The British Journal of Radiology, 72 (1999), 92-98 1999 The British Institute of Radiology

Pictorial review

Computed tomography in abdominal tuberculosis

SSURI,
MD, DABR,

S GUPTA,

MD, DNB and RSURI, MD, DNB

Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh160012, India

Abstract. The diagnosis of abdominal tuberculosis is often difficult because of its protean clinical manifestations and non-specific laboratory investigations. In the abdomen, tuberculosis may affect 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 appearances of abdominal tuberculosis which includes intestinal, lymph nodal, peritoneal, mesenteric, hepatic, splenic and pancreatic disease.

Abdommal 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 affect 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 intestinal involvement; whereas about one-third have only extraintestinal involvement [2]. Although barium studies remain the mainstay for delineating the intestinal changes, abdominal CT is considered essential for the evaluation of extraluminal, peritoneal, 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 afects multiple lymph node groups simultaneously [2]. Mesenteric and peripancreatic groups are involved most often, reflecting the lymphatic drainage of commonly afected sites in the small bowel and liver. In our experience, isolated retroperitoneal lymphadenopathy is uncommon; most patients with retroperitoneal lymph node involvement also have affected nodes at other sites. In the majority of patients (40-70%), CT shows enlarged nodes Received 18 March 1998 and in revised form 8 June 1998, accepted 26 August 1998. (Figure la) with hypodense centres and peripheral hyperdense enhancing rims [2, 3]. Other CT patterns of lymph node morphology include (i) conglomerate mixed density nodal masses, most likely representing multiple confluent nodes due to perinodal spread of inflammation (Figure lb); 1

(ii) enlarged nodes of homogeneous density, most often associated with low density nodes at other sites; and (iii) increased number (>3 in one CT section) of normal sized or mildly enlarged mesenteric nodes of homogeneous density, usually located along the mesenteric vessels or adjacent to the bowel loops (Figure lc). On CT, these diferent morphological features could signify evolving pathological stages of the disease, with early noncaseating granulomas and subsequent caseation necrosis [2]. Lymph nodes with low density centres, although characteristic of a tuberculous aetiology and representing 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 diferentiating tuberculosis from Whipple's disease. The involved lymph nodes occasionally show calciication; although this inding 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 calcification in patients from endemic areas in the absence of a known primary 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 involvement [6, 7]. Peritoneal tuberculosis is traditionally divided into three types [2, 7]: (i) "wet" with free or loculated ascites; (ii) "dry plastic" with mesenteric The British Journal of Radiology, January 1999

Pictorial review: CT in abdominal tuberculosis thickening, caseous lymph nodes and fibrous adhesions; and (iii) "fibrotic fixed", 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 infiltration with (wet type) or without (dry type) associated ascites (Figures 2 and 3). It has been suggested that high density (2545 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 reflecting 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 nodular (Figure 3) are encountered with almost equal frequency and do not help in differentiating from peritoneal carcinomatosis [6, 7]. Mesenteric infiltration (Figure 3) can range from mild involvement in the form of linear soft tissue strands, thickened and crowded vascular bundles, a "stellate" appearance, and/or subtle increase in mesenteric fat density, to more extensive involvement resulting in difuse iniltration with soft tissue density masses involving the leaves of the mesentery surrounding the adjacent small bowel loops. Ascitic fluid may occasionally extend into the mesenteric leaves (Figure 2c). Mesenteric abscess (Figure 3e) probably results from extensive caseation oflarge nodal masses.

without peripheral rim enhancement (Figures 5a-d). However, these lesions cannot be diferentiated from lymphoma, fungal infection or metastasis unless associated with characteristic lymph node or intestinal involvement [2, 3, 6]. Image guided ine needle aspiration biopsy has been helpful in patients with such unusual presentation.

Pancreatic tuberculosis
Pancreatic tuberculosis is unusual and solitary involvement is rare [2, 3, 6,10]. The pancreas can be involved in tuberculosis by either the haematogeneous 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 indings are non-speciic and may be seen in focal pancreatitis or pancreatic carcinoma. A tubercular aetiology can be suggested only by the presence of associated findings such as characteristichypodense lymph nodes, ascites or mural thickening in the ileocaecal region [10].

Abdominal tuberculosis in AIDS

Tuberculosis occurs with increased frequency in AIDS patients as the CD4 count drops below 400 cells per Whereas extrapulmonary manifestations are seen in only 10-15% of non-HIV infected patients, the incidence is much higher (about 50%) in patients with AIDS [11]. Mycobacterium tuberculosis infection in AIDS patients tends to be disseminated and may involve mesenteric lymph nodes, the peritoneum, solid visceral organs including the liver, spleen and pancreas and virtually any portion of the gastrointestinal tract,

Intestinal tuberculosis
The most common CT inding is mural thickening afecting 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 afects 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 involvement 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 afecting the ileal loops. These segments may also show luminal narrowing, with or without proximal dilatation. The presence of such lesions in combination with ileocaecal involvement should strongly suggest the diagnosis of tuberculosis.

Hepatosplenic tuberculosis
Tuberculosis of the liver and spleen usually occurs in miliary form with nodules ranging in size from 0.5 to 2 mm, which cannot be detected on CT [2, 6]. Macronodular involvement is uncommon and is manifested by single or multiple focal low density, non-enhancing lesions with or The British Journal of Radiology, January 1999 2

particularly the ileum and colon. The imaging findings 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 attenuation mesenteric lymphadenopathy is typically seen, although soft tissue attenuation adenopathy may also be encountered [12]. Infection with atypical mycobacteria (Mycobacterium avium and Mycobacterium intracellulare, 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].

( c )

Pictorial review: CT in abdominal tuberculosis

Figure 2. Peritoneal involvement. (a) Free ascites with omental thickening (arrow), (b) ascites with uniform peritoneal thickening (arrows) and (c) loculated fluid in the peritoneal cavity (small arrows) as well as in the mesenteric leaves (arrowhead) along with peritoneal enhancement. Note ileocaecal thickening (large arrow).

( b )

( c )

Figure 3. Peritoneal involvement, (a) "Smudged" appearance (arrows) of the omentum. Note soft tissue mesenteric infiltration (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 infiltration (asterix). (d) Irregular thickening of the mesenteric leaves (short arrows). Note enlarged retroperitoneal nodes (long arrow) and caecal wall thickening (arrowhead). (e) Large mesenteric abscess (arrows).

( d )

( e )

The British Journal of Radiology, January 1999

S Suri, S Gupta and R Suri

Figure 4. Ileocaecal involvement. (a) Thickened ileocaecal valve, along with mural thickening of the caecum 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) affecting one of the distal ileal loops.

( d )

The British Journal of Radiology, January 1999

Pictorial review: CT in abdominal tuberculosis

(c) Figure 5. Liver and spleen involvement. (a) Three discrete hypodense lesions in the spleen, (d) with irregular peripheral areas of enhancement. (b) Multiple small well defined hypodense lesions (few of which are confluent) in an enlarged spleen and few small hypodense lesions in liver. (c) Multiple small ill defined hypodense lesions in an enlarged spleen. (d) Multiple ill deined hypodense lesions in right lobe of liver, an enlarged spleen with few ill deined lesions.

Figure 6. CT scan showing an irregular hypodense lesion (arrow) in the pancreatic head.

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