohns disease Chronic amoebiasis Roundworm infestation Lymphomas Larger bowel malingnancy.

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Colonies of Mycobacterium tuberculosis Lowenstein-Jensen medium

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INVESTIGATIONS
Animal inoculation or culture of suspected tissue resulting in growth of M.tuberculosis Histological demonstration of acid fast bacilli in a lesion. Plain X-ray of the abdomen Laparoscopy Laparoscopic biopsy of tubercles found in the peritoneum or other parts

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Animal inoculation or culture of suspected tissue resulting in growth of M.tuberculosis Histological demonstration of acid fast bacilli in a lesion.

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Radiological studies:Chest X-ray, Plain X-ray abdomen, Small bowel barium meal, Barium enema, Computed tomography Ultrasonography Colonoscopy Immunological tests:ELISA

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MANAGEMENT
Medical Management :
Regimens included antitubercular therapy for 9 months with rifampicin, isoniazide and pyrazinamide and for 2 months followed by rifampicin and isoniazide for next 7 months.

For patients with intestinal TB, some clinicians administer corticosteroids routinely for the first 2 months of antitubercular treatment to decrease fibrosis during the healing process.

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Surgical treatment
The recommended surgical procedures today are conservative. Strictures which reduce the lumen by half or more and which cause proximal hypertrophy or dilation are treated by strictureplasty.

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NURSING MANAGEMENT
Preventing spreading of tuberculosis infection. Advocating adherence to the treatment regimen. Promoting activity and adequate nutrition. Proper preoperative and post operative care.

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