Department of Gastroenterology, General Hospital of Beijing Military Region
Intestinal tuberculosis is a chronic and specific intestinal infection caused by Mycobacterium tuberculosis (TMB).Mainly byMycobacterium tuberculosis hominisCause.A few areas have intestinal tuberculosis caused by Mycobacterium bovis due to drinking milk or dairy products without sterilization.This disease is generally seen in young and middle-aged people, women slightly more than men.
More than 90% of intestinal tuberculosis is caused by Mycobacterium tuberculosis hominis. In addition, drinking dairy products that have not been strictly disinfected can cause disease due to Mycobacterium tuberculosis bovis. Intestinal tuberculosis infection can be caused by oral and blood borne dissemination and the spread of tuberculosis in adjacent organs.tuberculosisThe pathogenesis of tuberculosis is the result of the interaction between human body and tuberculosis bacteria. Infection through the above ways is only the condition of disease. Only when the number of invading tuberculosis bacteria is large,virulenceLarge, with human bodyimmunityExceptionsIntestinal dysfunctionOnly when the local resistance is weakened can the disease occur.
Pathogenesis
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More than 90% of intestinal tuberculosis is caused byMycobacterium tuberculosis hominisA few can be caused by Mycobacterium bovis tuberculosis.The main routes of intestinal infection caused by Mycobacterium tuberculosis are enterogenous, hematogenous andDirect spread。
1. Enterogenic
Mycobacterium tuberculosis is mainly transmitted by mouth and invades the intestinal tract, and patients are often openpulmonary tuberculosis, which is caused by swallowing sputum containing Mycobacterium tuberculosis.Or often withOpen tuberculosisPatients eat together and lack necessary disinfection and isolation measures to cause disease.In a few cases, drinking unpasteurized milk or dairy products containing Mycobacterium tuberculosis may also causePrimaryIntestinal tuberculosis.This is because: under normal physiological conditions, intestinal contents pass through ileocecumphysiological sphincterIt remained in the terminal ileum for a long time before.In addition, the proximal colon often has anti peristalsis, which makes the intestinal contents in the cecumresidence timeLonger.In this way, there are more opportunities for Mycobacterium tuberculosis to contact with intestinal mucosa, increasing the chance of intestinal mucosa infection.There are abundantlymphoid tissueMycobacterium tuberculosis is easy to invade lymph tissue.
2. Blood borne miliary tuberculosis
Mycobacterium tuberculosis can spread through blood and cause intestinal tuberculosis.
3. Direct spread into the abdominal cavitytuberculosisStove
Most of them are located in the right lower abdomen, and most of them are located in ileocecal region because of intestinal tuberculosis.Often with upper abdomen orPeriumbilical pain, caused by ileocecal lesionsReferred pain, but the physical examination can still findTenderness spotLocated in the lower right abdomen.The pain is mostly dull orDull pain。Sometimes eating can induce abdominal pain with defecation, which will be relieved to varying degrees after defecationintestinal obstructionhappen now and thenAbdominal colic, often located in the right lower abdomen or around the umbilical cord, withabdominal distention、Hyperactivity of bowel sounds, intestinal type andPeristaltic wave。
Diarrhea is the main cause of ulcerative intestinal tuberculosisclinical manifestationone of.The frequency of defecation varies according to the severity and scope of the disease, generally 2-4 times a day, and more than 10 times a day for severe cases.Not accompaniedBe quick inside and heavy behind。The stool is paste like and generally does not contain mucus or pus and blood. In severe cases, it contains a small amount of mucusPurulent fluid, but blood in stool is rare.Sometimes the patient will have diarrhea and constipation alternately, which is caused by the diseaseGastrointestinal disordersofHyperplastic intestinal tuberculosisConstipation is the main manifestation.
It is usually located in the right lower abdomen, generally fixed, medium texture, with mild or moderate tenderness.Abdominal mass is mainly seen in proliferative intestinal tuberculosis, but also in ulcerative intestinal tuberculosis with localized peritonitis, adhesion between the affected intestinal segment and surrounding tissues, or bothTuberculosis of mesenteric lymph nodes。
The stool of ulcerative intestinal tuberculosis is mostly paste like, generally without naked eye mucus and pus, but a small amount can be seen under the microscopePurulent cellAndred blood cell。Fecal concentration searchMycobacterium tuberculosisThe positive is helpful for diagnosis, but only when the sputum is negative can it be meaningful.
Negative skin test or positive PPD antibody in blood is helpful for diagnosis, but negative cannot exclude the disease.
4. X-ray examination
X-ray gastrointestinalBarium meal It has important value in the diagnosis of intestinal tuberculosis.In concurrentintestinal obstructionThe barium meal examination should be careful to avoid aggravating the intestinal obstruction. If necessary, dilute barium can be used for examination.In addition to barium meal examination, barium should be routinely addedenemaCheck orColonoscopyIn order to find possible concurrent colonic lesions.In ulcerative intestinal tuberculosis, barium presents irritation signs in the affected intestinal segment, emptying quickly and filling poorly, while in the upper and lower intestinal segments of the lesion, barium is well filled, which is called X-ray barium shadowstierlin sign 。If the diseased intestinal segment can be filled, it will showMucosal plicaCoarse and disordered, the edge of the intestinal wall is irregular, sometimes serrated.Also visibleIntestinal cavityNarrowing, intestinal segment shortening and deformation, ileumcecumNormal angle disappears.
5. CT examination
Circular thickening of the intestinal wall can be seen, and eccentric thickening of the medial cecum can be seen in a few cases.This checksusceptibilityNot as good as intestinesX-ray radiography。
6. Colonoscopy
ColonoscopyIt can treat the whole colon and ileumLast paragraphDirect observation is of great value in the diagnosis of this disease if pathological changes can be found.The lesions are mainlyIleocecal partEndoscopy showed congestion and edema of intestinal mucosa,ulcerInflammation with different size and shapepolyp, intestinal cavity narrowing, etc.If biopsy can be foundcheeseNecrotizing granuloma like orMycobacterium tuberculosisIt is of diagnostic significance.
MainlySubacuteAnd chronic perforation, which can be formed in the abdominal cavityabscess, formed after collapseIntestinal fistula，intestinal hemorrhageIt is rare, with occasional acute intestinal perforation.It may be associated with tuberculous peritonitiscomplication。
The clinical manifestations, X-ray and endoscopic findings of this disease are often similar to those of intestinal tuberculosis, which must be carefully differentiated.The key points of differentiation include: ① no evidence of extraintestinal tuberculosis; ②There is a tendency of remission and recurrence, and the course of disease is generally longer; ③X-ray showed that although the lesions were mainly in the terminal ileum, other intestinal segments could be involved and distributed in segments; ④More concurrencyfistulaOr perianorectal lesions; ⑤The anti tuberculosis drug treatment was ineffective; ⑥Difficulties in clinical differential diagnosisExploratory laparotomyThe specimen and its surroundings are removedmesenterylymph glandNo evidence of tuberculosis, i.egranulomaLesion withoutCaseous necrosisNo mycobacterium tuberculosis was found in microscopic examination and animal inoculation.
This disease is older than intestinal tuberculosis, usually over 40 years old.Generally, there is no tuberculosis such as fever and night sweatToxemiaPerformance.X-ray examination mainly shows bariumFilling defectThe lesion is confined to the colon.Colonoscopy and biopsy can confirm the diagnosis of colon cancer.
Relevant infection history in the past.Pyogenic stoolCommon.Related to stool routine or incubation inspectionpathogen。Colonoscopy is helpful for differential diagnosis.The corresponding specific treatment is effective.
The purpose of treatment of intestinal tuberculosis is to eliminate symptoms, improve general condition, promote focus healing and prevent complications.emphasizeearly treatment Because the early lesion of intestinal tuberculosis is reversible.
1. Rest and nutrition
It can strengthen the resistance of patients and is the basis of treatment.
2. Antituberculous drugs
It is the key to the treatment of this disease.The selection, usage and treatment of drugs are the same aspulmonary tuberculosis。
IndicationsIncluding: ①Complete intestinal obstruction；②Acute or chronic intestinal perforationFistula formationFailure to close after medical treatment; ③Large amount of intestinal bleeding can not be effectively stopped after active rescue; ④Those who need exploratory laparotomy for difficult diagnosis.
prognosis
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stayAntituberculosis drugIntestinal tuberculosis before occurrenceprognosisPoor,mortalityHigh.After the extensive use of anti tuberculosis drugs in clinical practice, the prognosis of intestinal tuberculosis has been greatly improved, especially for mucosal tuberculosis, including intestinal tuberculosis.The prognosis of this disease depends on early diagnosis and timely treatment. When the disease is still in the exudative stage, it can be completely recovered after treatment,Good prognosis。The key to the prognosis is to select anti tuberculosis drugs reasonably and ensure adequate dose and course of treatment.
prevention
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Prevention is preventiontuberculosisThe fundamental approach of.And focus on the discovery of extraintestinal tuberculosis, especiallypulmonary tuberculosisOfearly diagnosis With active anti tuberculosis treatmentSputum bacteriumTurn negative to avoid intestinal infection caused by swallowing sputum containing bacteria.It is necessary to emphasize the importance ofHealth promotionEducation.The patient should be educated not to swallow sputum, and should keep defecation unobstructed.To strengthenHealth Supervision, advocate usingserving chopsticksWhen eating, milk should be sterilized.inoculationBCG vaccineIt can enhance the human body's ability toTuberculosis bacteriaOfResistance, which is conducive to the prevention of tuberculosis.
