Pictorial review

Computed tomography in abdominal tuberculosis

S SURI, MD, DABR, S GUPTA, MD, DNB and R SURI, MD, DNB
Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research,
Chandigarh-160012, India
Abstract. The diagnosis of abdominal tuberculosis is often dicult because of its protean clinical
manifestations and non-specic laboratory investigations. In the abdomen, tuberculosis may aect
the intestinal tract, lymph nodes, peritoneum and solid viscera in varying combinations. CT, with
its ability to provide a comprehensive overview of abdominal structures, is the imaging modality of
choice for evaluation of such patients. This pictorial review illustrates the spectrum of CT appear-
ances of abdominal tuberculosis which includes intestinal, lymph nodal, peritoneal, mesenteric,
hepatic, splenic and pancreatic disease.
Abdominal tuberculosis continues to be a major
cause of morbidity and mortality in developing
countries such as India. Its incidence is also
increasing in developed countries, mainly in
the immigrant population and in patients with
AIDS [1].
In the abdomen, tuberculosis may aect the
intestinal tract, lymph nodes, peritoneum and
solid viscera. As many as two-thirds of patients
with abdominal tuberculosis may have lymphade-
nopathy or peritoneal disease in addition to intest-
inal involvement; whereas about one-third have
only extraintestinal involvement [2]. Although bar-
ium studies remain the mainstay for delineating
the intestinal changes, abdominal CT is considered
essential for the evaluation of extraluminal, perito-
neal, nodal and visceral involvement. This pictorial
review illustrates the wide spectrum of changes
demonstrated on CT in patients with abdominal
tuberculosis, based on experience of 87 patients.
Tuberculous lymphadenopathy
Abdominal lymphadenopathy is the commonest
manifestation of tuberculosis on CT. Lymph node
involvement is seen in up to two-thirds of patients
with abdominal tuberculosis and usually aects
multiple lymph node groups simultaneously [2].
Mesenteric and peripancreatic groups are involved
most often, reecting the lymphatic drainage of
commonly aected sites in the small bowel and
liver. In our experience, isolated retroperitoneal
lymphadenopathy is uncommon; most patients
with retroperitoneal lymph node involvement also
have aected nodes at other sites. In the majority
of patients (40^70%), CT shows enlarged nodes
(Figure 1a) with hypodense centres and peripheral
hyperdense enhancing rims [2, 3]. Other CT pat-
terns of lymph node morphology include
(i) conglomerate mixed density nodal masses, most
likely representing multiple conuent nodes due to
perinodal spread of inammation (Figure 1b);
(ii) enlarged nodes of homogeneous density, most
often associated with low density nodes at other
sites; and (iii) increased number (.3 in one CT sec-
tion) of normal sized or mildly enlarged mesenteric
nodes of homogeneous density, usually located
along the mesenteric vessels or adjacent to the
bowel loops (Figure 1c). On CT, these dierent
morphological features could signify evolving
pathological stages of the disease, with early non-
caseating granulomas and subsequent caseation
necrosis [2].
Lymph nodes with low density centres, although
characteristic of a tuberculous aetiology and repre-
senting caseous necrosis, are not pathognomonic
and can be seen in metastasis from testicular
tumour, Whipple's disease and rarely in lymphoma
following radiotherapy [2, 3]. Nodal metastases
from testicular tumours initially drain into the
``sentinel nodes'' located in the renal perihilar
regions and subsequently spread to paralumbar
nodes and nodes at the aortic bifurcation [4]. On
the other hand, tuberculosis generally involves
the mesenteric and peripancreatic lymph nodes.
Associated intestinal and peritoneal changes help
in dierentiating tuberculosis from Whipple's
disease.
The involved lymph nodes occasionally show cal-
cication; although this nding is not pathognomo-
nic of tuberculosis and may rarely be seen in
metastases from teratomatous testicular tumours
and non-Hodgkins lymphoma after treatment [5].
However, nodal calcication in patients from ende-
mic areas in the absence of a known primary
Received 18 March 1998 and in revised form 8 June 1998,
accepted 26 August 1998.
The British Journal of Radiology, 72 (1999), 92^98
E
1999 The British Institute of Radiology
92 The British Journal of Radiology, January 1999
tumour suggests a tuberculous aetiology, especially
if supported by characteristic distribution and
appearance of nodes.
Tuberculous peritonitis
Peritoneal involvement in tuberculosis occurs
primarily by haematogeneous spread but may be
secondary to ruptured lymph nodes, a perforated
gastrointestinal lesion, or fallopian tube involve-
ment [6, 7]. Peritoneal tuberculosis is traditionally
divided into three types [2, 7]: (i) ``wet'' with free or
loculated ascites; (ii) ``dry plastic'' with mesenteric
thickening, caseous lymph nodes and brous adhe-
sions; and (iii) ``brotic xed'', with mass formation
of omentum and matting of bowel loops. In our
experience, there is considerable overlap between
the three types on CT. Peritoneal tuberculosis is
mainly manifested on CT by varying degrees of
mesenteric and/or omental inltration with (wet
type) or without (dry type) associated ascites
(Figures 2 and 3). It has been suggested that high
density (25^45 HU) ascites may be characteristic of
tuberculosis [2], which could be explained by the
high protein and cellular contents in a tuberculous
exudate. However, tuberculous ascites may also be
of near water density (Figure 2a), perhaps reecting
an earlier transudative stage of immune reaction [8].
Peritoneal enhancement (Figures 2b and c) is usually
associated with smooth uniform thickening of the
peritoneum [6, 7]. Nodular implants with irregular
thickening are extremely uncommon and should
suggest a diagnosis of peritoneal carcinomatosis [7].
All the three described patterns of omental
involvement, i.e. smudged, omental cake and nod-
ular (Figure 3) are encountered with almost equal
frequency and do not help in dierentiating from
peritoneal carcinomatosis [6, 7]. Mesenteric inl-
tration (Figure 3) can range from mild involvement
in the form of linear soft tissue strands, thickened
and crowded vascular bundles, a ``stellate'' appear-
ance, and/or subtle increase in mesenteric fat den-
sity, to more extensive involvement resulting in
diuse inltration with soft tissue density masses
involving the leaves of the mesentery surrounding
the adjacent small bowel loops. Ascitic uid may
occasionally extend into the mesenteric leaves
(Figure 2c). Mesenteric abscess (Figure 3e) prob-
ably results from extensive caseation of large nodal
masses.
Intestinal tuberculosis
The most common CT nding is mural thick-
ening aecting the ileocaecal region (Figures
4a^e), either limited to the terminal ileum or
caecum or, more commonly, simultaneously
involving both regions. This mural thickening is
usually concentric, but is occasionally eccentric
and predominantly aects the medial caecal wall
[2, 9]. In some patients, low density areas (Figure
4d) most likely to represent necrosis, may be
noted within the thickened wall. Ileocaecal invol-
vement is usually associated with enlarged hypo-
dense nodes in the adjacent mesentery (Figure
4b).
Skip areas of concentric mural thickening may
be seen elsewhere in the small bowel (Figure 4e),
usually aecting the ileal loops. These segments
may also show luminal narrowing, with or with-
out proximal dilatation. The presence of such
lesions in combination with ileocaecal involve-
ment should strongly suggest the diagnosis of
tuberculosis.
Hepatosplenic tuberculosis
Tuberculosis of the liver and spleen usually occurs
inmiliaryformwithnodulesranginginsizefrom0.5to
2 mm, which cannot be detected on CT [2, 6].
Macronodularinvolvementisuncommonandisman-
ifested by single or multiple focal low density, non-
enhancing lesions with or without peripheral rim
enhancement (Figures 5a^d). However, these lesions
cannot be dierentiated from lymphoma, fungal
infectionor metastasis unless associatedwith charac-
teristic lymph node or intestinal involvement [2, 3, 6].
Image guided ne needle aspiration biopsy has been
helpful inpatients withsuchunusual presentation.
Pancreatic tuberculosis
Pancreatic tuberculosis is unusual and solitary
involvement is rare [2, 3, 6, 10]. The pancreas can be
involvedintuberculosisbyeitherthehaematogeneous
route in miliary tuberculosis or by direct spread from
contiguous lymph nodes. CT may show an enlarged
pancreas with focal hypodense lesions, usually in the
head region (Figure 6). However, these ndings are
non-specic and may be seen in focal pancreatitis or
pancreatic carcinoma. Atubercular aetiology can be
suggested only by the presence of associated ndings
suchas characteristichypodenselymphnodes, ascites
or mural thickening inthe ileocaecal region[10].
Abdominal tuberculosis in AIDS
Tuberculosis occurs with increased frequency in
AIDS patients as the CD4 count drops below 400
cells per ml. Whereas extrapulmonary manifesta-
tions are seen in only 10^15% of non-HIV infected
patients, the incidence is much higher (about 50%)
in patients with AIDS [11]. Mycobacterium tuber-
culosis infection in AIDS patients tends to be dis-
seminated and may involve mesenteric lymph
nodes, the peritoneum, solid visceral organs
including the liver, spleen and pancreas and vir-
tually any portion of the gastrointestinal tract,
Pictorial review: CT in abdominal tuberculosis
93 The British Journal of Radiology, January 1999
particularly the ileum and colon. The imaging nd-
ings are usually indistinguishable from those seen
in non-AIDS patients. Fistulas are, however, more
commonly encountered in AIDS and may occur
from any segment of bowel. Necrotic low attenua-
tion mesenteric lymphadenopathy is typically seen,
although soft tissue attenuation adenopathy may
also be encountered [12].
Infection with atypical mycobacteria
(Mycobacterium avium and Mycobacterium intra-
cellulare, MAC), although rarely encountered in
non-immunocompromised patients, is one of
the most frequent infections in AIDS patients.
CT may show bowel wall thickening, hepato-
splenomegaly with focal lesions and bulky
mesenteric and retroperitoneal lymphadenopathy.
Adenopathy shows soft tissue attenuation in the
majority of the patients as granulomas are rarely
formed [12].
(a)
(c)
(b)
Figure 1. Abdominal lymph node involvement.
(a) Multiple enlarged retroperitoneal and mesenteric
lymph nodes with characteristic hypodense centres and
peripheral hyperdense rims. (b) A heterogeneous mixed
density lymph node mass (arrows) in the mesenteric
compartment. (c) An increased number of normal sized
soft tissue density mesenteric nodes (arrows).
S Suri, S Gupta and R Suri
94 The British Journal of Radiology, January 1999
(b) (a)
(c)
Figure 2. Peritoneal involvement. (a) Free ascites with
omental thickening (arrow), (b) ascites with uniform
peritoneal thickening (arrows) and (c) loculated uid in
the peritoneal cavity (small arrows) as well as in the
mesenteric leaves (arrowhead) along with peritoneal
enhancement. Note ileocaecal thickening (large arrow).
(c) (b)
(a)
(e) (d)
Figure 3. Peritoneal involvement. (a) ``Smudged''
appearance (arrows) of the omentum. Note soft tissue
mesenteric inltration (i) involving the small bowel
loops. (b) Omental ``cake'' formation (arrows) and
ascites. (c) Omental thickening (arrow), loculated
ascites (open arrow) and soft tissue mesenteric inltra-
tion (asterix). (d) Irregular thickening of the mesenteric
leaves (short arrows). Note enlarged retroperitoneal
nodes (long arrow) and caecal wall thickening (arrow-
head). (e) Large mesenteric abscess (arrows).
Pictorial review: CT in abdominal tuberculosis
95 The British Journal of Radiology, January 1999
(c)
(b) (a)
(e)
(d)
Figure 4. Ileocaecal involvement. (a) Thickened ileo-
caecal valve, along with mural thickening of the cae-
cum and terminal ileum (arrowhead). (b) Concentric
uniform mural thickening of the caecum (arrows) along
with an enlarged hypodense pericaecal node (open
arrow). (c) Mural thickening involving the terminal
ileum (arrow) only. (d) Gross irregular mixed density
mural thickening of the ileocaecal region (arrows) with
polypoidal projections into the caecal lumen. Note
hypodense as well as soft tissue density nodes in the
mesentery. (e) Ileocaecal mural thickening (white
arrow) along with focal mural thickening associated
with luminal narrowing (black arrows) aecting one of
the distal ileal loops.
S Suri, S Gupta and R Suri
96 The British Journal of Radiology, January 1999
(c)
(b) (a)
(d)
Figure 5. Liver and spleen involvement. (a) Three discrete hypodense lesions in the spleen, with irregular periph-
eral areas of enhancement. (b) Multiple small well dened hypodense lesions (few of which are conuent) in an
enlarged spleen and few small hypodense lesions in liver. (c) Multiple small ill dened hypodense lesions in an
enlarged spleen. (d) Multiple ill dened hypodense lesions in right lobe of liver, an enlarged spleen with few ill
dened lesions.
Figure 6. CT scan showing an irregular hypodense
lesion (arrow) in the pancreatic head.
Pictorial review: CT in abdominal tuberculosis
97 The British Journal of Radiology, January 1999
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