GI Grand Rounds Johanna Chan, PGY-5 Fellow - PowerPoint Presentation

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GI Grand Rounds

Johanna Chan, PGY-5 FellowBaylor College of Medicine6/5/2014Mentors: Dr. Kalpesh Patel Dr. Prasun Jalal

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No conflicts of interestNo financial disclosures

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HPI

Reason for consult: jaundice, abdominal pain33yo healthy woman with hypothyroidism, admitted with 1 week of subacute RUQ abdominal pain, N/V, jaundice, dark urine, and acholic stoolsSimilar episode 2005, resolved spontaneouslyWorse with foodSubjective fever, no chills, rigors, weight loss

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PMHx

:HypothyroidNo known prior liver diseaseMedications: − Synthroid 75 mcgPSHx: NoneFamHx:Mother: alive/wellFather: alive/wellNo liver disease or autoimmune disease

Allergies:

NKDA

SocHx

No

EtOH

, IVDA, nasal cocaine, blood transfusions, tattoos

Never smoker

Physician, originally from Bolivia

No recent needle exposures, antibiotics, unusual food exposures

Travel to California 1/2014, Bolivia 2012, Europe 2008

One household cat

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Physical Exam

T 98.2, BP 112/67, HR 78, RR 12, O2 sat 98% RAGen: NAD, AAOx4, well-appearingHEENT: +slight scleral icterus, PERRL, EOMI, MMM, OP clearCV: RRR no m/r/gChest: CTAB no wheezes, slight crackles at basesAbd: soft, nondistended, nontender, NABS, no organomegalyExt: WWP, no clubbing, cyanosis, or edemaNeuro: oriented x4, conversational

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Labs on admission

MCV

87

47%

PMNs

37%

lymphs

140

3.6

27

107

12

0.63

82

5.6

33.2

11.1

263

INR 1.0

LDH 139

Total

prot

8.4

Albumin 4.7

Total

bili

1.4

Direct

bili

1.0

Alk

phos

401

ALT 330

AST 172

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Imaging

CXR “normal” three years ago (exposed to TB previously as a medical student)RUQ U/SNormal liver size 12.4 cm, normal echogenicity, smooth contourNormal spleen size 9 cmGallbladder sludgeNo gallbladder wall thickening nor pericholecystic fluidCBD 9 mm, CHD 7 mm

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Clinical course

ERCP: smooth biliary stricture, CBD stentBrushing: rare atypical cells; interpretation limited by poor cellular preservation and low cellularityEUS/biopsy of porta hepatis mass:Extensively fragmented tissue containing granulomas with focal necrosisNo diagnostic dysplasia or malignancyStains negative for bacterial or fungal organismsZiehl Neelsen stain negative for acid fast organisms

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Next diagnostic steps?

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Clinical course

Diagnostic laparoscopy, laparoscopic cholecystectomy, and robotic periportal lymph node dissection and lymphadenectomyEvidence of chronic cholecystitisPosterior to CBD, well-formed and encapsulated periportal lymph node with granulomatous featuresNo evidence of miliary TB nor other intra-abdominal pathology

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Pathology

Periportal lymph node, biopsyBenign lymph node with noncaseating granulomasAFB stain negative for mycobacteriaGMS stain negative for fungal organisms

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Additional labs

CA 19-9 21CA 125 9CEA <0.5AFP 4IgG 1197IgG4 4.1IgM 140Anti-smooth muscle Ab <20Alpha 1 AT 190Ceruloplasmin 43HIV (−)Quantiferon TB (+)PPD (+)Blood cultures (−)Urine culture (−)

Surgically biopsied lymph node:

<1+

WBCs

No organisms

AFB smear negative

AFB culture negative at 42 days

Fungal smear negative

Fungal culture negative at 28 days

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Obstructive jaundice secondary to extrinsic

biliary compressionWorking diagnosis:Intra-abdominal tuberculosis in the immunocompetent patient

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Clinical questions

What are clinical features of abdominal tuberculosis (ATB)?What are diagnostic modalities and yield for abdominal tuberculosis?What are mechanisms for obstructive jaundice in abdominal tuberculosis?

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Clinical questions

What are clinical features of abdominal tuberculosis (ATB)?What are diagnostic modalities and yield for abdominal tuberculosis?What are mechanisms for obstructive jaundice in abdominal tuberculosis?

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Clinical features of ATB

1985 to 1992 showed a resurgence of TB in the U.S., coincident with AIDS epidemicTB incidence in U.S. declining since 1992Global prevalence of TB estimated at 32%; WHO estimates > 2 billion peoplePercentage of U.S. cases occurring in foreign-born persons is increasing (53% in 2003)Centers for Disease Control and Prevention. Trends in tuberculosis – United States, 1998-2003. MMWR Morb Mortal Wkly Rep 2004; 53:2009-14.Dye C et al. WHO Global Surveillance and Monitoring Project. JAMA 1999; 282: 677-86.

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Clinical features of ATB

Extrapulmonary TB accounts for 15-20% of cases in low-HIV prevalence areasOf these, abdominal tuberculosis accounts for 11% - 16% in non-HIV patients, or 1-3% of the total TBMuch higher frequency of extrapulmonary disease in HIV patients – up to 50-70%International standards for tuberculosis care (WHO). 2006 Jan.Uygur-Bayramicli O et al. 2003 May; 9(5):1098-101.Wang HS et al. Int J Tuberc Lung Dis 1998; 2: 569-574.

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Clinical features of ATB

Primary infection from reactivation of a dormant focus acquired somewhere in the pastSecondary disease: spread via swallowed sputum, ingestion of unpasteurized milk, or spread hematogenously or from an adjacent organ

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Clinical features of ATB

Prior to routine pasteurization of milk, abdominal tuberculosis was not uncommon in the UK.Between 1912 and 1937 some 65,000 people died of tuberculosis contracted from consuming milk in England and Wales alone.Wilson, GS (1943), British Medical Journal 1 (4286): 261.

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Author

YearCountry No. of patientsMamo JP et al.2013UK17Tan KK et al.2009Singapore57Chen HL et al.2009Taiwan

21

Ramesh

J et al.

2008

UK

86

Akinkuollie

AA et al.

2008

Nigeria

47

Tarcoveanu

E et al.

2007

Romania

22

Khan R et al.

2006

Pakistan

209

Bolukbas C et al.

2005Turkey88

Uzunkoy A et al.2004Turkey11

Uygur-Bayramicli O et al.2003Turkey

31Rai S et al.2003

UK36Muneef et al.

2001Saudi Arabia46

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Clinical features of ATB

Enteric, peritoneal, nodal, or solid visceral (liver, spleen, pancreas, kidney)Intestinal involvement (colon, TI) most common, ranges from 40 – 75% of abdominal TBAbdominal pain, bleeding, change in bowel habit, weight lossUlcerative or hypertrophic lesions, nodules, circumferential thickening on colonoscopyTuberculous peritonitisGreater risk in patients with HIV or cirrhosisAscites, abdominal pain, feverSAAG < 1.1 g/dL, exudative, lymphocytic-predominantKhan R et al. 2006 Oct 21;12 (39):6371-5.Riquelme A et al. J Clin Gastroenterol. 2006 Sep; 40(8): 705-10. 

Uygur-

Bayramicli

O et al. 2003 May;9(5):1098-101.

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Clinical features of ATB

Abdominal pain (28 – 90%)Fever (5 – 64%)Weight loss (5 – 60%)Nausea and vomiting (30 – 40%)Ascites (20 – 35%)Diarrhea (10 – 17%)Active pulmonary TB or prior pulmonary TB lesion (17 – 27%)Anemia in 10 – 11 g/dL rangeESR elevated in 50 – 60 mm/H range

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Clinical questions

What are clinical features of abdominal tuberculosis (ATB)?What are diagnostic modalities and yield for abdominal tuberculosis?What are mechanisms for obstructive jaundice in abdominal tuberculosis?

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Diagnosis of abdominal TB

DDx intra-abdominal malignancy, abdominal lymphoma, inflammatory bowel disease (Crohn’s), hepatitis, chronic pancreatitis, PUDAnemia and elevated ESR/CRP are the most common laboratory findingsNonspecific clinical features, laboratory findings, variable radiographic findingsMicrobiologic yield specific, not sensitiveBolukbas C et al. BMC Gastroenterol 2005; 5:21.Khan R et al. 2006 Oct 21;12 (39):6371-5.Mamo JP et al. Q J Med 2013 Apr; 106(4):347-54.Rai S et al. J R Soc Med 2003; 96:586-8.

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Diagnosis of abdominal TB

Constellation of clinical and radiographic featuresHighest yield for surgically obtained specimen (laparotomy/laparoscopy), followed by CT/US guided biopsy and endoscopyMany authors suggest therapeutic trial with antitubercular therapyHowever, cannot recommend routine empiric antitubercular therapyMay delay diagnosis of malignancy, lymphoma, Crohn’s, etc.Adverse effects with hepatitis, drug interactions, etc. not uncommonKhan R et al. 2006 Oct 21;12 (39):6371-5.Mamo JP et al. Q J Med 2013 Apr; 106(4):347-54.Rai S et al. J R Soc Med 2003; 96:586-8.

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Diagnostic yield in abdominal TB

AFB smear from samples insensitive (yield 0% - 6%)AFB culture insensitive (yield 7% in large series)Nucleic acid amplification tests (NAAT, e.g. PCR) insensitive (7.1%) and in meta-analysis, insensitive for extrapulmonary diseaseIFN gamma release assay (IGRA, e.g. Quant TB) tests usually negative; unclear role for diagnosis of active TBSupportive histology most helpful (>90% surgical specimen, 50-80% endoscopic specimen)Dinnes J et al. Health Technol Assess 2007; 11:1-196.Khan R et al. 2006 Oct 21;12 (39):6371-5.Mamo JP et al. Q J Med 2013 Apr; 106(4):347-54.

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Clinical questions

What are clinical features of abdominal tuberculosis (ATB)?What are diagnostic modalities and yield for abdominal tuberculosis?What are mechanisms for obstructive jaundice in abdominal tuberculosis?

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Case: obstructive jaundice due to TB

TB of pancreas itself may cause pseudoneoplastic obstructive jaundiceTB lymphadenitis may cause extrinsic CBD compression (smooth narrowing of CBD)Biliary TB itself may cause strictures, mimicking cholangiocarcinomaTB may cause retroperitoneal mass leading to biliary obstructionColovic R et al. World J Gastroenterol 2008; 14 (19): 3098-3100.

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Take home points

Maintain a high index of suspicion, especially in patients from TB-endemic countriesObtain samples for AFB and mycobacterial culture (laparotomy, laparoscopy, endoscopy)Microbiology is specific but extremely insensitiveMultidisciplinary approach including ID and surgeryEmpiric antitubercular treatment is not routinely recommended

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References

Bolukbas C et al. Clinical presentation of abdominal tuberculosis in HIV seronegative adults. BMC Gastroenterol 2005; 5:21.Centers for Disease Control and Prevention. Trends in tuberculosis – United States, 1998-2003. MMWR Morb Mortal Wkly Rep 2004; 53:2009-14.Colovic R et al. Tuberculous lymphadenitis as a cause of obstructive jaundice: a case report and literature review. World J Gastroenterol 2008 May 21; 14 (19): 3098-3100.Dinnes J et al. A systematic review of rapid diagnostic tests for the detection of tuberculosis infection. Health Technol Assess 2007; 11:1-196.Dye C et al. Consensus statement. Global burden of tuberculosis: estimated incidence, prevalence, and mortality by country. WHO Global Surveillance and Monitoring Project. JAMA 1999; 282: 677-86.Kapoor VK. Abdominal tuberculosis: the Indian contribution. Indian J

Gastroenterol

1998; 17: 141-147.

Khan R et al. Diagnostic dilemma of abdominal tuberculosis in non-HIV patients: an ongoing challenge for physicians. World J

Gastroenterol

. 2006 Oct 21;12 (39):6371-5.

International Standards for Tuberculosis Care (WHO). Endorsed by IDSA. Published January 2006. Accessed online 6/4/14

http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/International%20TB.pdf

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References (continued)

Mamo JP et al. Abdominal tuberculosis: a retrospective review of cases presenting to a UK district hospital. Q J Med 2013 Apr; 106(4):347-54.Misra SP et al. Colonic tuberculosis: clinical features, endoscopic appearance, and management. J Gastroenterol Hepatol 1999; 14: 723-729.Muneef MA et al. Tuberculosis in the belly: a review of forty-six cases involving the gastrointestinal tract and peritoneum. Scand J Gastroenterol 2001; 36: 528-532.Murphy TF et al. Biliary tract obstruction due to tuberculous adenitis. Am J Med 1980; 68: 452-454.Rai S et al. Diagnosis of abdominal tuberculosis: the importance of laparoscopy. J R Soc Med 2003; 96:586-8.Riquelme A et al. Value of adenosine deaminase

(ADA) in

ascitic

fluid for the diagnosis of

tuberculous

peritonitis: a meta-analysis. J

Clin

Gastroenterol

. 2006 Sep; 40(8): 705-10. 

Singhal

A et al. Abdominal tuberculosis in Bradford, UK: 1992-2002.

Eur

J

Gastroentrol

Hepatol

2005; 17: 967-971. 

Sheer TA et al. Gastrointestinal tuberculosis.

Curr Gastroenterol Rep 2003; 5:273-278. 

Sinan T et al. CT features in abdominal tuberculosis: 20 years experience. BMC Medical Imaging 2002; 2: 3-16.Uygur-Bayramicli O et al. A clinical dilemma: abdominal tuberculosis. 2003 May;9(5):1098-101.

Uzunkoy A et al. Diagnosis of abdominal tuberculosis: experience from 11 cases and review of the literature. 2004 Dec 15; 10(24):3647-9.Wang HS et al. The changing pattern of intestinal tuberculosis: 30 years’ experience. Int J Tuberc Lung Dis

1998; 2: 569-574.Wilson, G. S. (1943), “The Pasteurization of Milk,” British Medical Journal 1 (4286): 261.

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Questions or comments?