ABDOMINOPELVIC TUBERCULOSIS:
DIAGNOSIS !& MANAGEMENT
!
!
Mary Judith Q. Clemente, MD
!
!
INTRODUCTION
References
TUBERCULOSIS
q TB
is
still
a
global
public
health
problem.
q The
Philippines
belongs
to
the
high
TB
and
high
MDR
TB
countries
globally.
q Most
common
TB
infection
is
still
pulmonary.
References
World
Health
Organization
Global
TB
Report,
2016
WHO GLOBAL TB REPORT 2016
References
World
Health
Organization
Global
TB
Report,
2016!
Resurgence of TB
q Increase in HIV cases
q Emergence of MDR TB
q Migration
References
Abdominopelvic TB
q General
term
encompassing
TB
involving
any
abdominal
or
pelvic
organ
(ex.,
GI,
hepatic,
peritoneal,
endometrial,
tubal,
etc.)
q
Female
genital
TB
(FGTB)
involves
the
vulva,
vagina,
cervix,
endometrium,
tubes
and
ovaries
References
Female Genital TB
q First
case
of
reported
FGTB
was
in
1744
by
Morgagni.
q Postmortem
examination
of
a
20
year
old
female
showing
caseous
material
within
the
uterus
References
Epidemiology
q Prevalence
of
FGTB
is
difOicult
to
estimate
due
to
varied
clinical
presentations.
q Many
can
be
asymptomatic.
References
Estimated Incidences of FGTB in
Various Countries
References
2Varma,
T
(2008).
Tuberculosis
of
the
female
genital
tract.
In
Glob.
libr.
women's
med.,
(ISSN:
1756-‐2228)
2008;
DOI
10.3843/GLOWM.10034
PGH Data
q From
January
2010
to
December
2014:
176
cases
of
AP
TB
referred
References
PGH
Department
of
OB-‐GYN
Section
of
OB
IDS
Statistics
PATHOGENESIS
References
Pathogenesis
q Primary
genital
TB
is
rare.
q Hematogenous,
Lymphatic,
Direct
spread
q Sources:
Pulmonary,
GI,
Renal
References
Varma,
T
(2008).
Tuberculosis
of
the
female
genital
tract.
In
Glob.
libr.
women's
med.,
(ISSN:
1756-‐2228)
2008;
DOI
10.3843/GLOWM.10034
Pathogenesis- Hematogenous Spread
Spread Genital tract
Primary Lung
through blood
Infection
(ex.: FT)
stream
References
Varma,
T
(2008).
Tuberculosis
of
the
female
genital
tract.
In
Glob.
libr.
women's
med.,
(ISSN:
1756-‐2228)
2008;
DOI
10.3843/GLOWM.10034
Pathogenesis- Lymphatic Spread
Primary GI
Infection
Lymphatic
Genital tract
spread
(ex.: M. bovis)
References
Varma,
T
(2008).
Tuberculosis
of
the
female
genital
tract.
In
Glob.
libr.
women's
med.,
(ISSN:
1756-‐2228)
2008;
DOI
10.3843/GLOWM.10034
Pathogenesis- Direct Spread
Direct spread via
Primary Abdominopelvic peritoneal surfaces OR
Infection (ex.: rectum, Rupture of TB ulcer with Genital Tract
appendix, bladder)
spill into contiguous
organ
References
Varma,
T
(2008).
Tuberculosis
of
the
female
genital
tract.
In
Glob.
libr.
women's
med.,
(ISSN:
1756-‐2228)
2008;
DOI
10.3843/GLOWM.10034
Pathogenesis- Sexual Transmission ???
q In
very
rare
instances,
TB
can
be
transmitted
to
a
woman
via
a
partner
with
TB
epididymitis.
References
Varma,
T
(2008).
Tuberculosis
of
the
female
genital
tract.
In
Glob.
libr.
women's
med.,
(ISSN:
1756-‐2228)
2008;
DOI
10.3843/GLOWM.10034
CLINICAL
MANIFESTATION
References
Clinical Manifestation
q There
is
NO
single
reliable
clinical
manifestation
related
to
AP
TB.
q History
+
PE
+
diagnostics/imaging
+
high
index
of
suspicion
References
CLINICAL MANIFESTATION
8 6
MANIFESTATION NOBLE, 2001 BAQUIRAN, SEE, 2015
9
(n = 88) 2010 (n = 61)
(n = 12)
Abdominal pain 28.4% 50% 42.6%
Abdominal enlargement 42% 58% 29.5%
Abdominopelvic mass --- --- 9.8%
Vaginal Bleeding 5.7% --- 1.8%
Amenorrhea 19.3% 42% 8.8%
Weight loss --- 67% 57.9%
Fever --- 25% 33.3%
Anorexia --- 8.33% 29.8%
!References
6See V. (2015). Clinico-demographics of female genital tuberculosis in a tertiary government hospital: a five year retrospective study. Unpublished data.!
8 Noble MJ. (2001). Clinical features of patients with abdominopelvic tuberculosis. Unpublished data.!
9 Baquiran S. (2010). Establishing the relationship of Ca-125 trend with the clinical treatment response of patients with abdominopelvic tuberculosis. Unpublished data. !
Frequency of TB in the Female Genital Tract
Organ Frequency (%)
Fallopian tubes 90-100
Endometrium 50-60
Ovaries 20-30
Cervix 5-15
Vulva/Vagina 1
References
Schaeffer
G.
(1976)
Female
genital
tuberculosis.
Clin
Obstet
Gynecol
19:23.
Sharma, JB. (2015).Current diagnosis and management of female genital tuberculosis. J
Obstet Gynaecol India. 65(6): 362-371. !
TB Salpingitis
q Bilateral
involvement
is
seen
in
majority
of
cases
(>90%)
q Early
infection
may
show
no
gross
abnormalities.
q Progression
of
infection
may
cause
tubal
dilatation
q Types:
Exudative
and
Productive-‐Adhesive
References
Varma,
T
(2008).
Tuberculosis
of
the
female
genital
tract.
In
Glob.
libr.
women's
med.,
(ISSN:
1756-‐2228)
2008;
DOI
10.3843/GLOWM.10034
Spread of TB from the fallopian tubes
TB Salpingitis!
Ovaries! Endometrium!
Cervix!
Vagina!
Vulva!
References
TB Endometritis
q Usually
involves
the
fundus
q The
endometrium
is
shed
monthly
in
menstruating
women
only
to
be
re-‐infected
from
the
tubes
or
the
basalis.
q Extensive
involvement
may
cause
amenorrhea
or
uterine
adhesions
leading
to
infertility
References
TB Oophoritis
q True oophoritis- involvement of the stroma
q Peri-oophoritis- involvement of the surface/capsule
q The tunica albuginea may play a protective role.
References
TB Cervicitis
q The endocervix is mostly affected.
q May look like cervical cancer (ulcerative form)
q Other forms: papillomatous and miliary forms
References
TB of the vagina and vulva
q Extremely rare
q Nodule à irregular, ragged ulcer
References
DIAGNOSIS
References
Some Recommended Tests to
Help Diagnose AP Tuberculosis
Chest radiograph Ultrasonography
Tuberculin test Hysterosalpingography
Menstrual blood for TB culture Cervical cytology or biopsy
Endometrial tissue for culture or biopsy Laparoscopy
Peritoneal fluid for TB culture Hysteroscopy
Peritoneal tissue for biopsy Cystoscopy
!
References
TB Culture
q Gold Standard – isolation and identification of the organism
q Colonies visible in 6-8 weeks using the L-J media.
q Requires 100 organisms/ml sample
References
Histopathology
q Chronic granulomatous inflammation (CGI) with caseation necrosis
and Langhans giant cells
q Isolated finding of CGI is not solely indicative of TB.
References
Histopathology
References
Histopathology
References
TB-PCR
q Circumvents the limitations of culture (faster results)
q Extrapulmonary specimens tend to be paucibacillary and may
contain inhibitors precluding optimal cell lysis
!
References
!
!
CaulOield
A,
Wengenack
N.
(2016).
Diagnosis
of
active
tuberculosis
disease:
From
microscopy
to
molecular
techniques.
Journal
of
Clinical
Tuberculosis
and
Other
Mycobacterial
Diseases.
Vol.4
pp
33–43.
Cost of TB-PCR in 3 Metro Manila Hospitals
Hospital Cost (Php)
Philippine General Hospital 5,343
Manila Doctors Hospital 8,700
Lung Center of the Philippines 7,592
!
References
Acid-Fast Staining
q Identification of acid-fast bacilli on microscopy
q Typically used for sputum specimens
q Requires at least 10,000 organisms/mL of sample
q May also be used for extra-pulmonary specimens (urine, stool, tissue)
q Other organisms are acid-fast as well (Nocardia, Rhodococcus)
q Sensitivity (22%- 80%) depends on the microscopist.
References
CaulOield
A,
Wengenack
N.
(2016).
Diagnosis
of
active
tuberculosis
disease:
From
microscopy
to
molecular
techniques.
Journal
of
Clinical
Tuberculosis
and
Other
Mycobacterial
Diseases.
Vol.4
pp
33–43.
Imaging
q Imaging is not diagnostic BUT it may raise the clinician’s index of suspicion
q Ultrasound, Hysterosalpingography
References
Imaging- Ultrasonography
Findings Cabalona, 2004 Sharma, 2006
Adnexal masses! 78! 93!
Ascites with pseudocyst 76! 100!
formation!
Endometrial involvement ! 50! 83!
Thickened peritoneum! 69!
Pelvic adhesions!
Matted bowel loops!
Thickened bowel and uterine
serosa!
References
Cabalona, M (2004). Ultrasound findings in cases of abdominopelvic tuberculosis. Unpublished data.!
Sharma Journal of Obstetrics and Gynecology, India, 2006. Vol. 56. NO. 3: 203-204.!
!
!
Ultrasonography
References
Ultrasonography
References
Ultrasonography
References
Ultrasonography
References
Hysterosalpingography
q Calcification of FT, ovaries or lymph nodes
q Irregular contour of lumen of tubes
q Beaded appearance of tubes sec to tubal occlusion
q Tubal dilatation
q Peritubal adhesions
q Intrauterine adhesions, obliteration of uterine cavity
References
Imaging- Hysterosalpingography
References
Imaging- Hysterosalpingography
References
Laparoscopy
q Visualization of tuberculous lesions
q Laparoscopic-guided biopsy
q Usually performed if there is a diagnostic dilemma short
of doing a laparotomy
References
Laparoscopic Findings in Pelvic TB (n=85)
Laparoscopic Findings Percentage
Various grades of pelvic adhesion 65.8%
Tubercles on the peritoneum 12.9%
Tubo-ovarian masses 7.1%
Encysted ascites 7.1%
Caseous nodules 5.8%
Ovarian tubercles 1.2%
Hydrosalpinx 17.6% (right=11.7%; left=5.9%)
Fallopian tubes not visualized (surgically absent or due to 14.1%
dense adhesions)
Beaded tube 8.2% (right=3.5%; left= 4.7%)
Normal-looking fallopian tubes 7.1%
Pyosalpinx 5.8% (right=3.5%; left=2.35%)
Tubercles on tube 3.52%
Caseous granuloma of the tubes 3.52%
Tobacco pouch appearance of the tubes 2.35%
!
References
.!
Sharma
JB,
Roy
KK,
Pushparaj
M,
Kumar
S,
Malhotra
N,
Mittal
S.
(2008).
Laparoscopic
Oindings
in
female
genital
tuberculosis.
Arch
Gynecol
Obstet.
278(4):359-‐64
Laparotomy
q Usually performed inadvertently due to consideration of another
gynecologic pathology
q Common findings: adhesions, complex adnexal masses, ascites,
pseudocyst formation, caseous tubercles
References
Laparotomy
References
MANAGEMENT
References
Medical Management
q Anti-TB medication is the cornerstone of management
q PHILCAT – 6 month course (2 months HRZE + 4 months HR)
q Other experts recommend extending treatment to one year (2 months HRZE + 10
months HRE)
References
!
. !
Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control of Tuberculosis in Adult Filipinos 2016 Update
Dosing of anti-TB Drugs
Drug Dose
Isoniazid 5 (4-6) mg/kg
Rifampicin 10 (8-12) mg/kg
Pyrazinamide 25 (20-30) mg/kg
Ethambutol 15 (15-20) mg/kg
!
References
Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control of Tuberculosis in Adult Filipinos 2016 Update. !
Surgical Management
q Surgical management is reserved for special cases
• Drainage of abscesses
• Concomitant gynecologic pathology
• Persistent masses despite medical treatment
References
Monitoring
q There is no standard monitoring scheme for patients with AP
Tuberculosis
q Ca 125 as monitoring tool?
q Repeat biopsy after 6 months
q Clinical improvement: weight gain, resumption of menses
References
Requirements for Enrollment of Patients in the
TB-DOTS Program
Referral from a physician
Results of sputum AFB (if pulmonary)
Chest radiograph (if pulmonary)
If extra-pulmonary, results of imaging studies or other diagnostic indicating TB
!
References
SUMMARY
References
Summary
q TB is still a global and national public health problem.
q Female genital TB is usually secondary to infection from another site.
q There is NO single reliable sign or symptom indicative of AP TB.
q The gold standard in the diagnosis of AP TB is isolation and identification of the
pathogen (culture)
q Other diagnostics include histopathology, TB-PCR, AFB staining, imaging, laparoscopy
etc.
References
Summary
q Anti-TB medication is the cornerstone of treatment. (6-12 months)
q Surgery is reserved for special cases.
q Monitoring can include repeat imaging studies, repeat biopsy and improvement in the
patient’s clinical status.
References
INTERACTIVE
QUESTIONS
References
Interactive Question 1
What is the gold standard in the diagnosis of TB?
a. Biopsy/Histopathology
b. AFB staining
c. TB-PCR
d. Culture
References
Interactive Question 2
A 23 year old nulligravid came for abdominal enlargement of three months duration. She has a
history of inadequately treated pulmonary TB. On ultrasound, there was note of massive ascites. The
uterus was normal in size with a thin endometrium. Which of the following is the best diagnostic test
for this patient?
a. Laparotomy with biopsy
b. Endometrial curettage
c. Ascitic fluid TB-PCR
d. Menstrual blood TB culture
References
Interactive Question 3
Which of the following is a TRUE statement?
a. All patients with AP tuberculosis will have infertility.
b. For genital TB, the most commonly affected part of the genital tract is the endometrium.
c. If ovarian involvement is hematogenous, the ovarian surface is usually affected.
d. The tunica albuginea may play a role in protecting the ovaries from TB involvement.
References
Interactive Question 4
Which of the following is a TRUE statement ?
a. Imaging procedures are diagnostic for AP Tuberculosis
b. Positive AFB staining is exclusive for Mycobacterium species
c. The sensitivity of PCR is lower for extra-pulmonary specimens due to their
paucibacillary nature.
d. Elevated Ca-125 levels are specific for TB infection
References
Interactive Question 5
What is the cornerstone of TB treatment?
a. Medical management
b. Surgery
c. Combination of surgery and medical management
d. Depends on the situation
References
ABDOMINOPELVIC TUBERCULOSIS:
DIAGNOSIS !& MANAGEMENT
!
!
Mary Judith Q. Clemente, MD
!
!
