Year : 1997 | Volume
: 3 | Issue : 3 | Page : 133--139
CT and barium features of gastrointestinal and peritoneal tuberculosis
Department of Radiology, King Khalid University Hospital, Riyadh, Saudi Arabia
Department of Radiology, College of Medicine, P.O. Box. 7805, Riyadh-11472
The radiological features in barium gastrointestinal studies and computed tomographic (CT) examinations of 22 consecutive cases of proven peritoneal and/or intestinal tuberculosis were analyzed in order to highlight the radiological features which could provide ready identification of the disease. There were 15 cases of intestinal tuberculosis and 7 cases of peritoneal tuberculosis and 3 patients had both. The commonest location of intestinal tuberculosis was the ileocecal region (N=10) which occurred in association with colonic or ilea] disease. Bowel wall thickening in CT was largely asymmetrical but minimal and symmetrical wall thickening occurred with peritonitis. Luminal narrowing with or without mucosal tethering were seen in both CT and Barium studies. Peritoneal TB had either high density ascites with smudge or nodular omental surface with a thickened omental lining. Also detected was fibrinous dry peritonitis with thickened mesenteric tissue. Lymphadenopathy in the peripancreatic, mesenteric or paracaval were common to both intestinal or peritoneal tuberculosis (21 out of 22). Fifty percent of the patients showed some lymph nodes with necrotic centers. The differential diagnosis included malignant peritonitis and intestinal or mesenteric carcinoid. The study shows that a combination of barium gastrointestinal study and computed tomography can provide distinct features which could strongly suggest the diagnosis of intestinal or peritoneal tuberculosis.
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Makanjuola D. CT and barium features of gastrointestinal and peritoneal tuberculosis.Saudi J Gastroenterol 1997;3:133-139
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Makanjuola D. CT and barium features of gastrointestinal and peritoneal tuberculosis. Saudi J Gastroenterol [serial online] 1997 [cited 2022 Aug 13 ];3:133-139
Available from: https://www.saudijgastro.com/text.asp?1997/3/3/133/33922
With the global shrinkage due to easy communication and the advent of Acquired Immune Deficiency Syndrome (AIDS), tuberculosis has a comeback even in the developed countries ,, .
Abdominal tuberculosis which is second only to the lung in this environment has no specific clinical syndrome  . When it presents with the complications the diagnosis becomes most evasive , . The isolation of mycobacterium tuberculosis is not an easy process and even granulomas may not be found in the intestine but are usually found in the mesenteric lymphnodes  .
Apart from the radiological study of Denton and Hossain most other reported series from our environment have focused on the clinical, endoscopic and laparoscopic diagnosis and made passing remarks on radiological diagnosis ,,, . Barium gastrointestinal studies were earlier on the traditional way of investigating the gastrointestinal tract. While a good barium study provides an unprecedented mucosal detail and display luminal integrity, it is unable to identify extraluminal disease accurately. Therefore, with the advent of ultrasonography and to a larger extent computed tomography (CT) radiology is now playing an increasing role in the diagnosis of abdominal tuberculosis. Several reports have explained the CT features of peritoneal tuberculosis which includes high or low density ascites, smudgy omental deposits and parapancreatic and paracaval lymphadenopathy with necrotic centers ,,, . However, several physicians are probably unware of the enormous contributions CT can provide towards the diagnosis of abdominal tuberculous.
This communication presents the radiological findings in proven cases of intestinal and peritoneal tuberculosis in the hospital studies in order to increase the awareness of the current radiodiagnostic role.
Patients and methods
Over the past five years, 22 patients with proven peritoneal or abdominal tuberculosis who had radiological evaluation are presented. The age range was 6-72 years with a mean of 24 years. The clinical records, radiological evaluation and pathological findings were analyzed. The radiological evaluation involved barium gastrointestinal studies including barium meal (N=2), dedicated small bowel follow through (N=4), small bowel enema (N=11) and barium enema (N=3). Computed tomographic evaluations were obtained with CT/T8800GE medical system using the normal departmental protocol. Oral contrast was achieved with 1.5 ml of 2 percent barium sulfate. About I liter was given overnight or two hours earlier. The remaining half a liter was administered just prior to scanning. A bolus injection of 120 ml of 30% iodine provided intravenous contrast. 1 cm collimation were obtained from the dome of the diaphragm to the pelvis. Additional 5mm cuts were obtained whenever necessary.
The following observations were made in CT, bowel wall lesions were identified and characterized. Ascites was recorded as high (over 12 Hounsfield unit) or low density. The appearance of the surface of the omentum was characterized. The presence, nature and location of lymphadenopathy were recorded. The lesions identified in barium studies were also recorded.
The main presenting symptoms were intestinal obstruction (N=6), abdominal pain, distension and weight loss (N=2), tender right ilia fossa (N=15), malabsorption (N=2) and rectal bleeding (N=1). CT studies were performed in 19 cases while barium gastrointestinal studies were obtained in 20 patients.
[Table 1] shows the number and location of intra and extra-abdominal lesions identified. Ileocecal (N=13) and peritoneal (N=7) top the list. Three patients with peritoneal tuberculosis had intestinal involvement. Four patients had dual lesions as indicated below the table. Abdominal organ tuberculosis was associated with peritoneal and/or intestinal tuberculosis as shown in [Table 1].
The lesions identified in various barium studies where luminal narrowing (N=14) [Figure l], partial obstruction (N=10), adhesions with or without obstruction (N=9) [Figure 2], bowel loop displacement (N=4), transverse colonic ulcers occurred in (N=2), fistula formation (n=2) and sinus tract (N=1).
[Table 2] presents the various CT changes. The peritoneum showed either high [Figure 3] or low density ascites [Figure 4]a & b or had a dry fibrinous pattern [Figure 5]. The severe cases of peritonitis had bowel adhesions with tethered mucosal pattern [Figure 5]. Intestinal obstruction was a consequence in 4 of these cases. Lymphadenopathy was a very common feature, mesenteric, parapancreatic [Figure 6] and paracaval being most common. In 12 patients, the enlarged lymphnodes had necrotic centers [Figure 7]. Only one patient had no appreciable lymphadenopathy and was radiologically not considered as tuberculosis. Bowel wall changes were also varied. Asymmetrical thickening with spiky mucosal outline was the commonest.
Confirmation of the diagnosis was made by pathological specimens (N=20) obtained from endoscopic, surgical, laparoscopic and radiological biopsy. Two patients had dramatic response to antituberculous treatment following radiological and laparoscopic suspicion with inconclusive pathological report.
Although there is no known isolated diagnostic radiological feature, the analysis provides a combination of distinct features which in the appropriate clinical setting could provide a confident diagnosis of intestinal or peritoneal tuberculosis. For example, a young patient with unexplained ascites, smudgy omental surfaces with parapancreatic and mesenteric lymphnodes which have necrotic centers should be treated as a case of peritoneal tuberculosis until otherwise proven. Ascites could occur with malignancy or lymphoma but lymphadenopathy with necrotic center are not a known feature of untreated lymphoma. Large lymphadenopathy with hypodense center do occur with mesenteric carcinoid and Whipple disease but the clinical setting and additional radiological findings are different  . In mesenteric carcinoid, a mesenteric mass with spiculation radiating towards the mesenteric border of the small bowel will be seen while in Whipple disease, diffuse small bowel infiltration is the usual presentation. Malignant periotonitis can be very difficult to differentiate from tuberculosis peritonitis due to overlap of the findings. However, mesenteric macronodules, irregularity of the infiltrated omentum, thickened omental line and splenic abnormalities are more common in tuberculosis  .
Luminal narrowing with or without obstruction seen in barium studies could be due to lymphadenopathy [Figure 7], exophytic granulomatous [Figure l]b mass with enteritis or adhesion and these are best shown in CT which gives a global picture of extraluminal condition. Earlier radiological study on small bowel enema in intestinal obstruction had shown that intestinal tuberculosis was second only to adhesions as a cause of intestinal obstruction in the studied population  . Intestinal obstruction is also the commenest complication in intestinal tuberculosis  .
Ulceration with a tendency to constriction occurred in the colon. These ulcers are typically oriented in a direction perpendicular to the longitudinal axis of the colon and tend to be segmental. This orientation is said to be related to the arrangement of the submucosal lymphatic structures which are thought to be the primary site of gastrointestinal involvement  . One of our patients with this ulcer presented with rectal bleeding. A rare form of colonic tuberculosis which presents a diffuse colitis which can be confused with ulcerative colitis has also been described  .
Intestinal tuberculosis has long been classified as hypertrophic, ulcerative, ulcero nodular and stricturing and said to originate from the lung or ingestion of contaminated milk or direct spread from adjacent organ. However, only one patient out of the four who had features of pulmonary tuberculosis had active disease.
In intestinal tuberculosis, the most frequent location is the ileocecal region. This raises a frequent differential diagnosis of Crohn's disease, appendicular abscess or lymphoma, yersinia enterocolitis or yesima pseudotuberculosis.
In ileocecal tuberculosis, the hypertrophic and ulcerative type tend to be common. Hence, CT shows exophytic masses encircling the ulcerated bowel. Also in the adjacent mesentery lymphadenopathy with necrotic center may be seen displacing bowel loops. Bowel wall thickening is usually not as pronounced nor concentric as that of Crohn's and mural stratification which occurs in other idiopathic enteritis or colitides like Crohn's disease or ulcerative colitis was not seen. Also fibrofatty changes which are seen in the mesentery in Crohn's disease does not appear to be a feature of abdominal tuberculosis. In chronic treated ileocecal TB, barium studies can show a contracted cecum and with a patulous ileocecal valve which opens into a distended terminal ileum. This could be confused with ulcerative colitis with backwash ileitis. In appendicular abscess, CT shows collections usually with no bowel wall thickening. Lymphadenopathy spasm with partial intestinal obstruction frequently occurs with tuberculosis while intestinal obstruction is an unusual feature of lymphoma. Radiologically, mucosal nodularity, intra and extraluminal masses and lymphadenopathy without necrotic centers are usually shown in intestinal lymphoma.
Although the presence of unexplained ascites is often mentioned, the existence of tuberculous peritonitis and liver cirrhosis with renal failure has been well documented including within the population studied. Intestinal tuberculosis is also known to occur in patients receiving treatment for ulcerative colitis  . These findings give additional support for the use of CT to provide a global view of the abdomen when tuberculosis is suspected.
Although ultrasonography has received no attention in this material, it is certainly useful in providing information about abdominal organ involvement, lymphadenopathy and ileocecal masses and should he used in the absence of CT. Ultrasound is capable of showing ascites which could be multiseptated, omental thickening, lymphadenopathy in various locations and bowel wall thickening in intestinal tuberculosis. It is reliable in experienced hands and unique for children and pregnant women. However, CT undisputedly provides superior evaluation.
A combination of barium studies and computed tomography evaluation using adequate oral and intravenous contrast can provide a reasonably confident diagnosis of intestinal or peritoneal tuberculosis in the appropriate clinical setting. Therefore, a patient with unexplained ascites of high or low density with smudgy omental surface and with necrotic lymphadenopathy at the mesenteric or peripancreatic region should have a high index of suspicion. Intestinal involvement would include asymmetric bowel wall thickening with mucosal tethering and bowel obstruction
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