Sharma M P, Bhatia Vikram
Department of Gastroenterology, All India Institute of Medical Sciences, D II/23, Ansari Nagar, New Delhi 110-029, India.
Indian J Med Res. 2004 Oct;120(4):305-15.
Tuberculosis can involve any part of the gastrointestinal tract and is the sixth most frequent site of extrapulmonary involvement. Both the incidence and severity of abdominal tuberculosis are expected to increase with increasing incidence of HIV infection. Tuberculosis bacteria reach the gastrointestinal tract via haematogenous spread, ingestion of infected sputum, or direct spread from infected contiguous lymph nodes and fallopian tubes. The gross pathology is characterized by transverse ulcers, fibrosis, thickening and stricturing of the bowel wall, enlarged and matted mesenteric lymph nodes, omental thickening, and peritoneal tubercles. Peritoneal tuberculosis occurs in three forms : wet type with ascitis, dry type with adhesions, and fibrotic type with omental thickening and loculated ascites. The most common site of involvement of the gastrointestinal tuberculosis is the ileocaecal region. Ileocaecal and small bowel tuberculosis presents with a palpable mass in the right lower quadrant and/or complications of obstruction, perforation or malabsorption especially in the presence of stricture. Rare clinical presentations include dysphagia, odynophagia and a mid oesophageal ulcer due to oesophageal tuberculosis, dyspepsia and gastric outlet obstruction due to gastroduodenal tuberculosis, lower abdominal pain and haematochezia due to colonic tuberculosis, and annular rectal stricture and multiple perianal fistulae due to rectal and anal involvement. Chest X-rays show evidence of concomitant pulmonary lesions in less than 25 per cent of cases. Useful modalities for investigating a suspected case include small bowel barium meal, barium enema, ultrasonography, computed tomographic scan and colonoscopy. Ascitic fluid examination reveals straw coloured fluid with high protein, serum ascitis albumin gradient less than 1.1 g/dl, predominantly lymphocytic cells, and adenosine deaminase levels above 36 U/l. Laparoscopy is a very useful investigation in doubtful cases. Management is with conventional antitubercular therapy for at least 6 months. The recommended surgical procedures today are conservative and a period of preoperative drug therapy is controversial.
结核病可累及胃肠道的任何部位，是肺外受累的第六大常见部位。随着艾滋病毒感染率的上升，腹部结核病的发病率和严重程度预计都会增加。结核杆菌通过血行播散、摄入受感染痰液或从受感染的相邻淋巴结和输卵管直接蔓延到达胃肠道。大体病理特征为横形溃疡、纤维化、肠壁增厚和狭窄、肠系膜淋巴结肿大和融合、网膜增厚以及腹膜结节。腹膜结核有三种形式：有腹水的湿型、有粘连的干型和网膜增厚及局限性腹水的纤维化型。胃肠道结核最常受累的部位是回盲部。回盲部和小肠结核表现为右下腹可触及肿块和/或梗阻、穿孔或吸收不良等并发症，尤其是在存在狭窄的情况下。罕见的临床表现包括因食管结核导致的吞咽困难、吞咽痛和食管中段溃疡，因胃十二指肠结核导致的消化不良和胃出口梗阻，因结肠结核导致的下腹痛和便血，以及因直肠和肛门受累导致的环形直肠狭窄和多个肛周瘘管。胸部X线检查显示不到25%的病例有合并肺部病变的证据。用于调查疑似病例的有用方法包括小肠钡餐、钡灌肠、超声、计算机断层扫描和结肠镜检查。腹水检查显示草黄色液体，蛋白质含量高，血清腹水白蛋白梯度小于1.1 g/dl，以淋巴细胞为主，腺苷脱氨酶水平高于36 U/l。腹腔镜检查在疑难病例中是一项非常有用的检查。治疗采用常规抗结核治疗至少6个月。目前推荐的手术方法较为保守，术前药物治疗的疗程存在争议。
