intestinal tuberculosis
Introduction
Introduction to intestinal tuberculosis Intestinal tuberculosis is the most common tuberculosis in the digestive system. The vast majority are secondary to extraintestinal tuberculosis, especially cavitary tuberculosis. According to statistics, 25% to 50% of tuberculosis patients may have intestinal tuberculosis. The source of intestinal tuberculosis is mainly ingestive, caused by swallowing sputum containing tuberculosis, occasionally from food contaminated by tuberculosis, or from blood-borne or abdominal cavity, direct pelvic tuberculosis spread. The age of onset is mostly young and middle-aged, with more women than men, about 1.85:1. Pathologically divided into ulcer type, proliferative type and mixed type. basic knowledge The proportion of the disease: the probability of illness in the population is 0.001%, and the incidence of tuberculosis is up to 10%. Susceptible people: mostly young adults Mode of infection: non-infectious Complications: intestinal obstruction peritonitis intussusception
Cause
Intestinal tuberculosis
Bacterial infection (45%):
MTB mainly invades the intestine through oral infection. Patients often have open tuberculosis. They are sick due to swallowing their own sputum containing MTB, or they often eat with open tuberculosis patients, lacking the necessary disinfection and isolation measures to cause disease. In rare cases, unsterilized milk or dairy products containing MTB can also cause primary intestinal tuberculosis.
Disease factors (32%):
In the case of miliary tuberculosis, MTB can be transmitted by blood to cause intestinal tuberculosis. Intra-abdominal tuberculosis, such as female genital tuberculosis and direct spread of tuberculosis, can cause intestinal tuberculosis.
However, the above-mentioned route to obtain infection is only a disease-causing condition. Only when the number of invasive MTBs is large, the virulence is strong, and the human immune function is lowered, the intestinal dysfunction is disordered, and the local resistance is reduced.
Prevention
Enteral tuberculosis prevention
Preventive work is the fundamental way to prevent and treat tuberculosis, and focuses on the discovery of extraintestinal tuberculosis, especially the early diagnosis of tuberculosis and active anti-tuberculosis treatment, as soon as possible to make the bacteria turn negative, so as not to swallow the bacteria-containing sputum and cause the intestines Infection, we must emphasize health promotion education about tuberculosis.
Complication
Enteral tuberculosis complications Complications, intestinal obstruction, peritonitis, intussusception
In the process of chronic evolution of intestinal tuberculosis, various complications can occur.
1. Intestinal obstruction: It is the most common complication of this disease, mainly in proliferative intestinal tuberculosis. Ulcerative intestinal tuberculosis causes traction of the intestines due to adjacent peritoneal adhesions, restraint and compression, or scar contraction due to healing of intestinal ulcers. Intestinal stenosis can cause obstruction, obstruction is mostly chronic progressive, often in some patients, varying degrees of severity, prolonged prolonged time, can seriously affect the nutritional status of patients, a few can develop complete intestinal obstruction.
2. Intestinal perforation: the incidence is second to intestinal obstruction, ranking second, mainly subacute or chronic perforation, can form abscess in the abdominal cavity, form intestinal fistula after ulceration, acute perforation is less common, often occurs in obstruction Extremely dilated bowel, or seen in multiple intestinal stenosis caused by obstructive intestinal obstruction, although ulcerative intestinal tuberculosis has adhesions around the intestinal tract, ulcers generally do not break into the free abdominal cavity, but the disease develops rapidly, the body response is poor When the ulcer penetrates deep, it causes acute perforation.
3. Others: there are peritonitis, intestinal adhesions, intussusception and contractile diverticulum.
Symptom
Intestinal tuberculosis symptoms Common symptoms Abdominal pain Parenteral tuberculosis feces black with bloody bowel ileocecal tuberculosis intestinal perforation Irregular heat constipation Relaxation heat cacao face
The clinical manifestations of intestinal tuberculosis are not obvious at the early stage. Most of the onset is slow and the course of disease is long. If it coexists with extraintestinal tuberculosis, its clinical manifestations can be covered and ignored. Therefore, active extraintestinal tuberculosis such as obvious digestive tract Symptoms should be alert to the possibility of intestinal tuberculosis. The main clinical manifestations of this disease can be summarized as follows:
1. Abdominal pain is one of the common symptoms of this disease. The pain is mostly in the right lower abdomen, which reflects the pathological features of intestinal tuberculosis in the ileocecal area. However, it can also be caused by ileocecal lesions in the middle or upper umbilicus. Pain, after careful examination, the right lower abdomen tenderness point can be found. The nature of the pain is usually dull or dull. Sometimes it is induced at mealtime. Due to ileocecal lesions, the gastro-intestinal reflex or hypertrophy of the stomach and colon is hyperthyroidism. Eating promotes intestinal bowel or peristalsis. Strengthen, so that pain and defecation can occur, and there can be different degrees of relief after the stool. In the case of proliferative intestinal tuberculosis or complicated intestinal obstruction, there is abdominal cramps, often located in the right lower abdomen, accompanied by abdominal distension, bowel sounds hyperthyroidism, intestinal type and Creeping waves.
2. Abnormal bowel habits Due to inflammation and ulceration of the diseased bowel, the intestinal peristalsis is accelerated, the intestinal emptying is too fast, and the secondary malabsorption caused by it, so diarrhea is one of the main clinical manifestations of ulcerative intestinal tuberculosis, diarrhea Often with small bowel characteristics, stool is a paste or watery sample, does not contain mucus or pus and blood, without urgency and heavy weight, usually about 2 to 4 times a day, if the lesion is serious, the scope is wider, the number of diarrhea increases, there are Up to ten times a day, when the ulcer involves the sigmoid colon or transverse colon, it can contain mucus and pus, but the blood in the stool is rare. In addition, there is constipation, the stool is sheep feces, diarrhea and constipation alternate, and there is more proliferative intestinal tuberculosis. The secret is the main performance.
3. Abdominal masses are mainly found in proliferative intestinal tuberculosis, which is an extremely hyperplastic tuberculous granuloma that causes a tumor-like mass in the intestinal wall. In a small number of ulcerative intestinal tuberculosis patients with localized tuberculous peritonitis, due to its lesions of intestinal curvature and surrounding tissues Adhesion, or tuberculosis with mesenteric lymph nodes, abdominal mass, abdominal mass is often located in the right lower abdomen, generally fixed, medium texture, accompanied by tenderness of light and heavy.
4. Systemic symptoms and extraintestinal tuberculosis often have tuberculosis toxemia, ulcerative intestinal tuberculosis is more common, the performance is different, most of them are low fever or irregular heat in the afternoon, relaxation heat or heat retention, accompanied by night sweats Patients with burnout, weight loss, paleness, vitamin deficiency, fatty liver, dystrophic edema, etc., in addition to extra-intestinal tuberculosis, especially mesenteric lymph node tuberculosis, tuberculous peritonitis, tuberculosis Hyperplastic intestinal tuberculosis generally has a larger course of disease, but the general condition is better, no fever or sometimes low fever, and there is no evidence of active tuberculosis or other extraintestinal tuberculosis.
5. Abdominal signs without intestinal perforation, intestinal obstruction or cases with peritoneal tuberculosis or proliferative intestinal tuberculosis, except for tenderness in the right lower abdomen and umbilical circumference, usually no other special signs.
Examine
Intestinal tuberculosis examination
Laboratory inspection
1. Blood: ulcerative intestinal tuberculosis can have moderate anemia, white blood cell count is normal, but lymphocytes increase, 90% of patients with erythrocyte sedimentation rate increased significantly.
2. Fecal examination: ulcerated intestinal tuberculosis feces appearance paste, no mucus pus and blood, microscopic examination showed a small amount of pus cells and red blood cells, feces concentrated to find MTB and sputum positive has diagnostic significance, combined with tuberculosis, sputum can be positive, for diagnosis There is a reference.
3. Tuberculin test: can be positive or strong positive, strong positive for the diagnosis of proliferative intestinal tuberculosis.
4. Polymerase chain reaction: Polymerase chain reaction (PCR), also known as DNA in vitro amplification technology, PCR technology opens a new way for rapid, sensitive and specific diagnosis of tuberculosis at the genetic level.
Film degree exam
1. X-ray examination: X-ray barium meal angiography including double contrast or barium enema examination is of great significance for the diagnosis of intestinal tuberculosis. In addition to the examination of barium meal, in addition to the gastrointestinal organic disease, it can also understand its functional disorders. Therefore, it should be the first choice. For those with complicated intestinal obstruction, it is best to use barium enema because barium meal can aggravate intestinal obstruction, which often causes partial intestinal obstruction to evolve into complete intestinal obstruction. For patients with lesions involving colon, tincture should be added. Enema examinations often show more satisfactory colonic lesions.
In ulcerative intestinal tuberculosis, there are many irritations in the intestinal segment of the lesion. The sputum enters the place to empty quickly, and the filling is not good. The upper and lower ends of the lesion are well filled with the sputum, which is called X-ray shadow jumping sign. In ileocecal tuberculosis, due to inflammation and ulceration in the cecum and its adjacent ileum, the area is often not developed or developed very poorly. In the end of the ileum, there is a retention of expectorant retention. If the intestinal segment of the lesion is able to fill, it may be damaged by the mucous membrane. Seeing wrinkles and rough, the outline of the edge of the intestine is irregular, and due to ulceration, it shows signs of zigzag. When the fibrous tissue grows during the development of the lesion, sometimes the lumen of the intestine becomes narrow, the intestine is contracted and deformed, and the normal angle of the ileum is lost. The ileocecal valve is hardened and has a cecal inner impression. In addition, intestinal dysfunction often accelerates the movement of the barium meal in the gastrointestinal tract. It is almost completely empty within 12 hours, and the small intestine has a segmentation phenomenon. X-ray signs can be similar to those of ulcerative colitis, but the colonic tuberculosis involves the end of the ileum at the same time, the lesion is mainly in the proximal part of the colon, even if the lower part is involved, the lesion is more .
Proliferative intestinal tuberculosis mainly manifests as cecal or simultaneous ascending colon, proliferative stenosis at the end of ileum, contraction and deformity, visible filling defects, mucosal folds, intestinal wall stiffness, colonic pocket disappearance, often due to partial obstruction The proximal bowel is obviously enlarged.
2. Sigmoidoscopy and fiberoptic colonoscopy: General intestinal tuberculosis patients are not used as routine examination measures, but in patients with severe disease involving the sigmoid colon or rectum, biopsy can be performed by sigmoidoscopy and direct vision to clear the ulcer. The nature and scope are of great help for diagnosis and differential diagnosis. Fiber colonoscopy can be used to detect the lesions of the ascending colon, cecum and ileum, and can be used for biopsy and photography. It is of great value for the diagnosis of this disease. In the lesion, visible intestinal mucosal congestion, edema, contact with bleeding, nodular or polypoid bulge, sometimes visible irregular sneak ulcers, mucosal biopsy may have tuberculous nodules and caseous necrosis or acid resistance Bacilli is the most powerful basis for diagnosis.
3. Laparoscopy: In cases where there is no extensive adhesion in the abdominal cavity, and the diagnosis is very difficult, laparoscopy may be considered. There may be grayish white nodules on the serosal surface of the diseased intestinal segment, and typical biopsy has typical tuberculosis changes.
Diagnosis
Diagnosis and identification of intestinal tuberculosis
diagnosis
The diagnosis of intestinal tuberculosis should confirm the presence of Mycobacterium tuberculosis in intestinal mucosa. If there are the following conditions, intestinal tuberculosis should be considered.
1. Young and middle-aged patients have extraintestinal tuberculosis, especially in patients with open tuberculosis, or the systemic manifestations of tuberculosis after the original lesion has improved.
2. Clinical manifestations include diarrhea, abdominal pain, tenderness in the right lower quadrant, abdominal block, unexplained intestinal obstruction, fever, night sweats and other symptoms of tuberculosis.
3. X-ray barium meal examination found that the ileocecal area has irritation, intestinal lumen stenosis, intestinal segment shortening deformation and other signs.
4. Tuberculin test is strongly positive. For cases with high suspected intestinal tuberculosis, such as anti-tuberculosis treatment for 2 to 6 weeks, clinical diagnosis of intestinal tuberculosis can be made, such as lesions in the distal ileum and colon, colonoscopy and Biopsy can help diagnose and differential diagnosis. For those who have difficulty in diagnosis, mainly proliferative intestinal tuberculosis, sometimes laparotomy is needed to confirm the diagnosis.
Differential diagnosis
1. Crohn's disease: The clinical manifestations and X-ray barium meal performance of the disease can sometimes be similar to intestinal tuberculosis, which is easy to cause misdiagnosis, but there are still some differences between the two to identify:
(1) Intestinal tuberculosis is associated with tuberculosis in other organs.
(2) Intestinal tuberculosis complicated with intestinal fistula, bleeding, intestinal wall or organ abscess is less likely than Crohn's disease.
(3) X-ray examination of tuberculosis caused by intestinal shortening is more obvious than Crohn's disease, lesions involving the ileum are more common in Crohn's disease, and only involving the cecum is considered tuberculosis.
(4) endoscopic examination of intestinal tuberculosis ulcers are often ring-shaped, while Crohn's disease ulcers are mostly longitudinal, fissure ulcers and paving stones are more common in Crohn's disease.
(5) Histology (most important identification) Intestinal tuberculosis can find cheese necrosis or tuberculosis in the intestinal wall or mesenteric lymph nodes and Crohn disease.
(6) Anti-tuberculosis treatment of intestinal tuberculosis is effective, but Crohn's disease is ineffective.
(7) The recurrence rate of intestinal tuberculosis after surgical resection of lesions is lower than that of Crohn's disease. The recurrence rate of Crohn's disease is generally 50% within 5 years.
2. Colon cancer: This disease has abdominal pain, diarrhea, abdominal mass and progressive weight loss, pale and other manifestations, must be identified with intestinal tuberculosis, identification points can include the following aspects:
(1) The age of onset is generally larger than that of intestinal tuberculosis, often over 40 years old, and there is no evidence of intestinal tuberculosis.
(2) The course of disease has a progressive development trend, generally no fever, night sweats and other toxemia manifestations, while weight loss and other systemic consumption symptoms are more obvious.
(3) When the abdominal mass begins to appear, it can often be promoted. The adhesion is not as good as that of intestinal tuberculosis. The tenderness is often absent, but the surface is nodular and the texture is hard.
(4) The main finding of X-ray examination is that there is a filling defect in the lesion, but the scope is limited and does not involve the ileum.
(5) Intestinal obstruction is more common and occurs earlier.
(6) Fiberoptic colonoscopy can be seen in the tumor, and biopsy and cell brush smear can be used to confirm colon cancer diagnosis under direct vision.
3. Intestinal lymphoma: Intestinal lymphoma is a general condition, worse than intestinal tuberculosis, the abdominal mass appears earlier, X-ray shows that the mucosal folds of the dilated bowel are damaged, may be associated with superficial lymph nodes and hepatosplenomegaly, hilar Lymph node enlargement, anti-tuberculosis treatment is ineffective, if the lesion is in the ileocecal area, colonoscopy and biopsy often have a positive result, if the clinical identification is very difficult, early surgical exploration should be performed.
4. Amoeba or schistosomiasis granuloma: Intestinal amebiasis or schistosomiasis can form granulomatous lesions in its chronic phase, especially those involving ileocecal disease, often similar to intestinal tuberculosis, should be identified, but These patients have a history of epidemiology and infection after consulting the medical history, and their pus and blood are more obvious than intestinal tuberculosis. The stool test can detect the amoebic trophozoites, cysts or schistosomiasis eggs, and if necessary, the feces can be hatched to find schistosomiasis. Through the colonoscopy, the corresponding lesions can be seen, and specific treatment can achieve therapeutic effects.
5. Ulcerative colitis complicated with retrograde ileitis: the two are generally not difficult to identify, the clinical manifestations of this disease are mainly pus and blood, which is extremely rare in intestinal tuberculosis, ulcerative colitis, such as involving the ileum, its pathology must Involving the entire colon, and with the sigmoid colon, the rectum is the most serious, it is not difficult to make a diagnosis of rectal or sigmoidoscopy and biopsy.
6. Yersinia enteritis: Yersinia most frequently invades the terminal ileum, thickens the intestinal wall, changes the intestinal mucosal inflammation, and enlarges the mesenteric lymph nodes. Its performance is similar to that of ileal tuberculosis, but the course of Yersinia enteritis is short-lived. It can be self-healing, and can be distinguished from intestinal tuberculosis. If the feces, blood or tissue specimens are cultured in the acute phase, the bacteria may be positive, and serum agglutination test to determine the antibody titer is also helpful in diagnosing the disease.
7. Others: some rare diseases such as intestinal atypical mycobacterial disease (more common in AIDS patients), sexually transmitted lymphogranuloma, syphilis invading the intestine, enterobacterial peptic ulcer and biliary infection, etc., according to medical history , signs and related laboratory tests and other appropriate auxiliary examinations can be differentiated from intestinal tuberculosis.
