endometrial tuberculosis
Introduction
Introduction to endometrial tuberculosis Endometrial tuberculosis is often secondary to tuberculosis, kidney tuberculosis, gastrointestinal, bone or joint tuberculosis, and occasionally as part of whole body miliary tuberculosis. Infectious diseases of female genital organs caused by Mycobacterium tuberculosis often invade the fallopian tubes, and then gradually invade the endometrium, ovaries, rarely involving the cervix, vagina, and vulva. basic knowledge The proportion of illness: the probability of female disease is 0.003% Susceptible people: women Mode of infection: non-infectious Complications: uterine empyema, amenorrhea
Cause
Endometrial tuberculosis
Cause of disease (45%):
Endometrial tuberculosis is mostly spread by the spread of tubal tuberculosis. Female genital tuberculosis first infects the fallopian tube, and then gradually spreads to the endometrium, ovary, cervix, etc., due to the periodic shedding of the endometrium, the endometrial tuberculosis lesions are discharged, the lesions are mostly confined to the endometrium, and the early stage is scattered. Miliary nodules, very few severe lesions invade the muscle layer, the size of the palace is normal or slightly smaller, and the appearance is not abnormal.
Low resistance (35%):
When Mycobacterium tuberculosis infects the body, it usually does not develop immediately, but after a period of incubation. During the incubation period, when the body is in poor resistance, Mycobacterium tuberculosis can invade the endometrium and eventually will affect the lining of the endometrium.
Pathogenesis:
Tuberculous nodules can be seen under the endometrium of scraping. Caseous necrosis occurs in severe cases. The typical tuberculous nodules are 1-2 giant cells in the center. The cells are arranged in a horseshoe shape, surrounded by epithelial cells, and the outer side is surrounded. A large number of lymphocytes and plasma cells infiltrate, endometrial tuberculous nodules are characterized by glands around the tuberculous nodules are not sensitive to ovarian hormone response, manifested as persistent hyperplasia or insufficient secretion, severe endometrial tuberculosis may appear caseous necrosis The superficial ulcer causes most or all of the endometrium to be destroyed, and scars can be formed later, and the function of the intima is completely lost and amenorrhea occurs.
Prevention
Endometrial tuberculosis prevention
Endometrial tuberculosis is mostly secondary infection, and the primary lesion is mainly tuberculosis. Therefore, active prevention and treatment of tuberculosis is of great significance for the prevention of genital tuberculosis.
(1) Vaccination:
As with tuberculosis, in addition to strengthening anti-tuberculosis publicity and education, the health care of children and adolescents should be strengthened. To prevent tuberculosis infection, after unfortunately infected with tuberculosis, you should seek medical advice as soon as possible to avoid the spread of infection.
1. Inoculation age: Newborns with a body weight of 2200g or more can be vaccinated with BCG after 24 hours of birth, and can be replanted within 3 months if necessary. Infants after 3 months until adolescent girls, those with negative tuberculin test should be vaccinated with BCG.
2, contraindications: tuberculosis activity should avoid pregnancy. Desopo and Springett reported that the risk of recurrence of the disease after 5 years of follow-up after treatment is less than 1, so it is only 5 or more years after the condition is stable.
3, note: genital tuberculosis patients with vaginal secretions and menstrual blood may have tuberculosis, should strengthen isolation, to avoid infection.
(B), enhance the body's resistance and immunity:
Pay attention to the combination of work and rest, strengthen nutrition, eat more fresh fruits and vegetables rich in vitamins, eat more protein-rich poultry fish and eggs, milk, and participate in sports activities to enhance physical fitness.
Complication
Endometrial tuberculosis complications Complications
The endometrium can form uterine empyema when it is a cheese-like tissue or an ulcer; some patients have amenorrhea; most genital tuberculosis patients are complicated by infertility.
Symptom
Endometrial tuberculosis symptoms Common symptoms Lower abdominal pain Lower abdomen falling pain Vaginal secretions increased Low heat abdominal pain Night sweats fatigue
The clinical manifestations of tuberculosis in female genital organs are very inconsistent. Many patients may be asymptomatic. In severe cases, they may have the following manifestations:
Symptom
(1) Severe patients often have systemic manifestations such as weight loss, low fever, night sweats, fatigue, etc., and have a history of infertility and abnormal menstruation.
(2) increased vaginal secretions, in which endometrial tuberculosis due to the transformation of the endometrium into a cheese-like granuloma-like tissue, can appear serous odorous vaginal discharge, such as combined with cervical tuberculosis, may have purulent or pus Drainage and contact bleeding.
(3) abdominal pain, endometrial tuberculosis patients, 25% to 50% have varying degrees of lower abdominal pain, manifested as long-term lower abdominal pain, exacerbated before menstruation, such as combined with secondary septic infection, can appear obvious Abdominal pain, fever and other similar manifestations of acute pelvic inflammatory disease.
(4) menstrual changes, in the early stages of the disease manifested as menorrhagia, to the late stage due to intimal atrophy, the amount of menstruation is rare, and even amenorrhea.
2. Signs
Due to the severity of the lesions and the extent of the affected, the signs are quite different. Abdominal examination: mild patients with endometrial tuberculosis can be found without any abnormal findings. When there is peritoneal tuberculosis, the abdomen has tenderness, flexibility or ascites, forming a package. In the case of sexual effusion, the cystic mass may be inactive and inactive, and the mass may be adhered to the intestinal tube, and may have mild tenderness.
Examine
Endometrial tuberculosis examination
1. Blood: Unless there is a mixed infection, the white blood cell count is generally not high, and lymphocytes may increase in the classification count.
2. Polymerase chain reaction detection : Rapid detection of disease by quantitative detection of Mycobacterium tuberculosis specific polymerase chain reaction (PCR) in blood or tissue, research suggests that PCR detects different sites of Mycobacterium tuberculosis DNA It is a quick and sensitive method, but the judgment should consider the course of the disease.
3. Determination of serum CA125 value : serum CA125 level in patients with advanced abdominal tuberculosis is significantly increased, Thakur et al (2001), a 48-year-old woman with CT showed right ovarian mass with ascites, serum CA125 value up to 1255U / ml (normal 0 ~ 35U/ml), laparotomy for the diagnosis of ovarian malignant tumors, pathological histological examination of granuloma, CA125 level decreased to 42U/ml after 1 month of anti-tuberculosis treatment, suggesting serum of patients with abdominal mass with or without ascites An abnormally elevated CA125 value should also consider tuberculosis. Laparoscopy combined with tissue biopsy can confirm the diagnosis to avoid unnecessary laparotomy, and serum CA125 value detection can also be used to monitor the efficacy of anti-tuberculosis treatment.
4. Tuberculin test : tuberculin test positive indicates that there has been tuberculosis infection, its diagnosis is not significant, if it is strongly positive, it indicates that there is active disease in the body, but does not indicate the lesion site, negative results can not be ruled out Tuberculosis.
5. Mycobacterium tuberculosis culture and animal inoculation
Take the menstrual blood, scraped endometrium, cervical secretions, uterine secretions, pelvic mass puncture or pelvic effusion, etc., and check for positive results at 2 months, or inoculate these substances. Under the skin of the guinea pig abdominal wall, anatomical examination after 6-8 weeks, if the tuberculosis is found in the lymph nodes around the inoculation site, the diagnosis can be confirmed. If the result is positive, the drug sensitivity test can be further carried out to guide the clinical treatment.
Menstrual blood culture (take 6 to 8 ml of menstrual blood on the first day of menstruation) can avoid the spread of tuberculosis caused by curettage, but the positive rate is lower than that of endometrial bacteriology. It is generally recommended to perform histological examination, bacterial culture and animal inoculation at the same time. It can improve the rate of positive diagnosis. This method has certain technical requirements and it takes a long time to be used.
6. Histopathological examination
In the pelvic cavity, miliary-like nodules or cheese-like substances must be diagnosed. For infertility and suspicious patients, the endometrium should be taken for histopathological examination. The diagnosis should be performed within 12 hours after the menstrual cramps. When the lesions are more obvious, the curettage should be careful to scrape the uterine horn intima. The endometrial tuberculosis is mostly from the fallopian tube, so that the lesions first appear on both sides of the uterine cavity, and the scraped tissue should be sent to the pathological examination. It is best to serially slice the specimens to avoid missed diagnosis. For example, a typical tuberculous nodule can be diagnosed in the section. The endometrial inflammatory granuloma should be highly suspected of endometrial tuberculosis, no tuberculous lesions but giant cells. The system (macrophage has strong phagocytosis and killing effect on Mycobacterium tuberculosis) can not deny the existence of tuberculosis. Suspicious patients need to be reviewed every 2 to 3 months. If 3 times of endometrial examination are negative, they can be considered as no uterus. Endometrial tuberculosis exists, because of the risk of tuberculosis spread due to surgical curettage, preoperative and postoperative anti-tuberculosis drugs should be used for preventive treatment, other lesions such as cervix, vagina, vulva must also be pathological Histological examination to confirm the diagnosis.
7. X-ray inspection
(1) Chest X-ray: If necessary, X-ray examination of the gastrointestinal system and urinary system can be performed to find the primary lesion, but many patients often have their primary lesions healed when they find genital tuberculosis, and they do not stay. Traces, so X-ray film negative can not rule out pelvic tuberculosis.
(2) Abdominal X-ray: If the isolated calcification is shown, it indicates that there is pelvic lymph node tuberculosis.
(3) uterine tubal lipiodol angiography: uterine tubal iodine angiography has a certain value in the diagnosis of genital tuberculosis, its development characteristics are:
1 uterine cavity: different forms, can have varying degrees of stenosis or deformation, no curettage or a history of abortion can also be jagged edges.
2 The fallopian tube lumen has multiple stenosis, which is typical beaded or small stiff.
3 contrast agent into the uterine wall: interstitial, paraventricular lymphatic vessels or blood vessels should consider endometrial tuberculosis.
4 There is obstruction between the abdomen and the isthmus of the fallopian tube, accompanied by a perfusion defect of lipiodol into the interstitial of the fallopian tube.
5 corresponds to the fallopian tube, ovarian and pelvic lymph node: most scattered in the miliary translucent spot shadow, like calcification.
Uterine tubal iodine angiography may bring tuberculosis or cheese-like substances into the pelvic and abdominal cavity, and even cause the disease to spread and endanger life. Therefore, the indications should be strictly controlled. When the fallopian tube has empyema or other diseases, angiography should not be performed. Give anti-tuberculosis drugs to prevent the disease from worsening, and the appropriate time for angiography is 2 to 3 days after the net.
8. Laparoscopy
Laparoscopy is more valuable in the diagnosis of early stage pelvic tuberculosis in women. Laparoscopy is feasible in patients with negative endometrial histopathology and bacteriological examination. Microscopic observation of the serosal surface of the uterus and fallopian tubes is miliary. Nodules, there are no membranous adhesions around the fallopian tubes, and there are no tumors in the fallopian tubes and ovaries. At the same time, suspicious lesions can be taken for biopsy, and then the liquid is used for tuberculosis culture. Palmer et al. used laparoscopy to examine 99 suspected genitals. Among the tuberculosis patients, 10 cases were diagnosed. Because the appearance of the fallopian tube is unclear, and intestinal perforation is prone to occur if there is intestinal adhesion, the operation should be performed by an experienced doctor, and there is a contraindication in the abdominal cavity.
9. Hysteroscopy
Hysteroscopy can directly detect endometrial tuberculosis lesions, and can take living tissue for pathological examination under direct vision, but it may spread tuberculosis, and the severe adhesion of the uterine cavity due to tuberculosis damage may hinder the observation effect. It is difficult to identify with traumatic intrauterine adhesions, so it should not be used as the first choice. For example, hysteroscopic diagnosis must be performed. Before the microscopic examination, there should be no active tuberculosis, and anti-tuberculosis should be treated. Endometrial inflammation can be seen under hysteroscopy. The reaction is congested and red, the lesion is yellowish white or grayish yellow, the mild endometrium is uneven, the surface can be attached to the miliary white nodules; the severe lesions are the endometrial destruction of the tuberculosis, causing intrauterine adhesions, irregular shape The cavity can be filled with clutter, crispy polypoid, scar tissue, and even stone-like calcification, difficult to expand and separate.
Diagnosis
Diagnosis and diagnosis of endometrial tuberculosis
diagnosis
Patients with typical symptoms and signs have no difficulty in diagnosis. Most of them are missed or misdiagnosed because of no obvious symptoms and signs. Some patients are only confirmed by endometrial tuberculosis due to pathological histological examination of infertility. The situation should first consider genital tuberculosis:
1. Have a history of familial tuberculosis, have a history of tuberculosis exposure, or have had tuberculosis, pleurisy and intestinal tuberculosis.
2. Infertility with less menstruation or amenorrhea, symptoms such as lower abdominal pain, or pelvic cavity.
3. Unmarried women, history of asexual contact, complaining of low fever, night sweats, lower abdominal pain and menstrual disorders, anal examination of the pelvic attachment area thickened with sputum block should also think of this disease.
4. Chronic pelvic inflammatory disease has not healed for a long time. Some scholars have reported that 52 cases of pelvic genital tuberculosis patients have a history of tuberculosis in 22 cases, accounting for only 42.3%. Therefore, those without tuberculosis can not rule out genital tuberculosis, and should be carefully treated for elderly gynecological patients. Ask to check for tuberculosis.
Differential diagnosis
Endometrial pathology can identify the following diseases and make a clear diagnosis:
1. Endometrial cancer: When the cheese-like granuloma-like tissue can appear malodorous serous leucorrhea, endometrial cancer should be excluded.
2. Cervical cancer: cervical smear and biopsy can identify cervical cancer and cervical tuberculosis.
3. Non-specific pelvic inflammatory disease: There are many cases of childbirth, abortion, intrauterine device, gonorrhea or acute pelvic inflammatory disease. The clinical manifestations are more common in menstrual flow, while less amenorrhea, pelvic tuberculosis is mostly infertility, menstruation The amount is reduced or even amenorrhea, and the pelvic examination can affect the nodules or masses.
4. Pelvic endometriosis: There are many similarities between the two clinical manifestations, such as infertility, menstrual disorders, hypothermia, pelvic adhesions, thickening and nodules, but endometriosis dysmenorrhea, menstruation The amount is generally more, diagnostic curettage and uterine fallopian tube iodine angiography can help to confirm the diagnosis.
