Intestinal Tuberculosis | Medical Science Optional Notes for UPSC PDF Download

Hilton's Method of Incision and Drainage

The method of opening an abscess ensures that no blood vessel or nerve in the vicinity is damaged and is called Hilton's method, There are total 10 Steps of Hilton's Method of Incision and Drainage, These are as follows

• Topical Anesthesia: Achieve topical anesthesia using ethyl chloride spray.
• Stab Incision: Make an incision over the point of maximum fluctuation, situated in the most dependent area along skin creases, penetrating through the skin and subcutaneous tissue.
• Deeper Incision if Necessary: If no pus is encountered, use sinus forceps to cautiously deepen the surgical site, preventing damage to vital structures.
• Penetration through Deep Fascia: Insert closed forceps through the tough deep fascia, advancing toward the pus collection.
• Access to Abscess Cavity: Enter the abscess cavity and open the forceps parallel to vital structures.
• Pus Drainage: Allow pus to flow along the sides of the forceps' beaks.
• Thorough Cavity Exploration: Explore the entire cavity to identify any additional loculi.
• Drain Placement: Insert a soft yeast's or corrugated rubber drain into the abscess cavity's depth, securing the external part to the wound margin using sutures.
• Drain Duration: Leave the drain in place for at least 24 hours.
• Dressing Application: Apply dressing over the incision site.

Intestinal obstruction

• Definition of Intestinal Obstruction: Impairment in the normal passage of intestinal contents, attributed to either mechanical blockage or a failure in typical intestinal motility, without a physical obstructing lesion.

Classification Based on Nature of Presentation:

Acute Intestinal Obstruction

• Chronic Intestinal Obstruction:
  • Symptoms in chronic cases differ in predominance, timing, and degree compared to acute obstruction.
  • Functional cases may exhibit symptoms persisting for months or years.
  • Initial relative constipation progresses to absolute constipation, accompanied by distension.
  • In large bowel disease, the caecum experiences the most significant distension, marked by the onset of pain.
  • Vomiting is a late feature, resulting in less severe dehydration.

Acute on Chronic Intestinal Obstruction

• Subacute Intestinal Obstruction:
  • Incomplete obstruction is implied, allowing continued passage of flatus and/or feces beyond 6-12 hours after symptom onset.
  • Characterized by colicky abdominal pain, vomiting, and abdominal distension.
  • May evolve from acute obstruction, resolving spontaneously or with conservative management within a few hours.

Intestinal obstruction

Dynamic (Peristalsis working against a mechanical obstruction):

• Intraluminal Causes:
  • Faecal impaction
  • Foreign bodies
  • Bezoars
  • Gallstones
• Intramural Causes:
  • Stricture
  • Malignancy
  • Intussusception
  • Volvulus
• Extramural Causes:
  • Bands/adhesions
  • Hernia

Adynamic (No mechanical obstruction, inadequate or absent peristalsis):

• Paralytic Ileus
• Pseudo-obstruction

Intestinal obstruction

• Abdominal Pain:
  • Nature: Sudden and severe, colicky.
  • Location: Umbilical or lower abdominal region.
  • Strangulation: Suspected in cases of severe pain.
• Distension
• Vomiting
• Constipation:
  • Type: Absolute constipation.
• Additional Features:
  • Dehydration.
  • Hypokalemia.
  • Pyrexia.
  • Abdominal tenderness with rigidity and severe pain (Strangulation).
  • High-pitched bowel sounds.

Intestinal Obstruction-Management

• Supportive Measures:
  • Nasogastric tube for gastrointestinal drainage.
  • Fluid and electrolyte correction with normal saline (NS).
  • Broad-spectrum antibiotics.
• Surgical Treatment:
  • Generally necessary for most cases of intestinal obstruction.
  • Delayed until resuscitation is complete, unless there are signs of strangulation or evidence of closed-loop obstruction.
• Principles of Surgical Intervention:
  • Surgical intervention should not be delayed excessively, especially in cases of unrelieved acute intestinal obstruction, to avoid the risk of ischemia.
  • In cases of adhesions, surgery can be delayed up to 72 hours.
  • Decompress the distended proximal bowel operatively to relieve pressure.
  • Manage the segment at the site of obstruction through enterolysis, excision, or bypass.
  • Assess the viability of the bowel; if not viable, resect it.
  • In cases of sepsis, administer inotropic therapy, and raise both ends of the bowel as stomas for regular assessment.
  • Correct the underlying cause of obstruction.

Differentiation between viable and non-viable intestine

Intestinal Obstruction-Assessment

Right iliac fossa mass

Abdominal wall
(a) Hematoma
(b) Abscess
(c) Incisional hernia
(d) Lipoma
(e) Desmoid tumor

Appendicular mass 

• appendicular abscess 
• appendicular mucocele 
• appendicular neoplasms

Ileocecal tuberculosis (hyperplastic type) 

• Intussusception 
• Carcinoma cecum 
• Tubo-ovarian mass, e.g. abscess 
• Undescendcd testis 
• Transplanted kidney 
• Ectopic kidney 
• Psoas abscess 
• Non-Hodgkin lymphoma 
• Actinomycosis
• Amoeboma
• Crohns disease

Intestinal Tuberculosis

Two principle, disease presentations

Modes of Infection

• Swallowing of sputum with direct seeding.
• Hematogenous spread.
• Ingestion of milk from cows affected by bovine tuberculosis.

Commonly Affected Gastrointestinal Sites: Although any part of the gastrointestinal tract can be affected, the terminal ileum and cecum are most frequently involved.

Common Presenting Symptoms

• Abdominal pain and swelling.
• Obstruction.
• Hematochezia (blood in stool).
• Palpable mass in the abdomen.
• Fever, weight loss, anorexia, and night sweats.

Diagnostic Approach: Given that surgery is often necessary, the diagnosis is typically confirmed through histologic examination and culture of intraoperatively obtained specimens.

Surgical Intervention

• Ileocaecal resection is the standard procedure for terminal ileal disease.
• Primary anastomosis between the ileum and ascending or transverse colon is performed based on the extent of the disease.

Tuberculous Peritonitis

• Follows either direct spread of tubercle bacilli from ruptured lymph nodes and intraabdominal organs or hematogenous seeding.
• Nonspecific abdominal pain, fever, and ascites should raise suspicion of tuberculous peritonitis.

TB Peritonitis

• Prevalence of Peritoneal Involvement in Abdominal TB: Approximately 50-83% of patients with abdominal tuberculosis can expect to have peritoneal involvement.
• Common Presenting Features:
  • Ascites is a common presenting feature.
  • Abdominal pain, sweats, malaise, and weight loss are frequently observed.
• Characteristics of Peritoneal Deposits: Multiple tubercle deposits are evident on both layers of the peritoneum.
• Diagnostic Approaches:
  • Abdominal ultrasonography or CT scans are used to identify ascites and detect lymphadenopathy, as well as diffuse thickening of the peritoneum, mesentery, and/or omentum.
  • Ascitic fluid analysis reveals a straw-colored exudate (protein >25-30 g/L) with white cells >500 mm3 and lymphocytes >40%.
  • Diagnostic smears for acid-fast bacilli are only conclusive in less than 3% of patients, and culture results may take 4-8 weeks with no guarantee of a positive outcome.
  • Laparoscopy and peritoneal biopsy may be helpful, combining typical appearances with histology.
• Management Strategies:
  • The management of tuberculosis is primarily supportive, focusing on nutrition and hydration.
  • Medical management involves systemic antituberculous therapy, recognizing that multiple-drug resistance may be higher for abdominal tuberculosis compared to pulmonary tuberculosis.
  • Surgery may be necessary for specific complications such as intestinal obstruction.

Peritonitis

Definition of Peritonitis

Peritonitis is characterized as inflammation of the peritoneum and can manifest as either localized or generalized inflammation.

Causes of Peritoneal Inflammation

• Peritoneal inflammation can result from various causes, including bacterial sources from both gastrointestinal and non-gastrointestinal origins.
• Other causes include chemical factors such as bile or barium, allergic reactions like starch peritonitis, traumatic incidents such as operative handling, ischemic events like strangulated bowel or vascular occlusion, and miscellaneous factors like familial Mediterranean fever.

Routes to Peritoneal Infection

Peritoneal infection can occur through different pathways, including:

• Gastrointestinal perforation, such as from a perforated ulcer, appendix, or diverticulum.
• Transmural translocation without perforation, seen in conditions like pancreatitis, ischaemic bowel, or primary bacterial peritonitis.
• Exogenous contamination, which can result from drains, open surgery, trauma, or peritoneal dialysis.
• Female genital tract infection, as observed in pelvic inflammatory disease.
• Rarely, peritonitis can result from hematogenous spread, typically associated with conditions like septicaemia.

Peritonitis-Clinical features

• Abdominal Pain: Pain in the abdomen, exacerbated by movement, coughing, and deep respiration.
• Constitutional Upset: Generalized constitutional symptoms include anorexia, malaise, fever, and lassitude.
• Gastrointestinal Distress: Gastrointestinal symptoms involve nausea with or without vomiting.
• Pyrexia: Fever may be present but can also be absent.
• Elevated Pulse Rate: An increase in the pulse rate.
• Abdominal Wall Symptoms: Tenderness with possible guarding or rigidity, as well as rebound tenderness on the abdominal wall.
• Pelvic Peritonitis Signs: Pain or tenderness during rectal or vaginal examinations, indicative of pelvic peritonitis.
• Bowel Sounds: Bowel sounds may be absent or reduced.
• Later Stage Complications: In later stages, the development of 'septic shock' characterized by systemic inflammatory response syndrome (SIRS) and multi-organ dysfunction syndrome (MODS).

Peritonitis-Diagnosis

Bedside

• Use urine dipsticks to check for urinary tract infections.
• Consider performing an ECG if there is uncertainty about the cause of abdominal pain or if the patient has a cardiac history.

Blood Tests

• Conduct baseline tests for urea and electrolyte levels.
• Perform a full blood count to assess white cell count.
• Estimate serum amylase levels to help diagnose acute pancreatitis, keeping in mind that moderately elevated values are common after other abdominal issues or surgeries.

Imaging

• Take an upright chest X-ray to reveal free sub-diaphragmatic gas.
• Use a supine abdominal X-ray to confirm the presence of dilated gas-filled bowel loops, indicative of paralytic ileus.
• Consider multiplanar computed tomography (CT) for identifying the cause of peritonitis and influencing management decisions.
• Utilize ultrasonography in specific situations, such as pelvic peritonitis in women or localized right upper quadrant peritonism.

Invasive Procedures

• Perform peritoneal diagnostic aspiration.
• Provide general care, including nutritional support, pain relief, and correction of fluid loss and circulating volume.
• Address electrolyte imbalances.
• Offer multiorgan support in the case of septic shock.
• Consider central venous pressure (CVP) monitoring.
• Use nasogastric tube decompression.
• Administer broad-spectrum antibiotics.

Surgery

• Advocate early surgical intervention over a 'wait and see' approach, assuming the patient is fit for anesthesia and resuscitation has restored normal body physiology.
• Focus on removing or diverting the cause, followed by thorough peritoneal lavage and drainage.
• After addressing the cause, explore the entire peritoneal cavity to remove all seropurulent exudate, using a large volume of saline with dissolved antiseptic or antibiotic if needed (typically 3 liters).

Peritonitis-Complications

Systemic Complications of Peritonitis

• Septic shock
• Systemic inflammatory response syndrome (SIRS)
• Multi-organ dysfunction syndrome (MODS)
• Fatality

Abdominal Complications of Peritonitis

• Paralytic ileus
• Persistence or recurrence of abscess or inflammatory mass
• Portal pyaemia or liver abscess
• Small bowel obstruction due to adhesions

Intestinal Tuberculosis-Repeats

Q1: Describe the pathology and management of lleocaecal Tuberculosis. (1999)

Q2: Classify the types of intestinal obstruction. How would you manage a 20-year old lady with (Tuberculous) stricture with perforation in terminal ileum? (2001)

Q3: What are the causes and clinical features of acute intestinal obstruction? How will you assess and prepare such a patient for operative management?  (2007)

Q4: How would you manage a 21-year-old lady admitted with features suggestive of repeated episodes of sub-acute intestinal obstruction? Her mother was treated for pulmonary tuberculosis. (2010)

Q5: What are the key clinical features of abdominal tuberculosis? How would you investigate a patient suspected to be a case of abdominal tuberculosis? Briefly discuss the role of surgery in the management of a patient with abdominal tuberculosis. (2015) 

Q6: A 25-year-old male presented with history of off and on central abdominal distension with evening rising temperature and weight loss. On abdominal examination, firm, non-tender lump is present in right iliac fossa. (2017)
(i) Discuss the differential diagnosis of the above-mentioned case.
(ii) Mention the investigations and its findings.
(iii) Outline the management of ileocaecal tuberculosis. 

Q7: A 25-year-old young patient is presented to the emergency department with severe pain in abdomen for the last 3 hours. On clinical examination, the patient is oriented, but is dehydrated, having tachycardia with a blood pressure of 90/60 mm Hg. Discuss the differential diagnosis of this patient. How will you investigate the case? Briefly outline the management of peptic ulcer perforation peritonitis. (2018)