消化内科课件 双语肠结核与结核性腹膜炎

*1 Zhirou Tan Department of Gastroenterology, The First Affiliated Hospital Department of Gastroenterology, The First Affiliated Hospital of Guangxi Medical Universityof Guangxi Medical University Intestinal Tuberculosis and Intestinal Tuberculosis and Tuberculous Peritonitis Tuberculous Peritonitis *2 Section ISection I I Intestinal Tuberculosisntestinal Tuberculosis *3 I Intestinal tuberculosisntestinal tuberculosis( (肠结核肠结核) ) is is a specific chronic intestinal infectionchronic intestinal infection caused by caused by mycobacterium tuberculosismycobacterium tuberculosis( (结核分枝杆菌结核分枝杆菌) ). . DefinitionDefinition EpidemiologyEpidemiology Most patients are youngMost patients are young female is more than malefemale is more than male *4 Mycobacterium tuberculosis EtiologyEtiology *5 1.Oral infection1.Oral infection pulmonary tuberculosis or laryngeal（喉喉） tuberculosis drinking un-pasteurized milk eating with patients 2. Hematogenous disseminated: miliary 2. Hematogenous disseminated: miliary （粟粒性）（粟粒性） tuberculosis tuberculosis 3.Direct spread of intra-abdominal tuberculosis 3.Direct spread of intra-abdominal tuberculosis PathogenesisPathogenesis *6 v Predilection site ：ileocecalileocecal(回盲部回盲部) , ascending ascending colon, jejunumcolon, jejunum( (空肠空肠), ), transverse colon, transverse colon, descending colon, appendix, duodenum and descending colon, appendix, duodenum and sigmoid colon.sigmoid colon. vv Pathological typePathological type l l Ulcer typeUlcer type l l ProliferativeProliferative (增生增生) l l MixedMixed PathologyPathology *7 l Ulcer typeUlcer type Mycobacterium tuberculosistuberculosis ulcer lymphatic groups, local hyperemia, edema, inflammatory exudate Caseous necrosis *8 l l Proliferative Proliferative Tuberculous granuloma and Tuberculous granuloma and fibrous tissue proliferationfibrous tissue proliferation Hardening or thickening of bowel wallHardening or thickening of bowel wall intestinal stenosis, intestinal stenosis, obstructionobstruction l l Mixed Mixed *9 l l Abdominal pain: Abdominal pain: right lower quadrant, relieve after defecation after defecation l l Diarrhea and constipation Diarrhea and constipation : : ulcer- diarrhea, diarrhea, fecal paste. proliferative- constipationproliferative- constipation l l Abdominal massAbdominal mass :proliferative:proliferative l l Other symptoms Other symptoms ：TB toxemia, tuberculosis parenteral TB toxemia, tuberculosis parenteral performanceperformance Clinical manifestationsClinical manifestations *10 ComplicationsComplications l l Intestinal obstructionIntestinal obstruction l l Fistula, abdominal abscessFistula, abdominal abscess l l Intestinal perforation, intestinal Intestinal perforation, intestinal bleedingbleeding *11 l l ESR ESR , Hb, Hb , PPD (tuberculin skin test) positive or , PPD (tuberculin skin test) positive or strongly positivestrongly positive , T-spot Laboratory and other testsLaboratory and other tests X-ray barium meal or barium enema examination lStierlin sign sign lMucosa coarse, the mural margin just looks likethe mural margin just looks like sawtooth, colon narrowsawtooth, colon narrow . *12 *13 l l Mucosal Mucosal lesions, lesions, hyperemia, hyperemia, edema, edema, ulcers ulcers ( ( rat-bite-like rat-bite-like edges) edges) or or nodular nodular masses masses or or inflammatory polyps, bowel stenosisinflammatory polyps, bowel stenosis . l l Histological Histological examination: examination: caseous(caseous(干酪样干酪样) ) necrosis. Mycobacterium tuberculosisnecrosis. Mycobacterium tuberculosis . Colonoscopy *14 Ulcer Ascending colon tuberculosis (ulcer-typeAscending colon tuberculosis (ulcer-type) *15 Ulcer Ileocecal tuberculosisIleocecal tuberculosis Granulation hyperplasia *16 1. 1. Young Young and and middle-aged middle-aged patients patients with with parenteral parenteral tuberculosis tuberculosis 2. Clinical manifestations 2. Clinical manifestations 3. Colonoscopy3. Colonoscopy 4. PPD test: postive4. PPD test: postive 5. Biopsy (caseating granulomas) 5. Biopsy (caseating granulomas) 6. Anti-tuberculosis treatment (2 to 6 weeks) effective6. Anti-tuberculosis treatment (2 to 6 weeks) effective 7. Exploratory laparotomy7. Exploratory laparotomy (剖腹探查剖腹探查) Diagnosis and differential diagnosisDiagnosis and differential diagnosis DiagnosisDiagnosis *17 l l CrohndiseaseCrohndisease l l C Colon cancerolon cancer l l Amoebic dysenteryAmoebic dysentery l l Schistosomiasis Schistosomiasis l l Others: Others: such such as as malignant malignant lymphomalymphoma D Differential ifferential diagnosisdiagnosis *18 项目项目肠结核肠结核克罗恩病克罗恩病 肠外结核肠外结核多见多见一般无一般无 病程病程缓解与复发倾向不明显缓解与复发倾向不明显缓解与复发倾向较明显缓解与复发倾向较明显 瘘管、腹腔脓肿、肛周瘘管、腹腔脓肿、肛周 病变病变 少见少见可见可见 病变节段分布病变节段分布常无常无有有 溃疡形态溃疡形态常呈横行、浅表而不规则常呈横行、浅表而不规则多呈纵行、裂隙状多呈纵行、裂隙状 活检活检抗酸杆菌阳性有助诊断抗酸杆菌阳性有助诊断 见干酪样肉芽肿可确诊见干酪样肉芽肿可确诊 抗酸杆菌阴性抗酸杆菌阴性 无干酪样肉芽肿无干酪样肉芽肿 结核菌素试验结核菌素试验强阳性倾向肠结核诊断强阳性倾向肠结核诊断一般不呈强阳性一般不呈强阳性 抗结核治疗抗结核治疗症状明显改善、内镜所见改症状明显改善、内镜所见改 善善/ /好转好转 症状多无明显改善、内镜所症状多无明显改善、内镜所 见无改善见无改善 手术切除标本病理检查手术切除标本病理检查见干酪样肉芽肿可确诊见干酪样肉芽肿可确诊均不见干酪样肉芽肿可排除均不见干酪样肉芽肿可排除 肠结核肠结核 肠结核与肠结核与CrohnCrohn病的鉴别病的鉴别 *19 l l Rest and nutritionRest and nutrition Standard antituberculosis treatmentStandard antituberculosis treatment Early,Early, regularity, full course, appropriate amount, combination Isoniazid Isoniazid ( (异烟肼), ),pyrazinamidepyrazinamide( (吡嗪酰胺), ), rifampin rifampin ( (利福平 ) ) l l Surgical treatmentSurgical treatment : : complete intestinal complete intestinal obstruction, acute intestinal perforation, intestinal obstruction, acute intestinal perforation, intestinal bleeding, diagnostic difficultiesbleeding, diagnostic difficulties Treatment *20 Section 2 Section 2 Tuberculous PeritonitisTuberculous Peritonitis *21 It is a chronic diffuse peritoneal infection caused byIt is a chronic diffuse peritoneal infection caused by mycobacterium tuberculosismycobacterium tuberculosis OverviewOverview vvDefinitionDefinition EpidemiologyEpidemiology Most patients are youngMost patients are young female is more than malefemale is more than male *22 1.Etiology 1.Etiology Mycobacterium tuberculosisMycobacterium tuberculosis 2. 2. InfectionInfection (1) Direct spread(1) Direct spread Mesenteric lymph nodes, fallopian Mesenteric lymph nodes, fallopian tubetube( (输卵管输卵管), ), intestinal tuberculosis intestinal tuberculosis (2) Hematogenous disseminated(2) Hematogenous disseminated Pulmonary tuberculosis, uberculosis, bone joints, testicularbone joints, testicular( (睾丸睾丸) ) tuberculosis , tuberculous tuberculosis , tuberculous meningitismeningitis( (多浆膜炎多浆膜炎) ) Etiology and pathogenesisEtiology and pathogenesis *23 vv ExudationExudation typetype vv Adhesion typeAdhesion type vv Cheese typeCheese type PathologyPathology *24 vvSymptomsSymptoms l l TB toxemia - fever, night sweats, weight loss, anemia, TB toxemia - fever, night sweats, weight loss, anemia, fatigue fatigue l l Abdominal painAbdominal pain - lower quadrant, umbilicus(脐周脐周) l l DiarrheaDiarrhea l l Distention : ascites, sepsis, peritonitis, intestinal dysfunctionDistention : ascites, sepsis, peritonitis, intestinal dysfunction vvAbdominal signsAbdominal signs l l Abdominal tenderness or Abdominal tenderness or dough kneading sensation(柔韧感柔韧感) l l Abdominal mass Abdominal mass l l AsciteAscite Clinical manifestationsClinical manifestations *25 vv Intestinal obstructionIntestinal obstruction vv Fistula, intra-abdominal abscess Fistula, intra-abdominal abscess ComplicationsComplications *26 1.ESR 1.ESR 2.PPD or T-SPOT positive or strongly positive2.PPD or T-SPOT positive or strongly positive 3.BUS:ascites3.BUS:ascites 4.Ascites :exudate,4.Ascites :exudate, lymphocyte predominance, ADAlymphocyte predominance, ADA bacterial culture bacterial culture 5. Abdominal plain film X-ray and gastrointestinal 5. Abdominal plain film X-ray and gastrointestinal barium meal examinationbarium meal examination 6.LaparoscopicLaparoscopic( (腹腔镜) ) peritoneal biopsy ,pathological peritoneal biopsy ,pathological examinationexamination Laboratory and other testsLaboratory and other tests *27 DiagnosisDiagnosis 1. 1.Young and middle-aged patients with tuberculosis Young and middle-aged patients with tuberculosis historyhistory 2. Clinical manifestations 2. Clinical manifestations 3. A 3. Ascites examination 4. PPD : postive 4. PPD : postive 5. X-ray 5. X-ray 6. Laparoscopic peritoneal biopsy 6. Laparoscopic peritoneal biopsy (caseating granulomas) (caseating granulomas) 7. Anti-tuberculosis treatment (2 to 6 weeks) effective 7. Anti-tuberculosis treatment (2 to 6 weeks) effective Diagnosis and differential diagnosisDiagnosis and differential diagnosis *28 AscitesAscites Intra-abdominal malignancyIntra-abdominal malignancy CirrhosisCirrhosis Other diseases Other diseases Abdominal