European Journal of Radiology 55 (2005) 173–180

Abdominal tuberculosis: Imaging features

José M. Pereira ∗ , Antonio J. Madureira, Alberto Vieira, Isabel Ramos
Department of Radiology, Hospital de S. João, Porto, Portugal

Received 13 April 2005; received in revised form 15 April 2005; accepted 18 April 2005

Abstract

Radiological findings of abdominal tuberculosis can mimic those of many different diseases. A high level of suspicion is required, especially
in high-risk population. In this article, we will describe barium studies, ultrasound (US) and computed tomography (CT) findings of abdominal
tuberculosis (TB), with emphasis in the latest. We will illustrate CT findings that can help in the diagnosis of abdominal tuberculosis and
describe imaging features that differentiate it from other inflammatory and neoplastic diseases, particularly lymphoma and Crohn’s disease.
As tuberculosis can affect any organ in the abdomen, emphasis is placed to ileocecal involvement, lymphadenopathy, peritonitis and solid
organ disease (liver, spleen and pancreas). A positive culture or hystologic analysis of biopsy is still required in many patients for definitive
diagnosis.
Learning objectives:
1. To review the relevant pathophysiology of abdominal tuberculosis.
2. Illustrate CT findings that can help in the diagnosis.
© 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Tuberculosis; Abdominal; CT; Ileocecal

1. Introduction to be familiar with the spectrum of CT appearances seen in

Abdominal tuberculosis (TB) is an uncommon condition
in the western countries, but there has been a resurgence of the
disease, becoming an endemic disease in most of the develop-
ing countries [1], largely due to the AIDS epidemic. Although
the presence of thoracic tuberculosis may be suggestive of as-
sociated abdominal TB, only 15% of patients with abdominal
TB have evidence of pulmonary disease [2]. For the purpose
of this discussion, the authors comment about abdominal TB
will be confined to involvement of the gastrointestinal tract,
lymphatic system, peritoneum and its reflections, hepatobil-
iary system and spleen. Conventional barium studies and ul-
trasound (US) findings of abdominal TB will be described.
Emphasis will be placed to the advantages of computed to-
mography (CT) over the former studies, by demonstrating
the entire range of involvement in a single examination. With
the widespread use of CT in the abdomen, it is important
∗ Corresponding author.
E-mail address: jmpjesus@yahoo.com (J.M. Pereira).
abdominal TB.
2. Gastrointestinal tuberculosis
2.1. Pathophisiology
Intestinal TB is a rare manifestation of TB; however, it is
a common form of abdominal TB. Tubercle bacilli infect the
gastrointestinal tract after being coughed into the mouth and
then swallowed or by ingestion of infected milk. The bacilli
penetrate the mucosa and infect the submucosal lymphoid
tissue, resulting in the epithelioid tubercle. Mucosal slough-
ing and ulceration occur 2–4 weeks later and results in the
ulcerative form of the disease, which is most common. The
ulcers typically are small and multiple with irregular mar-
gins. The surrounding mucosa shows considerable thicken-
ing. With progression there is granuloma formation, caseous
necrosis and cicatrisation [3]. A less common hypertrophic
form is characterized by abundant inflammatory response and

0720-048X/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ejrad.2005.04.015
174 J.M. Pereira et al. / European Journal of Radiology 55 (2005) 173–180

reactive tissue producing a multinodular mucosal pattern or

neoplasm-like mass [3]. Disseminated infection to abdominal
viscera can also occur by hematogeneous and lymphatic routs
from distant source of infection, such as the lungs. Patients
with intestinal involvement most commonly complain of di-
arrhea with other frequent complaints including fever, night
sweats, abdominal pain and distention, anorexia and weight
loss. The chest radiographs may be normal in 50–60% of the
patients [3–5].
Although mucosal changes are best evaluated by barium
examinations, evidence of extramucosal disease is both in-
direct and incomplete with this technique. Ultrasound and
computed tomography show extramucosal changes directly
and can also occasionally pick up some mucosal changes [6].
CT also makes an important contribution in evaluating most
of the complications of the intestinal tuberculosis, such as
small bowel obstruction, perforation, abscess formation, fis-
tulae, intussusception and vascular complications like bowel
wall ischemia. The diagnosis is usually obtained by US- or
CT-guided biopsy in most cases.
The most frequent region of involvement is the ileocecal Fig. 1. Ileocecal tuberculosis. Single-contrast barium enema study shows
junction, followed by the ileum, cecum, ascending colon, changes of advanced disease with fixed and narrowed terminal ileum and
jejunum, rest of the colon, rectum, duodenum and stomach, conical and shrunken cecum (arrows) due to fibrosis. These findings are
in descending order of frequency [7]. non-specific and can most often mimic Crohn’s disease.

2.2. Ileocecal TB that envelops the terminal ileum (Fig. 4). Adherent loops and
mesenteric thickening centered at the ileocecal valve can also
Although tuberculosis can involve any region of the gas- together form part of this soft-tissue mass. Some nodes con-
trointestinal (GI) tract, in about 90% of cases it affects the tain low-density centers consistent with caseation necrosis.
ileocecal valve, and the adjacent ileum and colon [3,8]. Be- Pericecal or mesenteric fat shows either absence or minimal
cause the pathologic involvement occurs at the ileocecal valve haziness [10].
and adjacent to it, the radiographic appearance of the valve In most patients, the differential diagnosis from Crohn’s
was considered an important indicator of the presence of tu- disease cannot be made unless a history of tuberculosis or a
berculous infection. positive chest film is present. A normal chest, however, does
Thickening of the valve lips and/or wide gaping between not exclude intestinal tuberculosis [3,5]. Radiological differ-
the valve and narrowed terminal ileum (Fleischner sign), has
been described as a characteristic sign on barium examination
[3,8]. Although this sign is seen occasionally, the majority
of barium studies show non-specific inflammatory changes
involving the terminal ileum and cecum (Fig. 1). In advanced
disease, the cecum becomes conical and shrunken resulting
in a widely open ileocecal valve with fixed and narrowed
terminal ileum due to fibrosis (Stierlin’s sign) [3,8].
Ultrasonography usually reveals uniform and concentric
bowel wall thickening in most patients (Fig. 2). Occasionally,
ulceration is seen. Matted masses constituted by thickened
bowel loops, ascites and regional lymph nodes may also be
observed with US [9].
CT is an excellent method for evaluation of the gross mor-
phology of the pathologic process [10]. When the inflamma-
tory process is mild, CT shows only slight and symmetric wall
thickening and a few small regional lymph nodes (Fig. 3).
With the advance of the process, a CT appearance more char-
Fig. 2. Ileocecal tuberculosis. Sonogram study in a patient with abdomi-
acteristic of TB is seen and consists of asymmetric thicken- nal pain due to gastrointestinal tuberculosis shows uniform and concentric
ing of the ileocecal valve and medial wall of the cecum, and thickening of the wall of terminal ileum (between marks). Involvement of the
large lymph nodes, forming a heterogeneous soft-tissue mass cecum and the pericecal hypoechoic lymph nodes were present (not shown).
 J.M. Pereira et al. / European Journal of Radiology 55 (2005) 173–180 175

entiation of early-stage ileocecal tuberculosis from Crohn’s

disease and lymphoma is usually impossible; however, the
imaging features of advanced stages of ileocecal TB are not
compatible with Crohn’s disease and unusual for lymphoma
[6,10] (Table 1). Amebiasis may produce the typical shrunken
cecum seen in TB, but small bowel association is very rare
with amebiasis. Cecal carcinoma is always limited by the
ileocecal valve.

2.3. Esophageal TB

TB of the esophagus is a rare condition that occurs sec-

Fig. 3. Ileocecal tuberculosis. Transverse contrast-enhanced CT image
shows mild wall thickening of the cecum (arrowhead) with increase number
of normal sized soft-tissue density pericecal nodes (arrows).
ondary to the spread of bacilli from adjacent lymph nodes,
or from pulmonary and vertebral tuberculosis. Esophageal
involvement usually manifests as extrinsic compression with
displacement or narrowing due to adjacent lymphadenopathy
most frequently at the level of the carina. With progression
there are ulceration and fistula formation. Chronic fibrotic
changes result in traction diverticula and strictures. Barium
examinations show these findings very nicely. CT is a more
reliable method to determine the full extent of the disease
into the mediastinum [11].
2.4. Gastric TB

Gastric TB is very rare and is usually difficult to diag-

nose. The antrum and distal body are the sites usually in-
volved. Antral narrowing occurs most frequently secondary
to ulceration and fibrosis, but sometimes due to surrounding
caseating lymphadenopathy, which can be well documented
on CT [6,12]. Severe wall thickening may be seen in the hy-
pertrophy form. Fistula and sinus are rare but suggestive of
TB.

2.5. TB of the duodenum

Duodenal involvement is uncommon and usually ob-

struction is due to extrinsic compression by adjacent lym-
phadenopathy. A matted mass containing enlarged lymph
nodes and thickened mesenteric root is demonstrated by US
or CT [13].

Table 1
Differentiating imaging features of ileocecal involvement by tuberculosis
and Crohn’s disease
Tuberculosis Crohn’s disease
Asymmetric wall thickening, Circumferential bowel wall
irregular thickening
Fleischner sign on barium studies Cobblestone appearance on
barium
No creeping fat Creeping fat (abnormal quantity
of mesenteric fat)
Fig. 4. Ileocecal tuberculosis. Axial contrast-enhanced CT images showing:
Positive chest film (50%) Negative chest film
(A) thickened ileocecal valve, along with circumferential wall thickening of
Omental and peritoneal Normal omentum and peritoneum
the cecum (long arrow) and the terminal ileum (short arrows). (B) Concentric
thickening
uniform mural thickening of terminal ileum (long arrows) and medial wall of
Enlarged lymph nodes with Enlarged soft-tissue density
cecum (short arrow) along with enlarged hypodense adjacent lymph nodes
low-density centers lymph nodes
(arrowheads).
176 J.M. Pereira et al. / European Journal of Radiology 55 (2005) 173–180

2.6. TB of the jejunum and ileum

Tuberculous involvement of small bowel, except of the

terminal ileum, occurs infrequently, usually in association
with peritonitis. Non-specific mucosal ulcers and fold thick-
ening are seen on barium studies, and bowel wall thicken-
ing is demonstrated on CT (Fig. 5). Isolated circumferential
stricture demonstrated well on double-contrast small bowel
barium examination has been described [14].

2.7. TB of the colon

The large bowel is involved only in 9% of cases without

small wall involvement [6]. Short or long segment (more than
5 cm) involvement can occur, the latter being usually contigu-
ous with ileocecal involvement. Short segment involvement is
more often seen around the hepatic flexure. Barium study of-
ten shows colonic strictures (Fig. 6A). The CT findings of the
affected segment includes circumferential wall thickening,
narrowing of the lumen and ulcerations (Fig. 6B). Marked
shortening and distortion of the colon can occur in advanced
disease.

3. Tuberculous lymphadenopathy

Pathophisiology and imaging features

Lymphadenopathy is the most common manifestation of

abdominal tuberculosis, and is usually associated with GI
tuberculosis and less commonly with peritoneal or solid organ
involvement; however, it can also be the only sign of the
disease, especially in the periportal region [15].
Three major routes of transmition are described: the most
common, ingestion of infected material with the tubercle
bacilli, such as sputum or milk; hematogeneous spread of
bacteria from a distant site of infection, more commonly the
lungs; directly from the serosa of adjacent infected organs or
structures.

Fig. 6. Colonic tuberculosis. (A) Barium enema shows two focal areas of
stricture (arrows) in the descending and transverse colon, patient had no
history of inflammatory bowel disease. (B) Transverse contrast-enhanced CT
image of a patient with prolonged fever and abdominal pain shows marked
infiltration and asymmetrical thickening of the ascending colon (arrow). Note
also mesenteric enlarged lymph node (arrowhead) and absence of pericolonic
haziness.

Commonly involved mesenteric root, celiac, porta hep-

atis and peripancreatic lymph nodes is explained by the
Fig. 5. Tuberculosis of the ileum. Transverse contrast-enhanced CT image drainage of the ingested infected material by the lymphatics
shows symmetric mural thickening involving a segment of the ileum (ar- of the ileocecal region, jejunum, ileum and right side of the
rows). Note also the adjacent lymph node (arrowhead). colon.
 J.M. Pereira et al. / European Journal of Radiology 55 (2005) 173–180 177

Adenopathy patterns vary widely, including increase num-

ber of normal size nodes, scattered mildly enlarged nodes,
localized clusters of enlarged nodes and large conglom-
erated masses (Figs. 3 and 7). More commonly, enlarged
lymph nodes in patients with abdominal TB are circular or
ovoid and range from 12 to 40 mm (mean 20 mm), indi-
cating pathologic self-limiting growth [16]. On US, lymph
nodes are either discrete or appear as matted conglomer-
ate masses. Enlarged nodes usually contain central hypoe-
choic areas (Fig. 8) [13]. Lymph node enlargement is better
assessed on CT than on US [12,18]. Caseation and lique-
faction substances at the center of the enlarged lymph node
has a low attenuation, whereas peripheral inflammatory lym-
phatic tissue has a higher attenuation on enhanced CT. CT
attenuation of the central non-enhancing tissue ranges from
28 to 84 HU. Three enhanced patterns are noted after in-
travenous contrast administration [19]. Peripheral enhance-

Fig. 8. Tuberculous lymphadenopathy. Sonogram scan reveals some hypoe-

choic lymph nodes (N) in a patient with abdominal tuberculosis. Ileocecal
wall thickening was seen on CT scans (not shown).

ment, the most frequent pattern, homogeneous and homo-

geneous mixed with peripheral enhancement are less com-
mon. Lymph node calcifications may be also present (Fig. 9)
[13,17].
Although peripheral enhancement is very characteristic
of lymphadenopathy TB, it is not a pathognomonic sign,
as it is also noted in other processes such as lymphoma,
metastatic malignancy, pyogenic infection and Whipple’s dis-
ease [19,13,20,21].

Fig. 7. Tuberculous lymphadenitis. Transverse contrast-enhanced CT im-
ages showing: (A) multiple enlarged mesenteric and pericecal lymph nodes
with characteristic hypodense centers and peripheral enhancement (arrows).
Note also colonic wall thickening. (B) A heterogeneous mixed density com-
posed of a large conglomerate of peripheral enhancing lymph nodes in the
mesenteric compartment (arrows).
Fig. 9. Lymphadenopathy tuberculosis. Transverse contrast-enhanced CT
image shows enlarged periaortic lymph nodes with calcification (arrows),
and one retroaortic hypodense lymph node with peripheral enhancement
(arrowhead). Massive lymph node calcification at the celiac axis was seen
(not shown). Note the anterior displacement of the left kidney by an large
psoas abscess (*).
178 J.M. Pereira et al. / European Journal of Radiology 55 (2005) 173–180

4. Peritonitis

4.1. Pathophisiology

Although tuberculous involvement limited only to the

peritoneum is rare, peritoneal involvement is frequently seen
in association with widespread abdominal disease [22]. This
involvement of the peritoneal cavity, mesentery and omen-
tum appears to develop from the rupture of mesenteric lymph
nodes seeded by hematogenous or lymphatic routes from the
primary lesion sites [6] or direct spread from the serosa by
continuity from adjacent glands or structures; therefore, the
mesenteric nodules seen on CT represent tubercles either in
the lymph nodes or on the mesenteric surfaces [23]. Patients
are present with abdominal pain, distention and fever.

4.2. Mesentery involvement

The most common mesenteric changes in tuberculous in-

volvement include micronodular (less 5 mm) and macron-
odular (equal to or more than 5 mm) lesions, thickening of the
mesentery leaves and loss of normal configuration (mesen-
tery shows an admixture of soft-tissue densities, fluid densi-
ties and bowel loops) [13,23] (Fig. 10).

4.3. Omental involvement

Omental involvement is classified as nodular, smudged
(infiltration with ill-defined lesions) or caked (soft-tissue re-
placement) and as irregular or regular thickened [23]. CT has
greater sensitivity than US for delineating omental changes
in most cases [24]. Smudged type with a regular omental line
is the most common findings on CT in patients with omental
involvement (Fig. 10A). Caked type is uncommon, and when
present carcinomatous peritonitis should be raised as the first
differential diagnosis [23,24].
4.4. Peritoneal involvement
Peritoneal thickening and tiny nodules are the most fre-
quent findings in peritoneal tuberculosis. Diffuse, regular,
echo-poor peritoneal thickening of 2–6 mm or irregular thick-
ening with tiny nodules less than 5 mm are demonstrated on
US [25,26], and better visualized in the presence of ascites.
CT shows pronounce enhancement of a smooth thickened
peritoneum (Fig. 10B); less frequently, nodules are found
[23].
4.5. Ascites
Free or loculated ascites is seen in 30–100% of cases of
peritoneal involvement, and is demonstrated by both US and
CT [13,26]; however, US is recommended as the first modal-
ity of investigation to image very small quantities of ascites
and loculated fluid clinically unsuspected [27]. Multiple, fine,
Fig. 10. Tuberculous peritonitis. Axial contrast-enhanced CT images show:
(A) thickening and heterogeneous density with a smudged pattern of the
greater omentum (arrowheads) and the mesentery (short arrows). Note also
enlarged mesenteric lymph node (long arrow) and left psoas muscle abscess
(*). (B) Large amount of high-density ascitic fluid with marked thickening
and enhancement of peritoneum (arrows). Note also the infiltrated mesentery
of small bowel (*) and the free air (arrowheads) resulting from ileocecal
perforation (not shown).
complete or incomplete and mobile strands of fibrin and de-
bris are revealed on US. Septa are found in 30–100% of
the patients, and in 45% it assumes a lattice-like appearance
[26,28]. Bowel loops float in the ascitic fluid on US when a
large amount of ascites is present.
On CT, the fluid typically has high attenuation values
(25–45 HU), which probably reflect the high protein and cel-
lular content of the fluid [13] (Fig. 10B). Tuberculous chy-
lous ascites is rare, and when present a fat-fluid level can be
demonstrated on US and CT [29].
Three forms of tuberculous peritonitis have been described
[6]. The “wet” type is seen in 90% of cases and is character-
ized by large amounts of viscous ascitic fluid that is diffusely
distributed or loculated. The “fibrotic-fixed” type is less com-
mon and is characterized by large omental masses, matted and
tethered bowel loops and mesentery, and occasionally locu-
lated ascites. The “dry” or “plastic” type is unusual and is
characterized by caseous nodules, fibrous peritoneal reaction
and dense adhesions.
The clinical and radiological differentiation of tuberculous
peritonitis and peritoneal carcinomatosis can be challenging,
 J.M. Pereira et al. / European Journal of Radiology 55 (2005) 173–180
and has a crucial importance, as peritoneal tuberculosis, if
promptly diagnose, has an effective therapy and good sur-
vival rate. Although most analyzed CT findings overlap these
diseases, using a combination of some CT findings, such
as mesenteric macronodule, relative regularity of infiltrated
omentum covered by a thin line, masses with low-density
center and calcification and splenic lesions increase the abil-
ity of distinguishing tuberculous peritonitis from peritoneal
carcinomatosis [23,24].
5. Solid organ involvement
5.1. Pathophisiology
Solid organ involvement by TB may occur either often
from pulmonary or miliary TB or through portal vein from
GI lesions.
5.2. Hepatic and splenic TB
Involvement of the liver and spleen is a common autopsy
finding in patients with disseminated TB, with a reported
prevalence of 80–100% [6]. However, it is usually in a fine
miliary pattern and most of the time below the resolving ca-
pacity of CT [9]. This explains that the most common pre-
sentation is non-specific hepatosplenomegaly. On occasion
the individual lesions may appear on CT as tiny low-density
foci scattered throughout the involved organs (Fig. 11). On
ultrasound they may present as the “bright liver or spleen”
pattern with diffuse hyperechogenicity.
Rarely, TB may present in a macronodular form (also
called pseudotumor or tuberculoma) and this presentation
is most frequent without overt pulmonary or gastrointesti-
nal tract involvement. It manifests as diffuse liver or spleen
enlargement with multiple hypoechoic (US) or hypodense
(CT) small masses scattered throughout the organ, rang-
Fig. 11. Tuberculous involvement of the liver and spleen. Axial contrast-
enhanced CT images show tiny low-density foci scattered throughout the
enlarged liver and spleen (arrows) in a patient with disseminated tuberculo-
sis. A chest film showed pulmonary tuberculosis (not shown).
179
ing in size from 1 to 3 cm or a single tumor-like mass
[30].
Early in the evolution of the lesion its appearance on
contrast-enhanced images is similar to that of an abscess
whereas more advanced lesions usually calcify [31]. The dif-
ferential diagnosis of the macronodular form includes metas-
tases, abscesses and primary malignancy.
5.3. Pancreatic TB
Pancreatic involvement is also rare. Pancreatic tubercu-
lous abscesses appear as well-defined hypoechoic lesions in
US and as hypodense necrotic lesions within an enlarged
pancreatic head on CT scan. The diagnosis of pancreatic TB
should be obtained by percutaneous biopsy as pancreatic ma-
lignancies, abscesses and chronic pancreatitis are considered
in the differential diagnosis.
6. Conclusion
Since the mid 1980s, a resurgence of TB has occurred,
largely due to the AIDS epidemic, being a serious public
health threat worldwide. Imaging feature are usually indis-
tinguishable from those seen in AIDS and non-AIDS patients.
Determining the correct diagnosis of TB still remains chal-
lenging, as the clinical and radiological features have a wide
spectrum, mimicking many diseases. Although there are no
pathognomonic radiological findings, features that suggest
the correct diagnosis include advanced ileocecal changes,
such as cecal amputation, shortening of ascending colon, gap-
ing of the ileocecal valve and gross thickening of the terminal
ileum, misty mesentery with large necrotic lymph nodes, free
or loculated ascites with thin-mobile septa, smooth peritoneal
thickening and enhancement and smudged omental involve-
ment. The diagnosis still requires a high suspicion index.
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