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The Gastroenterology Training Handbook
For Specialist Registrars
•Gastro Oesophageal Reflux Disease
•Benign Oesophageal Lesions
•Clinical Presentations of Gastric Conditions
•Gastric Polyps and Masses
•Peptic Ulcer Disease
•Gastritis and Gastropathy
•Small Bowel Infections
•Small Bowel Masses
•Colorectal and Anal Cancer
•Diagnostic Pathways for Colonic Disease
•Colonic Vascular Disorders
•Colonic Motility Disorders
•Proteins, Fats and Sugars
•Clinical Conditions and Nutrition
•Pancreatic Masses and Cysts
•Extra Intestinal Manifestations
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Written by Dr Sebastian Zeki
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TB can affect the upper female reproductive
tract (fallopian tube, endometrium, ovaries)
by extension from an intraabdominal focus,
hematogenous seeding, or ascending from
lower genital tract (cervix, vagina, vulva)
tube and endometrium are most
The finding of endometrial TB always means
that the tubes are infected but
salpingitis can exist without associated
A variety of clinical manifestations have been
reported including a pelvic mass, infertility,
abnormal uterine bleeding, and pelvic pain.
In most cases, the diagnosis is made most
readily by endometrial biopsy for histology
Genital TB is an important cause of infertility
in developing countries; in a report from
India, it accounted for 7.5 % of 492 patients
who underwent a hysterosalpinogram for
evaluation of infertility.
Even after treatment it is irreversible in 20%
The organism penetrates the mucosa and localizes
in the submucosal lymphoid tissue, where it
initiates an inflammatory reaction with subsequent
caseation necrosis, mucosal ulceration, and
Nonspecific chronic abdominal pain in
Anorexia, fatigue, fever, night sweats,
weight loss, diarrhea, constipation, or
blood in the stool can be present.
mass in 35%.
Small bowel obstruction and colonic
Ulcerative (60 %)- multiple superficial
ulcers.(assoc with virulent clinical course).
Hypertrophic (10 %)- scarring, fibrosis, and
Ulcerohypertrophic (30 %)-inflammatory mass
around the ileocecal valve with thickened and
ulcerated intestinal walls (usually ileocaecal).
Ileocecal most commonly
involved due to relative stasis
and abundant lymphoid tissue
Histology and biopsy culture
establishes diagnosis in up to 80
At endoscopy take samples
from ulcer margins and bed (TB
granulomas are submucosal).
PCR of biopsy has ahigher
sensitivity and specificity than
routine culture and can get
results in 48hrs.
If the diagnosis is unclear, then
an exploratory laparotomy is
Empirical TB course and
relaparotomy is indicated if
there is no improvement in 2
Imaging is non-specific and usually shows an ileitis.
The most common CT finding is concentric mural thickening of the
ileocecal region, with or without proximal intestinal dilatation.
Asymmetric thickening of the medial caecal wall is occasionally seen.
Characteristic lymphadenopathy with hypodense centers, representing
caseous liquefaction, is present in the adjacent mesentery.
Anti-TB drugs are usually very effective.
Compliance is the best determinant of outcome.
The surgical resection should be conservative.
Multiple small bowel strictures are treated by strictureplasty to avoid major resection.
Bypass surgery for obstructing lesions should be avoided because of complications of blind loop syndrome.
An alternative is colonoscopic balloon dilation, which can be used to manage readily accessible, short and fibrous
ileal strictures causing subacute
It looks very similar to CD apart from lesions tend to be more
circumferential and are usually surrounded by inflamed mucosa.
A patulous valve with surrounding heaped up folds or a destroyed
valve with a fish mouth opening is more likely to be caused by TB
favouring TB over
TB granulomas are submucosal
and large, confluent with
TB ulcers are lined by aggregate
inflammation is seen.
CD granulomas are infrequent,
small, nonconfluent, or
enhanced colitis, and high
prevalence of chronic inflamm
tion in endoscopically normal
appearing areas also characterize
Ascites more common in TB than Crohn’s
Surgery is indicated for complications:
Confined perforation with abscess or fistula,
Obstruction not responding to medical management.
Obstruction most common complication; patients with multiple and/or long strictures are less likely to respond to medical
Obstruction is exacerbated during antituberculous therapy due to healing by cicatrisation.
Written by Dr Sebastian Zeki
Analysis of bacterial communities during C. difficile infection in the mouse.