Haq, T U

Islam, U M

Khan, Z A

Shaikh, M Y

English

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eCommons@AKUDepartment of Radiology Medical College, PakistanDecember 1994Ileocaecal tuberculosis: a pictorial essay of variousappearances on small bowel enemaM Y. ShaikhT U. HaqAga Khan University, tanveer.haq@aku.eduU M. IslamZ A. KhanFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_radiolPart of the Radiology CommonsRecommended CitationShaikh, M. Y., Haq, T. U., Islam, U. M., Khan, Z. A. (1994). Ileocaecal tuberculosis: a pictorial essay of various appearances on smallbowel enema. Journal of Pakistan Medical Association, 44(12), 295-297.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_radiol/201Ileocaecal Tuberculosis: A Pictorial Essay of VariousAppearances on Small Bowel EnemaPages with reference to book, From 295 To 297 Mohammed Y. Shaikh, Umar M. Islam ( Department of Radiology, Aga Khan University Hospital, Karachi. ) Tanveer ul Haq ( Department of Radiology, Aga Khan University Hospital, Karachi ) Zahid A. Khan ( Department of RadIology, Aga Khan University Hospital, Karachi. ) In third world countries, where tuberculosis is endemic and Crohn’s disease is infrequent, tuberculosisis by far the most common cause of inflammatory disease of the bowel. Although any part of thegastrointestinal tract can be involved, the ileocaecal region and the ascending colon are thepredominant sites of involvement in 50-90% of cases1,2. The infection may occur following ingestionof infected milk or sputum or by the haematogenous spread to submucosal lymphatic structures from adistant pulmonary infection. Nowadays reports stress that it is due to the human form and not thebovine type of mycobacterium3. Intestinal tuberculosis is considered to occur more often secondary toadvanced pulmonary tuberculosis. More recent experience does not support this relationship as clearlyand less than 50% of patients with intestinal involvement have radiological evidence of pulmonarydisease4. In Indo-Pakistan the introduction of antituberculous drugs has reduced the incidence ofgastrointestinal tuberculosis associated with pulmonary disease to approximately 5%5. However.primary tuberculosis of the intestinal tract is more common6. The gross anatomic features are describedin three forms, i.e., ulcerative. hypertrophic and mixed, depending upon the stage of development andtype of infection. Early lesions are usually ulcerative, the ulceis being transverse, quite short andcommonly multiple. In the hypertrophic form, which is more common in the ileocaecal area and colonthan in the small bowel, the intestinal wall is massively thickened and densely fibrotic. Variousradiological methods can be performed if ileocaecal tuberculosis is suspected. Plain radiographs mayshow signs of intestinal obstruction, perforation, enteroliths, calcified lymph nodes and ascites.Ultrasound can show ascites, enlarged paraaortic lymph nodes and sometimes ileocaecal mass, Smallbowel enema has much better yield than any other investigation including conventional barium mealfollow-through examination. Double contrast small bowel enema with good bowel distension can evenbe picked up early subtle changes at ileocaecal region. Other methods to demonstrate ileocaecal regionare large bowel barium enema and peroral pneumocolon. Recent studies showed that CT has a role inconjunction with barium studies for the initial assessment of ileocaecal tuberculosis. The location aswell as the intestinal and mesenteric extent of the inflammatory process are well demonstrated with CT.At the same time. evaluation of distal peritoneal, solid-organ, or retroperitoneal disease can be done7.However, CT is less helpful providing the anatomical details of bowel as well as early changes, ascompared to barium studies.The various features seen on small bowel enema are:1) Ulcerations: Earliest changes are stiffness or rigidity and nodularity (Figure 1)in terminal ileum8. Spasm and accelerated transit time in an area of ulcerative enteritis is typical in theacute phase of infection. The ulcerative lesions most commonly seen are short and multiple, givingspiculated margin to the bowel wall (Figure 2)and occurring at several levels with normal intervening bowel but in rare cases may involve a longportion of intestine. The ulcers may be annular or circular or less commonly elongated (Figure 3), ovalor irregular and lying transversely. Ulcers located in the more distal ileum extend as a rule to theadjacent colon.2) Hypertrophic lesions: They are more common and appearas hourglass (Figure 4)orangulated strictures and often multiple. The prevalvularileum is circumferentially narrowed (Figure5).Segmental dilatation of the intervening bowel loops seen.3) Fixity: The coils of intestine are relatively fixed and cannot be easily separated during fluoroscopicpalpation and their position remains unchanged in supine and erect positions. Fixity and adherence ofcoils results in hypomotility seen as prolonged transit time and dilatation.4) Mucosal folds: Initially they become coarsened, irregular and show nodularity (Figure 1). Later theterminal ileum becomes thickened, straight and rigid with complete obliteration of the mucosal folds.5) Ileocaecal valve: It becomes very much thickened and appears as a mass in the caecum. The valvebecomes distorted if ulceration and granulation develops. There is often a wide gap between theileocaecal valve and the narrow ileum next to it, so called “inverted umbrella” defect (Figure 6)or Fleischer sign5. The loss of normal ileocaecal angle, so that the tennis ileum either runs directly or ata right angle into the caecum is again a consequence of the hypertiophic process and has beendescribed as typical of ileocaecal tuberculosis9. The valve becomes incompetent and widely open.6) Caecum: The caecum becomes scarred and contracted. Fibrosis results in shortening of theascending colon and pulled up caecum with its coned appearance (Figure 7).The caecal recess may be more or less retracted or amputated such that the terminal ileum continuouswithout apparent transition into the ascending colon. The fibrotic ileum emptying directly into theascending colon through a widely open ileocaecal valve without the visualization of contracted caecumis called Stierlin\'s sign10 (Figures 3 and 8).References 1.Patton, J.J. and Moore, T.C. Massive megscolon and megsileum in childhood due to tubereulousstenosis of the ascending colon. Surgery, 1970;67:5 13-18.2. Carrera, G.F., Young, S. and Lewicki, AM. Intestinal tuberculosis. Gastrointest. Rsdiol., 1976;1 :147-55.3. Chswla. S. Intestinal tuberculosis. In: Cockshott, P. and Middlemiss, H. (ed): Clinical radiology intropics. Edinburg., Churchill Livingstone, 1979, pp. 105-10.4. Werbeloff, L., Novis, B.H., Bank, S. and Marks, IN. The radiology of tuberculosis of thegastrointestinal tract. Br.J .Radiol., 197346 :329-36.5. Thoeni, R.F. and Margulis, A.R. Gastrointestinal tuberculosis. Semin. Roentgenol., 1979;14:283-96.6. Anand, 3.3. Hypertrophie ileocaecsl tuberculosis in India. with a record of 50 hemicolectomies. Ann.Royal Coll. Surg., 1956;19:205-22.7. Balthazar, E.J., Gordon, R. and Hulniek, D. Ileocaecal tuberculosis: CT and radiological evaluation.Am.J.Roentgenol., 1990; 154:499-503.8. Bromabart, M. and Massion, I. Rsdiologic differences between ileocaecal tuberculosis and Crohn\'sdisease. Am.J.Dig.Dis., 1961 ;6:589-603.9. Anscombe, AR., Keddie, NC. and Schofield, P.R Caecal tuberculosis. GUT,1967;8:337-43.10. Tabrisky, 3., Lindstrom, R.R., Peter, R. et al. Tuberculous enteritis, review of a protean disease.Arn.J.Gsstroenterol., 1975;63:49-57.

Ileocaecal tuberculosis: a pictorial essay of various appearances on small bowel enema

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Ileocaecal tuberculosis: a pictorial essay of various appearances on small bowel enema

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