Peritoneal tuberculosis diagnosis. Tuberculosis of the intestines, peritoneum, mesenteric lymph nodes

Abdominal tuberculosis is never primary. The source of damage is the lungs, peribronchial lymph nodes, intestines, bones, and joints.

The routes of penetration of the tuberculosis bacillus into the peritoneum can be different. In the first place is spread through the bloodstream, then through the lymphatic vessels and, finally, through direct spread of tuberculosis from the abdominal organs (intestines, mesenteric lymph nodes, female genital organs, kidneys).

There are 3 forms of abdominal tuberculosis:

serous (exudative) with millet-like rashes along the peritoneum and with the formation of serous fluid;
adhesive (adhesive), also called dry, characterized by an abundant amount of adhesions between the intestines, omentum, and peritoneum. Between such adhesions there may be an encysted cavity with effusion;
nodular-tumor-like (purulent) form, characterized by the formation of large nodular tumor-like formations due to adhesions between the intestines, omentum, and parietal peritoneum. Between these adhesions, when they are separated, large quantities of cheesy masses are found, in some places liquefied, purulently softened.

Symptoms of abdominal tuberculosis

The disease affects mainly young people, but often occurs in both childhood and old age. The course is chronic, which is sometimes worsened by acute attacks of intestinal obstruction.

Clinical signs of tuberculous inflammation of the peritoneum can be very unclear. Against the background of emaciation, mild fatigue, vague pain, dyspeptic symptoms, and diarrhea appear. The pain is cramping, sometimes dull. Patients very often have a fever, but there is a fever-free course when abdominal pain is diagnosed as acute, and when tuberculous peritonitis is unexpectedly found. There is a combination of tuberculous peritonitis and an attack. The intensity of the pain depends on the degree of narrowing of the intestines. Vomiting is very rare and appears only in acute cases or during exacerbation of latent peritonitis. Palpation usually provides little information. Pressure sensitivity is negligible. When palpated, the entire abdomen is often painful.

At the onset of the dry form of abdominal tuberculosis, the diagnosis is only presumptive based on general symptoms and the presence of tuberculosis in the patient. From the moment palpable tumor-like formations appear, the diagnosis becomes easier. It is possible to differentiate the tumor-like form of tuberculosis from true tumors on the basis of the multiplicity of lesions, age and slow general course. The exudative form is most easily recognized, especially in children.

The amount of liquid effusion in the exudative form is sometimes significant and the process resembles ascites. If there are encysted accumulations of fluid in the abdominal cavity, they are sometimes mistakenly interpreted as ovarian tumors or hydatid cysts.

Recognition is facilitated if the initial disease of any organ with tuberculosis is established, as well as the presence of a positive serological reaction.

It is sometimes very difficult to distinguish abdominal tuberculosis from peritoneal cancer. Here the issue is resolved by examining tissues taken during surgery.

Treatment of abdominal tuberculosis

Treatment of tuberculous peritonitis is carried out surgically. It is produced, which in itself often gives healing; to this is added the intraperitoneal administration of streptomycin 1 g diluted in 20 ml of 0.5% novocaine. Administration of streptomycin can be repeated in the future either through a small incision or by punctures. A puncture of the abdominal cavity and infusion of streptomycin are carried out according to the same rules as the injection of oxygen or air for diagnostic purposes. At the same time, treatment is also carried out with PAS and ftivazid. All these activities lead to good results.

There are a number of theories to explain the beneficial effect of laparotomy on the course of tuberculous peritonitis. It is believed that air entering the abdomen during laparotomy has a beneficial effect. It was further thought that laparotomy facilitates the release of a large amount of fluid from the peritoneal cavity, thereby reducing the amount of toxins, etc. Laparotomy has a beneficial effect only on exudative forms, especially during the period when the effusion reaches large sizes.

Tuberculosis of the abdominal organs (abdominal) accounts for 2-3% of cases among other localizations of extrapulmonary tuberculosis.

Pathogenesis And pathomorphology. Abdominal tuberculosis develops with lymphogenous, hematogenous or contact spread from foci of primary or post-primary infection. The alimentary route of infection is currently given a modest place. In the intestine, the terminal ileum and cecum are usually affected. Macroscopically, the intestinal wall is edematous, the serous membrane is dull, full-blooded with miliary grayish-yellowish dense rashes. With infiltrative ulcerative tuberculosis of the intestines, ulcerative defects of irregular shape of various sizes are found on the mucous membrane. Microscopy reveals foci of destruction of the mucous membrane with the formation of an ulcerative defect reaching the muscular or serous layer of the intestinal wall. Caseified confluent epithelioid giant cell granulomas are found in large numbers in all layers of the intestinal wall and at the edges of ulcers. Perforation of a tuberculous ulcer leads to the development of diffuse peritonitis.

Tuberculosis can affect the peritoneum and omentum. In this case, grayish-whitish millet-like rashes are macroscopically determined. Peritoneal tuberculosis has two forms - exudative and adhesive. The mesenteric lymph nodes are enlarged in size, and multiple epithelioid giant cell granulomas are microscopically detected.

Clinical picture The disease consists of general symptoms caused by specific intoxication and local manifestations.

In the early period of the disease it is difficult to diagnose due to the paucity of symptoms, and in the late period - due to the variety of clinical manifestations.

Intestinal tuberculosis manifests itself in the form of ulcerative, hypertrophic, stenotic and ulcerative-hypertrophic forms: the ileocecal region is most often affected. The disease proceeds latently and with various manifestations of general and local symptoms. In most cases, it has a wave-like character with periods of exacerbations and remissions. The pain is characterized by persistence and is localized in the right iliac region, varying in duration and intensity. Loose stools and bloating are common. The abdomen is evenly swollen without changes in configuration; palpation is soft and painful in the right iliac region. The cecum appears swollen and compacted. The terminal part of the ileum is palpated in the form of a dense cord. Complications of intestinal tuberculosis include intestinal obstruction, ulcer perforation, bleeding, and peritonitis. Tuberculosis of the appendix occurs with the clinical picture of appendicitis. Other parts of the colon are rarely affected.

Tuberculous peritonitis is both a manifestation of the period of primary tuberculosis infection and a secondary lesion in tuberculosis of the intestines, mesenteric lymph nodes, and genital organs. There are tubercular, exudative, exudative-adhesive and caseous-ulcerative forms of tuberculous peritonitis.

Tuberous tuberculous peritonitis characterized by an acute course; begins with fever, chills and abdominal pain. The tongue is dry, with a whitish coating. The anterior abdominal wall is tense, does not participate in breathing, symptoms of peritoneal irritation are clearly visible (symptoms of Voskresensky, Shchetkin-Blumberg, Sitkovsky, etc.). The vast majority of patients are operated on as an emergency. In this case, tuberculate rashes are found on the peritoneum.

Exudativetuberculous peritonitis is characterized by the formation of exudate in the abdominal cavity. The disease develops gradually with the appearance of vague abdominal pain, unstable stools, subfebrile temperature, weakness, and dyspeptic disorders. The abdomen increases in volume, sometimes to large sizes. Symptoms of peritoneal irritation are smoothed out, and the presence of ascitic fluid is determined.

Adhesive peritonitis manifests itself as a complication of tuberculosis of the abdominal organs with the formation of multiple adhesions. The clinical course is undulating. Patients complain of general weakness, abdominal pain, nausea, and diarrhea. A common complication is adhesive intestinal obstruction.

Exudative-adhesive peritonitis characterized by the appearance of encysted exudate, determined by percussion. The general condition of the patient remains satisfactory for a long time.

Caseous-ulcerative peritonitis characterized by the appearance of cheesy necrosis on the parietal and visceral peritoneum with the formation of ulcers of various sizes. The clinical course resembles the picture of adhesive peritonitis. This is the most severe form of tuberculous peritonitis, complications of which are fistulas into the internal organs and out through the abdominal wall. The general condition of the patients is extremely serious; there is a high temperature.

Tuberculous mesadenitis. The course can be acute and chronic with remissions and exacerbations. In acute cases, the patient complains

It refers to abdominal pain of various locations, but most often in the navel and right iliac region. The pain can be intense and resembles an acute abdominal pain. The abdomen is evenly swollen, not tense, the anterior abdominal wall is involved in breathing. Palpation of the abdomen reveals moderate pain in the navel area (positive Sternberg's sign), positive Kliin's sign (displacement of pain when moving the patient to the left side), symptoms of peritoneal irritation are not pronounced.

Chronic tuberculous mesadenitis It proceeds in waves, with periods of exacerbations followed by remissions. A common symptom is abdominal pain, which corresponds to the localization of the pathological process (along the projection of the mesenteric root). The pain can be dull, aching or paroxysmal in the form of colic. Patients often complain of bloating, which increases towards the end of the day. Pain may be due to pressure from calcified lymph nodes.

Thus, abdominal tuberculosis does not have pathognomonic symptoms. Many signs are often found in various general somatic diseases, therefore the majority of patients are examined in the general medical network under various diagnoses, missing

Diagnostics. X-ray examination and endoscopy (laparoscopy, colonoscopy) are performed. During an X-ray examination, the detection of calcified lymph nodes in the abdominal cavity almost always indicates the presence of tuberculous mesadenitis. Visceroptosis, impaired motor function of the stomach and intestines, displacement and fixation of small intestinal loops due to adhesions or conglomerates of enlarged lymph nodes may also be observed. With tuberculous peritonitis, the unimpeded passage of barium through the lumen of the small intestine and the adhesion of the intestinal loops to each other are revealed; signs of intestinal obstruction are often detected (Kloiber's cup). To identify changes in the intestinal lumen, a colonoscopy is performed with a biopsy of the changed area of the mucous membrane.

In recent years, ultrasound has been used in diagnosis, but there are no ultrasonographic characteristics in the differentiation of metastases, lymphomas and tuberculosis of internal organs.

Histological examination of biopsy material remains the leading method in the diagnosis of tuberculosis of all forms.

Treatment. The goal of treatment is to relieve symptoms of intoxication, resolve local inflammatory changes, prevent and relieve complications. At the first stage, treatment is carried out in a hospital setting.

Chemotherapy in the absence of data on drug resistance of MBT is carried out with four drugs - isoniazid, rifampicin, pyrazinamide, ethambutol. In the presence of drug resistance, treatment is carried out according to an individual regimen.

Pathogenetic treatment includes detoxification agents, vitamin therapy, hepatoprotectors, and enzyme therapy. To restore functionality, local treatment is prescribed - electrophoresis with lidase and terrilitin.

Surgical intervention is performed in case of complicated abdominal tuberculosis as an emergency or planned procedure, depending on the severity of the complication.

Intestinal tuberculosis is an infectious disease that can become chronic. The disease is caused by the spread of harmful microorganisms, which, when multiplying, cause damage to the organ. The peculiarity of the infection is that when infected with this form, no noticeable changes occur in the body, that is, no specific reactions are observed. Common symptoms may include pain and intoxication. Diagnostics consists of an X-ray scan of the intestine, ultrasound of individual organs located in the abdominal region. It is also possible to detect the disease using Koch bacillus tests. Treatment can be either conservative (taking special medications) or surgical (surgery).

Sore intestines

Abdominal tuberculosis is characterized by the fact that it is almost impossible to detect it in the early stages. Disguising itself as symptoms of other diseases, it manages to seriously affect the intestines and intraperitoneal organs, which can lead to serious consequences. This is a significant problem in diagnosing the disease.

The main cause of intestinal tuberculosis is the entry of harmful bacteria into the mucous membrane of the gastrointestinal tract. This is often associated with the consumption of spoiled food, or with excessive swallowing of infected sputum (in the case of a pulmonary form). This factor is considered the main one. But it is worth noting that the body is able to resist infection by these bacteria if the patient’s general immunity is in order. In this case, favorable conditions for their reproduction will not be created.

There are several types of intestinal tuberculosis depending on the route of infection. The primary form is the most dangerous, since it is almost impossible to recognize it in the early stages. In this case, the infection enters the body through the alimentary route through the consumption of contaminated food (infected milk), or through airborne droplets from infected people.

To protect yourself from infection, it is necessary to heat treat food, especially meat and milk. Animals are often the main carriers of Koch's bacillus, but it is humans who are susceptible to infection. With insufficient immunity, bacteria penetrate inside and begin to infect organs. Almost always intestinal tuberculosis is provoked by pulmonary tuberculosis.

Symptoms

The disease occurs with virtually no visible symptoms. It is often very difficult to monitor the prognosis of a given disease. There are cases that the first symptoms appear after a very long time from the moment of infection.

In the first stages, slight pain in the abdominal area may occur. This is due to the fact that bacteria begin to penetrate the mucous membrane, nausea and intestinal dysfunction are possible.
The further course of the disease is accompanied by increased pain, it becomes permanent.
The general health condition deteriorates, the patient loses appetite, and rapidly loses weight.
There is an increase in body temperature, chills, malaise, and weakness.

Diagnosis of the disease at this stage becomes possible, so it is necessary to consult a doctor who will make a diagnosis and begin treatment. This needs to be done as early as possible, since the infection during this period can either worsen or subside.

In the absence of proper treatment, the condition will noticeably worsen, and the disease will rapidly progress. As a result, the development of acute appendicitis and the appearance of stool mixed with blood is possible. All these reactions can become irreversible. In this case, delayed treatment may be useless and may not lead to improvement.

It is very important to consult a doctor in time, since the disease is easier to treat at an earlier stage and prevent the development of possible complications.

Diagnostics

If the symptoms of the pulmonary form can still be determined, then in the case of abdominal tuberculosis it is not so simple. First, it is necessary to carry out a differential diagnosis of intestinal tuberculosis and Crohn's disease.

In rare cases, it is possible to detect an intestinal infection, but only if the patient's lungs were initially affected. The development of abdominal tuberculosis is very closely related to pulmonary tuberculosis, so it would be advisable to check the intestines for possible infection. Even if nothing is found during the initial diagnosis, the scanning procedure must be repeated again. In this case, the risk of development can be significantly reduced.

Often the examination begins with a gastroenterologist. If this method does not give certain results, then an additional blood test and X-ray scan of the gastrointestinal tract may be performed.

In most cases, endoscopy provides the best results. This procedure can reveal the presence of primary symptoms, which manifest themselves in the formation of ulcers and polyps.

Treatment

In case of intestinal tuberculosis, mandatory hospitalization in a dispensary is necessary. The doctor prescribes a special diet, draws up a treatment regimen and prescribes the necessary medications. The most commonly used are Rifampicin and Ftivazid.

The course of admission is individual and can last up to two years. With timely initiation and proper treatment, it is possible to completely destroy harmful bacteria. In rare cases, surgical intervention is resorted to.

Peritoneal tuberculosis or tuberculous peritonitis

Abdominal disease is often associated with damage to the lymph nodes. When infected with this form, other systems may also be affected.

The difference from intestinal damage is slight. The clinical picture is similar:

Patients also experience abdominal pain that gradually increases.
In some cases, patients begin to feel feverish, complain of fever and general malaise.

Identifying this disease is problematic; sometimes you can palpate a tumor-like formation in the abdominal cavity.

It is worth noting that this form of damage also cannot be primary. Infection of the abdominal cavity is associated with the presence of pulmonary tuberculosis. The infection can enter through the bloodstream by swallowing infected sputum.

The disease is severe and has adverse consequences associated with obstruction of the gastrointestinal tract. Treatment is carried out with drugs whose action is aimed at combating harmful bacteria.

It should be remembered that any form of tuberculosis is contagious. The pulmonary form is especially dangerous, since bacteria in this case are transmitted by airborne droplets, and any person whose immunity is weakened can fall into the risk zone. Also, the appearance of such a disease can be facilitated by poor nutrition, unfavorable socio-economic conditions, and damp rooms. It is very important to protect yourself from these factors and regularly visit a doctor at the slightest discomfort.

GOU SPO SYZRAN MEDICAL COLLEGE

ABSTRACT ON THE TOPIC:

"Intestinal tuberculosis

Tuberculosis of mesenteric lymph nodes"

Prepared by: student of group 421

Bakhareva Evgenia

Checked by: Nagulova O.V.

Intestinal tuberculosis

Intestinal tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis. It is manifested by the formation of specific granulomas in various parts of the intestine, most often in the ileocecal region. The incidence of tuberculosis has increased significantly in recent years and, according to data, reaches 47.5 cases per 100,000 population.

Etiology and pathogenesis

Typically, intestinal tuberculosis is a secondary process that occurs against the background of the progression of pulmonary tuberculosis. Less commonly, the lesion is primary as a consequence of nutritional infection.

The stomach is highly resistant to tuberculosis infection. Therefore, even the systematic ingestion of a large number of virulent bacteria during pulmonary tuberculosis does not always lead to secondary damage to the stomach and intestines.

With intestinal tuberculosis, the lymph nodes of the mesentery are primarily affected: tuberculous mesadenitis develops. In the affected areas of the intestine, specific infiltrative-ulcerative tumor-like formations or multiple small dense red nodules (granulomas) appear. Tuberculous granulomas suppurate and open to form bleeding, confluent ulcers. In case of perforation, limited or diffuse peritonitis develops. The pathological process is localized mainly in the distal small intestine in places where Peyer's patches are concentrated or in the cecum.

Less commonly, ulcerative-destructive lesions form in the ascending and transverse colon. Tuberculosis of the rectum and anorectal region is very rare. It is characterized by perirectal abscesses and chronic ulcers. Ulcers do not tend to heal and lead to narrowing of the rectum. When a tuberculous abscess is opened, a pararectal fistula (paraproctitis) is formed.

Intestinal disease in tuberculosis is possible both with and without a specific anatomical lesion. In the latter case, the patient experiences general symptoms characteristic of tuberculosis (fever, sweating, blood changes, etc.). Intestinal symptoms are characterized by prolonged diarrhea that is resistant to conventional therapy. During this period, mesenteric lymph nodes may also be involved in the process.

Mesenteric lymphadenitis. It manifests itself as pain around the navel, aggravated by walking and physical stress. On palpation, pain is localized predominantly in the projection of the mesenteric root: the upper left (Porges point) and right lower quadrants of the abdomen. Clinical improvement in this case occurs only after the administration of tuberculostatic drugs. As the process progresses and specific inflammatory changes form in the intestines, abdominal pain appears, more often in the right iliac region, weakness, malaise and symptoms of intoxication increase. Upon palpation in the right iliac region, a smooth or lumpy, slightly painful tumor can be detected.

Ulcerative-destructive intestinal lesions. Manifested by symptoms of peritoneal irritation, fever increases with large ranges between morning and evening body temperatures. Blood appears in the stool, and upon microscopy, leukocytes and red blood cells appear. During the ulcerative-destructive process, complications often develop: perforation, intestinal bleeding, external intestinal and intestinal obstruction. Characteristic symptoms of rectal tuberculosis are tenesmus and false urge to defecate, the presence of pus and blood in the stool. Pain in the rectum is uncharacteristic and appears mainly when the anorectal area is affected.

Intestinal tuberculosis is diagnosed using a comprehensive examination, including plain radiography of the chest, abdominal cavity, irrigoscopy, fluoroscopy of the small intestine, colonoscopy and laparoscopy with biopsy, and tuberculin tests. As one of the screening methods for diagnosing tuberculous intestinal lesions, it is proposed to make wider use of stool tests for occult blood.

X-ray examination of the cecum or ascending colon reveals a “crescentic” filling defect, lack of haustration, rigid narrowing of the lumen and shortening of the size of this section of the intestine, paradoxical retention of barium in the cecum when other sections are released.

Ultrasound is of particular importance in the diagnosis of intestinal tuberculosis. Characteristic signs in this case may be segmental damage to the intestine, enlarged regional lymph nodes and encysted ascites. Tuberculosis of the anorectal region and rectum is detected during proctological examination. Tuberculous ulcers are located at different levels of the rectum, have raised edges, a flat bottom, covered with purulent contents. The intestinal lumen is usually narrowed. Tuberculous paraproctitis is characterized by a long course, copious discharge and absence of pain.

Tuberculosis of the intestine is considered established when Mycobacterium tuberculosis is detected in tissue or biological fluids. Modern methods of cultivating Mycobacterium tuberculosis allow for specific identification of isolated microorganisms. This process is quite long. The reproduction time of mycobacteria is 20㪰 hours. Primary isolation of the pathogen from clinical material requires from 4 to 8 weeks.

The intradermal tuberculin test is a reliable way to recognize primary tuberculosis infection. The reaction should be taken into account after 48㫠 hours by measuring the transverse diameter of the induration revealed by palpation. In patients with tuberculosis, the size of this seal is at least 17 mm. People who are infected but not sick have similar reactions. Tuberculin sensitivity is not specific, as it can develop as a result of contact with non-pathogenic environmental mycobacteria; a paradoxical absence of skin tuberculosis reactivity in infected individuals (anergy) is also possible. It is observed in 15% of patients with tuberculosis and is associated with a number of painful conditions and impaired immune status.

Differential diagnosis

Recognizing tuberculous lesions is very difficult, since the clinical, radiological and endoscopic signs of it have much in common with other inflammatory diseases. Differential diagnosis should be made with Crohn's disease and ulcerative colitis, amoebic dysentery and intestinal tumors. Histological examination helps to exclude tumors and amoebic dysentery. In Crohn's disease and tuberculosis, endoscopic biopsy may reveal sarcoid-like granulomas. They consist of clusters of lymphocytes, in the center of which single giant cells of the Pirogov-Langhans type can be found. In contrast to Crohn's disease, in tuberculosis, along with granulomas, foci of caseous necrosis appear.

Modern treatment of uncomplicated forms is carried out with effective tuberculostatic drugs. However, it is not always possible to achieve a cure. This is due to the presence of drug-resistant mutants of mycobacteria. In order to prevent their development, two effective drugs should be used simultaneously. The slow reproduction of mycobacteria and their ability to remain in an inactive state for a long time necessitate the use of long courses of chemotherapy.

Treatment of intestinal tuberculosis should be carried out in specialized tuberculosis hospitals. One of the most effective treatment regimens for intestinal tuberculosis is daily administration of isoniazid and rifampicin for 9 months or isoniazid and ethambutol for 18 months. These treatment methods achieve favorable results in 95 and 99% of patients. The main problems associated with the implementation of treatment anti-tuberculosis programs are the lack of discipline of patients and the possibility of side effects of tuberculostatic drugs. The number of patients who voluntarily stop treatment can range from 15 to 40㫔%.

Dangerous consequences of the toxic effect of tuberculostatic drugs are hepatitis, neuritis of the vestibulocochlear and optic nerves, thrombocytopenia and renal failure.

Side effects of drugs that force changes in the treatment program are observed in 3% of patients receiving isoniazid and rifampicin and in 1% receiving isoniazid and ethambutol. If complications develop, surgical treatment is indicated.

The prognosis for intestinal tuberculosis is serious and largely depends on the timeliness of diagnosis and treatment. In advanced forms with widespread destructive changes in the small intestine, the prognosis is rather unfavorable due to severe malabsorption syndrome and relapses of intestinal obstruction. When the colon is affected, the prognosis is less pessimistic due to the possibility of extensive resection of the affected intestine.

Prevention

The incidence of tuberculosis in individuals who respond positively to tuberculin administration can be significantly reduced by chemoprophylaxis with isoniazid prescribed for 1 year. Preventive treatment should be given to persons who are in household contact with patients with active tuberculosis, as well as patients who react positively to tuberculin, regularly receive immunosuppressive, corticosteroid drugs and suffer from immunodeficiencies of various origins. Vaccination with bacillus Calmette-Guerin (BCG), carried out for most people, is more effective than 80%. In areas with a high prevalence of tuberculosis, vaccination should be given to every person under 20 years of age without prior tuberculin testing.

Tuberculosis of mesenteric lymph nodes (mesadenitis)

Mesadenitis, or tuberculosis of the mesenteric lymph nodes, can develop in both primary and secondary tuberculosis. Secondary tuberculous mesadenitis is observed only with a sharp decrease in the body's defenses caused by a severe progressive course of pulmonary or extrapulmonary tuberculosis; More often, the occurrence of mesadenitis can be associated with the primary form of tuberculosis.

Damage to the abdominal nodes in some patients is caused by the causative agent of bovine tuberculosis during alimentary penetration of infection. In modern conditions, tuberculous lesions of the lymph nodes of the abdominal cavity are rare, which is largely due to the timely detection and successful treatment of patients with primary tuberculosis.

All groups of lymph nodes of the abdominal cavity can be involved in the tuberculosis process, but most often and with greater expression the disease develops in the mesenteric lymph nodes. Mesenteric lymph nodes affected by tuberculosis may be slightly enlarged, but often reach significant sizes and are closely fused into large conglomerates. If the course of mesadenitis is unfavorable, the tuberculous process spreads to the serous membranes and intestinal walls. The formation of cold abscesses in the abdominal cavity is possible, sometimes opening into the abdominal cavity or outward, as well as the spread of tuberculosis infection in the body through the lymphogenous route. A favorable course of the disease leads to calcification of the lymph nodes, which develops with mesadenitis much earlier than with bronchoadenitis.

Histological examination can reveal various stages of the evolution of mesadenitis - from the development of a tuberculous tubercle to the formation of a glandular cavity. There are three forms of mesadenitis: infiltrative, caseous and fibrous. The course of the disease is usually long-term, but in most cases it is benign: progressive mesadenitis is extremely rare.

The most common symptom of mesadenitis is pain, usually localized in the umbilical or right iliac region, where the largest number of lymph nodes are concentrated. The nature of the pain can be varied: dull or acute, in the form of attacks. There is an increase in pain with physical exertion. In the acute period of the disease, pain can simulate the picture of appendicitis, pancreatitis and even a perforated gastric ulcer.

Almost always, various dyspeptic disorders are observed with mesadenitis: loss of appetite, occasional nausea, vomiting and irregular bowel movements. The occurrence of these symptoms is associated with the neuro-reflex effect of inflammation on the gastrointestinal tract or with the involvement of the peritoneum in the tuberculosis process.

With a long course of the disease, the development of hyperacid gastritis and impaired liver function are possible.

Examination and palpation reveal abdominal bloating, tension and pain at various points, depending on the damage to the corresponding nodes. The cause of bloating and abdominal tension is flatulence, and sometimes effusion in the abdominal cavity. In places where pain is localized, deep palpation can identify fixed or sedentary enlarged single lymph nodes or clusters of them. The most accessible for palpation are the mesenteric lymph nodes to the right of the navel above the location of the cecum and to the left along the mesentery. Here, dullness of percussion sound is also possible.

The patient's hemogram shows a decreased hemoglobin content, a shift of band neutrophils to the left, lymphocytosis, and an increased ESR.

An X-ray examination of the abdominal cavity may reveal enlarged and changed lymph nodes in the form of oval or round formations, often with a granular structure due to the deposition of lime in them.

Tuberculin tests in patients with active mesadenitis are in most cases sharply positive. The body's reaction to subcutaneous injection of tuberculin is of great diagnostic importance. The appearance or intensification of pain in the abdominal cavity after the administration of tuberculin simultaneously with a general reaction may indicate the presence of an active tuberculous process in the mesenteric lymph nodes.

The commonality of some symptoms of mesadenitis with symptoms of appendicitis, pancreatitis, gastric ulcer, carcinomatosis and lymphogranulomatosis requires knowledge of the differential diagnostic differences between these diseases.

Nonspecific mesadenitis occurs during various inflammatory processes in the abdominal organs, as well as during chronic inflammatory processes in the upper respiratory tract. The clinical manifestations of nonspecific mesadenitis are extremely similar to those of tuberculous mesadenitis. Differential diagnosis is based on anamnestic data: with nonspecific mesadenitis there are often indications of chronic tonsillitis, inflammatory diseases of the abdominal organs, with tuberculous mesadenitis - indications of previous tuberculosis of other organs. The main differential diagnostic tests are hemogram and tuberculin diagnostics. With nonspecific mesadenitis, the hemogram shows leukocytosis up to 11-10-10-15-10-3 in 1 μl (11,000-15,000), a significant shift of neutrophils to the left, lymphocytosis, and an increase in ESR. Tuberculin tests are negative or mild. The body's response to subcutaneous injection of tuberculin is not observed.

In acute appendicitis, there is a sudden onset of pain in the right iliac region. Their intensity usually increases, while with mesadenitis the pain is constant. With appendicitis, symptoms of peritoneal irritation are pronounced. With recurrent appendicitis, during an exacerbation, the pain is paroxysmal in nature, accompanied by nausea, vomiting, and fever. A blood test reveals leukocytosis and an increase in the number of band neutrophils.

The acute period of pancreatitis is also characterized by the sudden appearance of very severe pain in the epigastric region and to the left of the rectus abdominis muscle. Pain may radiate to the left iliac region and left thigh. There is an increase in the content of diastase in the urine and blood.

Gastric ulcer is accompanied by the appearance of strictly localized pain in the epigastric region; pain radiates to the back. X-ray examination reveals corresponding changes in the stomach.

Peritoneal carcinomatosis is a very rare disease. The main symptoms of carcinomatosis are severe intoxication of the body, progressive course of the disease, severe anemia and negative reactions to tuberculin. Changed lymph nodes in carcinomatosis are palpably defined as denser formations than in tuberculous mesadenitis.

The mesenteric form of lymphogranulomatosis occurs with wave-like fever. Lymphogranulomatosis is characterized by enlargement of the lymph nodes during the period of rising temperature. The hemogram reveals leukopenia and lymphopenia, monocytosis and eosinophilia. Lymphogranulomatosis progresses rapidly.

Clinical manifestations of chronic colitis are often mistaken for tuberculous mesadenitis, but in chronic colitis, abdominal pain is often caused by eating rough and fatty foods. When palpating the abdomen, diffuse pain is determined, but mainly along the colon.

The main method of treating patients with tuberculous mesadenitis is the use of antibacterial drugs according to the generally accepted treatment regimen for patients with tuberculosis.

During the acute course of the process, the use of three main anti-tuberculosis drugs (streptomycin, isoniazid, PAS) in optimally tolerated doses with the simultaneous administration of vitamins B and C complexes is indicated. In the chronic course of mesadenitis, one can limit oneself to the prescription of drugs from the group GINK and PAS. The total duration of treatment is 12-18 months.

Intestinal tuberculosis

Intestinal tuberculosis has long been considered a very serious and difficult to treat disease. The appearance of persistent diarrhea in tuberculosis patients in the 18th and 19th centuries was considered by doctors as a fatal sign of pulmonary consumption. Intestinal tuberculosis was observed mainly in patients with fibro-cavernous and chronic disseminated tuberculosis.

Currently, due to the widespread use of tuberculostatic drugs and the more benign course of tuberculosis, a specific intestinal disease is rarely observed, occurs with mild clinical symptoms and is curable.

The tuberculosis process in the intestine can occur through sputogenic, lymphohematogenous and contact routes. The possibility of sputogenic intestinal infection has been confirmed by experimental studies. Adding sputum containing Mycobacterium tuberculosis to animal feed caused intestinal tuberculosis. The same experiments confirmed the great resistance of the intestine, since the development of a specific process in it required long-term (6 months) feeding of animals with infected material and a large amount of this material. Experiments conducted on guinea pigs showed that in animals fed food poor in vitamins, tuberculosis developed much faster.

Although animal experiments are a weak analogy with the development of tuberculosis in humans, they still indicate the possibility of intestinal tuberculosis in humans when bacillary sputum penetrates the gastrointestinal tract. This can most often occur in patients with cavities in the lungs. The development of extensive tuberculosis predominantly in the ileocecal region of the intestine can be explained by fecal stasis, which can occur in patients with destructive tuberculosis.

It would be incorrect to associate the development of intestinal tuberculosis only with the entry of infectious material from the pulmonary cavities into the gastrointestinal tract. The confounding theory cannot explain the occurrence of intestinal tuberculosis in various forms of pulmonary and especially extrapulmonary tuberculosis. A specific intestinal disease is observed in patients with hematogenously disseminated and focal pulmonary tuberculosis, with bone tuberculosis and other localizations of this disease.

V. G. Shtefko, through experiments with intravenous infection of animals, proved the possibility of developing intestinal tuberculosis by hematogenous route.

Lymphogenous infection of the intestine with tuberculosis through the pleuroperitoneal lymphatic tract, as well as through contact due to the transition of the inflammatory process to the intestine during tuberculosis of neighboring organs, for example, with tuberculous adnexitis, is also possible.

Pathomorphological changes in intestinal tuberculosis can be in the form of scattered foci: circular ulcers across the mucous membrane - anular tuberculosis; ulcers located predominantly along the length of the intestinal mucosa - longitudinal tuberculosis; ulcers are round, irregularly shaped and bay-shaped, located mainly in the cecum and colon - irregular tuberculosis.

There may be perifocal inflammation around the lesions and ulcers. The ulcerative process destroys not only the mucous and submucosal layers, but also the muscle layer. The serosa of the intestine is involved in the pathological process; in these cases, it is cloudy, hyperemic, and covered in limited areas with fibrinous deposits. The development of limited peritonitis and fusion of intestinal loops, omentum with the abdominal wall is possible.

Most often, tuberculosis is localized in the ileocecal region, but other parts of the small and large intestines, as well as the rectum, can also be affected.

Clinical symptoms of intestinal tuberculosis can vary in form and intensity.

With intestinal tuberculosis, low-grade fever, weight loss, depression, and irritability are observed.

Due to severe and prolonged intoxication, patients often experience irregular bowel movements with frequent urges. These symptoms are similar to the clinical manifestations of colitis. The appearance of such symptoms in patients with minor manifestations or subsided pulmonary tuberculosis serves as a basis for suspicion of intestinal tuberculosis, especially if in patients constipation is replaced by diarrhea and pain in the intestines occurs. Pain may be due to spastic contraction of the ulcerated area of the intestine with simultaneous stretching of the proximal part of the latter. A patient with intestinal tuberculosis may experience a feeling of pressure, heaviness and fullness in the right iliac region.

When examining the patient, in some cases one may notice swelling and pain near the navel and in the ileocecal region; The ascending part of the colon and ileum are painful and hardened on palpation.

All of these symptoms are observed with extensive ulcerative intestinal tuberculosis, which is rare in recent times.

In the complex of signs of intestinal tuberculosis, a significant place is occupied by data from laboratory tests and X-ray examination of the intestine.

Blood can be found in the stool of ulcerative intestinal tuberculosis, but the sources of blood in the stool are numerous and only the detection of blood after a special diet followed by the patient for 3 days is significant. The stool may also contain protein (Triboulet reaction), mucus, organic acids and ammonia (during the fermentative putrefactive process).

Mycobacterium tuberculosis can be found in flakes of mucus and pus, but it must be borne in mind that they can enter the feces not only from the intestines. Thus, there are no individual symptoms and laboratory data characteristic only of intestinal tuberculosis. In this regard, X-ray examination is of great importance for diagnosing this disease. The study is performed with a contrast mass (barium sulfate), which leaves the stomach almost completely after 2.5-3 hours; the small intestine fills within 20-25 minutes; after 1.5-2 hours, the contrast mass descends into the ileum. After 2-4 hours, barium enters the cecum. The cecum remains partially or completely filled for 4 to 24 hours. Bowel emptying from the contrast mass occurs after 36-48 seconds.

With intestinal tuberculosis, a spastic filling defect is observed due to increased excitability of the ulcerated area. 5-8 hours after taking barium, in patients with intestinal tuberculosis there is no shadow of the cecum (Stirlin’s symptom). In the ulcerated areas of the intestine, a speckled pattern formed by the remnants of the contrast agent is visible.

Intestinal tuberculosis must be differentiated from a number of diseases: non-tuberculous ulcerative colitis, amyloidosis, dysentery and other, mainly chronic diseases, such as intestinal tumors.

There is no special therapeutic diet for intestinal tuberculosis; fasting or the so-called weak diet (rice water, rice porridge, etc.) are not justified.

With correct and long-term (12-18 months) chemotherapy, intestinal tuberculosis is clinically and morphologically curable; at the site of ulcerations in the intestines, scars of varying sizes may form.

All groups of lymph nodes of the abdominal cavity can be involved in the tuberculosis process, but the disease most often and more severely develops in the mesenteric lymph nodes. Mesenteric lymph nodes affected by tuberculosis may be slightly enlarged, but often reach significant sizes and are closely fused into large conglomerates. If the course of mesadenitis is unfavorable, the tuberculous process spreads to the serous membranes and intestinal walls. The formation of cold abscesses in the abdominal cavity is possible, sometimes opening into the abdominal cavity or outward, as well as the spread of tuberculosis infection in the body through the lymphogenous route. A favorable course of the disease leads to calcification of the lymph nodes, which develops with mesadenitis much earlier than with bronchoadenitis.

With a long course of the disease, the development of hyperacid gastritis and impaired liver function are possible.

The patient's hemogram shows a decreased hemoglobin content, a shift of band neutrophils to the left, lymphocytosis, and an increased ESR.

Nonspecific mesadenitis occurs during various inflammatory processes in the abdominal organs, as well as during chronic inflammatory processes in the upper respiratory tract. The clinical manifestations of nonspecific mesadenitis are extremely similar to those of tuberculous mesadenitis. Differential diagnosis is based on anamnestic data: with nonspecific mesadenitis there are often indications of chronic tonsillitis, inflammatory diseases of the abdominal organs, with tuberculous mesadenitis - indications of previous tuberculosis of other organs. The main differential diagnostic tests are hemogram and tuberculin diagnostics. With nonspecific mesadenitis, the hemogram shows leukocytosis up to 11 10 3 -15 10 3 in 1 μl (11,000-15,000), a significant shift of neutrophils to the left, lymphocytosis, and an increase in ESR. Tuberculin tests are negative or mild. The body's response to subcutaneous injection of tuberculin is not observed.

Gastric ulcer is accompanied by the appearance of strictly localized pain in the epigastric region; pain radiates to the back. X-ray examination reveals corresponding changes in the stomach.

Peritoneal carinomatosis is a very rare disease. The main symptoms of carcinomatosis are severe intoxication of the body, progressive course of the disease, severe anemia and negative reactions to tuberculin. Changed lymph nodes in carcinomatosis are palpated as denser formations than in tuberculous mesadenitis.

The main method of treating patients with tuberculous mesadenitis is the use of antibacterial drugs according to the generally accepted treatment regimen for patients with tuberculosis.