G. I. TB

 Gastrointestinal TB

Gastrointestinal TB is uncommon, Various pathogenetic mechanisms are involved: swallowing of sputum with direct seeding, hematogenous spread, or (largely in developing areas) ingestion of milk from cows affected by bovine TB. Although any portion of the gastrointestinal tract may be affected, the terminal ileum and the cecum are the sites most commonly involved. Abdominal pain (similar to that associated with appendicitis) and swelling, obstruction, hematochezia(blood in stool) and a palpable mass in the abdomen are common findings at presentation. Fever, weight loss, anorexia, and night sweats are also common. With intestinal-wall involvement, ulcerations and fistulae may simulate Crohn's disease; the differential diagnosis with this entity is always difficult.

Tuberculous peritonitis follows either the direct spread of tubercle bacilli from ruptured lymph nodes and intraabdominal organs (e.g., genital TB in women) or hematogenous seeding. Nonspecific abdominal pain, fever, and ascites should raise the suspicion of tuberculous peritonitis. The coexistence of cirrhosis in patients with tuberculous peritonitis complicates the diagnosis. In tuberculous peritonitis, paracentesis reveals an exudative fluid with a high protein content and leukocytosis that is usually lymphocytic.

Clinical Profile and Risk Assessment

Presenting Features: Long-standing right lower abdominal pain, changes in bowel habit (obstructive symptoms or diarrhea), weight loss, low-grade pyrexia, night sweats, and sometimes gastrointestinal bleeding.

Physical Findings: Right iliac fossa mass on palpation or signs of partial intestinal obstruction.

Predisposing Factors: Residence in areas where TB is endemic, HIV, or other immunocompromised conditions, a history of pulmonary TB, and less frequently consumption of unpasteurized milk harboring M. bovis.

Associated Disease: Simultaneous pulmonary or peritoneal TB can be identified through chest imaging or fluid analysis.

  Laboratory Workup

Routine Tests: Normocytic anemia and elevated ESR or CRP are common but non-specific.

Tuberculin Skin Test , IGRA: Indication of exposure to TB, but not specific to gastrointestinal involvement.

Microbiological Evidence:

AFB Staining and Culture: Still the gold standard, but sensitivity in mucosal biopsies is low (<30–40%).

PCR for M. tuberculosis: Provides increased sensitivity; multiplex PCR for IS6110 and MPB64 increases specificity but may produce false positives from non-tuberculous mycobacteria.

   Radiologic Evaluation

  CT and MRI Findings

CECT or CT Enterography: Typical signs include asymmetric ileocecal wall thickening, retracted cecum, rim-enhancing necrotic lymph nodes, and peritoneal thickening.

MRI Enterography: Useful in the evaluation of detailed bowel wall and extraluminal complications when a reduction of radiation exposure is needed.

Key Differentiators

·         ITB: Short-segment disease, ileocecal predominance, necrotic nodes.

·         Crohn's disease: Long-segment or skip lesions, creeping fat, and common fistulas.

·         Endoscopy and Biopsy

·         Colonoscopy: Can show transverse ulcers with a ragged border, nodularity, deformed or patent ileocecal valve, and strictures.

·         Sampling: Deep biopsies in multiple numbers increase diagnostic yield; endoscopic ultrasound-guided FNAC of lymph nodes can add to confirmation.

  Histopathological Characteristics

Diagnostic Clues: Confluent, large, caseating granulomas with epithelioid  histiocytes and Langhans-type giant cells are strongly suggestive.

Quantitative Indicators: Submucosal granulomas >200 μm and >5 granulomas per high-power field suggest ITB instead of CD.

Additional Testing: Ziehl–Neelsen staining identifies AFB in only a minority; culture is still essential for drug-susceptibility testing.

  Differential Diagnosis

Aspect	ITB	Crohn’s Disease	Adenocarcinoma/Lymphoma
Location	Predominantly ileocecal	Ileum ± colon, skip lesions	Variable
Ulcer Orientation	Transverse	Longitudinal	Irregular masses
Lymph Node Pattern	Necrotic, rim-enhancing	Homogeneous	Firm, non-necrotic
Fistulization	Uncommon	Common	Rare
ATT Response	Marked improvement in 6–8 weeks	No specific response	No response

 

Other conditions  e.g., Yersinia enterocolitica infection, amebiasis, and Behçet's disease can also present as ITB but are differentiated by stool cultures, serology, or systemic signs.

 Trial of Therapy

When biopsy and microbiology are still not yielding evidence, a monitored course of ATT can be attempted. Significant symptom and imaging response within 6–8 weeks is highly suggestive of ITB. Malignancy must always be ruled out before such therapy.

 Multidisciplinary Collaboration

 Gastroenterologists: Carry out endoscopy and follow therapeutic response.

 Radiologists: Offer detailed cross-sectional imaging interpretation.

 Pathologists: Diagnosis of granulomatous features and histologic confirmation of TB.

 Infectious Disease Specialists: Evaluate pulmonary involvement and resistance patterns.

Conclusion

ITB diagnosis involves the combination of clinical suspicion with radiologic, endoscopic, histologic, and microbiologic information. Ulcer shape, lymph node morphology, granuloma type, and initial response to ATT are noted with attention to differentiate ITB from CD or malignancy. Coordination and multidisciplinary management reduce delays in diagnosis and maximize patient management.

 

 Gastropathy

 Causes, Symptoms, and How to Manage It

Understanding Gastropathy

Gastropathy is a damage or irritation to the lining of your stomach, but not much inflammation. Think of it as the stomach’s protective layer being worn down or injured. It’s different from gastritis, which usually involves active inflammation. Gastropathy is often spotted during an endoscopy, where the stomach lining may look red, thickened, or eroded.

What Can Cause Gastropathy?

There is no single one reason for gastropathy it can develop for many reasons. Some of the most common include:

1. Medications That Irritate the Stomach

Pain relievers like aspirin or ibuprofen (NSAIDs) can harm the stomach’s protective lining.

The long-term steroid use and Chemotherapy drugs can have similar effects.

2. Bile Reflux or Chemical Damage

Sometimes bile or digestive fluids back up into the stomach, This is more common after stomach surgeries or in chronic bile reflux, causing irritation.

3. Alcohol and Tobacco

Too much alcohol and Smoking use weakens the stomach’s defenses, reduces blood flow to the stomach, slowing healing and making damage worse.

4. Severe Physical Stress

Major surgery, serious infections, or injuries can decrease blood flow to the stomach lining, leading to stress-induced gastropathy.

5. Portal Hypertensive Gastropathy

Portal hypertensive gastropathy (PHG) is a stomach lining abnormality seen in people with portal hypertension, most commonly due to liver cirrhosis. Increased pressure in the portal vein causes fragile, dilated blood vessels in the stomach mucosa, making them prone to bleeding.

6. Other Triggers

Radiation therapy to the abdomen.

Swallowing corrosive substances.

Chronic conditions like chronic kidney disease (CKD) or vascular diseases.

Recognizing Symptoms

Gastropathy doesn’t always cause noticeable problems, especially early on. But when symptoms do show up, they may include:

A dull ache or burning in the Epigastric region.

Nausea or vomiting.

Bloating or indigestion.

Black or tar-like stools (a sign of bleeding).

Fatigue or weakness, nervousness, poor concentration from slow blood loss.

Steps to Diagnose It

To confirm gastropathy, doctors may:

Perform an endoscopy to look at the stomach lining directly.

Take a biopsy to check for inflammation, infection, or other conditions.

Order blood tests( e.g. CBC, LFT, KFT, LIPIDP ROFILE, CRP, ESR, RBS) to look for anemia or liver problems.

Use imaging tests (USG, FIBROSCAN, CT abdomen) if vascular issues are suspected.

Treatment and Management Options

The right treatment depends on what’s causing the problem:

1. Lifestyle Changes

Cut back on alcohol and quit smoking.

Avoid spicy, greasy, or acidic foods.

Eat smaller, more frequent meals.

If bile reflux is a concern, elevating your head while sleeping may help.

2. Medications

Proton Pump Inhibitors (PPIs) reduce stomach acid and help healing.

Sucralfate or antacids coat and protect the stomach lining.

Prokinetic drugs can improve bile flow and stomach motility.

Beta-blockers may be prescribed for portal hypertensive gastropathy.

If NSAIDs are the cause, your doctor may suggest switching to other pain relievers.

3. Addressing Underlying Conditions

Managing liver disease, kidney issues, or other chronic illnesses can prevent further damage.

In hospital settings, to rule out and managing the underlying conditions.

4. Procedures for Severe Cases

If there’s bleeding, an endoscopic variceal ligation (EVL) is done. In rare cases, surgery and other measures may be necessary.

Prevention Tips

Take pain relievers like NSAIDs only as advised by a doctor.

Limit alcohol intake and quit smoking.

Treat liver and digestive issues early.

Seek medical attention for unexplained stomach pain, nausea, or dark stools,(Hematochezia).

Outlook

With the right care, most people with gastropathy recover without lasting problems. But leaving it untreated can lead to ulcers or serious bleeding so early evaluation and treatment are key.

 Liver Function Tests

Liver function tests (LFTs) are a panel of blood tests used to evaluate liver health, diagnose liver diseases, and monitor treatment effectiveness. These tests measure enzymes, proteins, and substances either produced by the liver or affected by its function. A thorough understanding of each test helps in identifying liver conditions more accurately.

1. Alanine Aminotransferase (ALT)

Purpose: ALT is an enzyme primarily found in liver cells (hepatocytes).

What It Indicates: When liver cells are damaged or inflamed such as in hepatitis or fatty liver disease ALT leaks into the bloodstream. Persistently high ALT suggests ongoing liver injury.

2. Aspartate Aminotransferase (AST)

Purpose: AST is present in the liver, heart, muscles, and kidneys.

What It Indicates: Elevated AST can point to liver damage but is less specific because muscle injury or heart conditions (like a heart attack) can also raise AST levels. It’s often interpreted alongside ALT.

3. Alkaline Phosphatase (ALP)

Purpose: ALP is an enzyme found in the liver, bile ducts, and bones.

What It Indicates: High ALP may signal bile duct obstruction (cholestasis), liver inflammation, or certain bone diseases. In liver disorders, ALP elevation is often accompanied by increased GGT levels for confirmation.

4. Gamma-Glutamyl Transferase (GGT)

Purpose: GGT is an enzyme concentrated in the liver and bile ducts.

What It Indicates: Elevated GGT is an early marker for bile duct obstruction and can indicate alcohol-related liver injury or toxin exposure. It is frequently used with ALP to confirm liver-related causes of elevated ALP.

5. Total Bilirubin

Purpose: Bilirubin is a yellow pigment formed when red blood cells break down.

What It Indicates: The liver processes bilirubin for excretion. High total bilirubin may cause jaundice and often indicates liver dysfunction, bile duct blockage, or increased red blood cell breakdown (hemolysis).

6. Direct (Conjugated) Bilirubin

Purpose:

Direct (conjugated) bilirubin testing evaluates the portion of bilirubin that has already been processed by the liver and linked with glucuronic acid, making it water-soluble. This conversion enables its passage into bile and subsequent elimination through the intestines. Measuring the conjugated form helps distinguish liver disorders such as hepatitis or cirrhosis and bile duct blockages like gallstones or tumors from bilirubin increases caused by excessive red blood cell breakdown. It serves as an important indicator for assessing jaundice, bile flow, and the liver’s ability to excrete waste.

What It Indicates: Elevated direct bilirubin typically points to bile flow obstruction or liver diseases like hepatitis or cirrhosis.

7.Indirect (unconjugated) Bilirubin

Purpose: Measures bilirubin that has not yet been processed (conjugated) by the liver. Indirect bilirubin is formed when red blood cells break down and release hemoglobin, which is then converted into bilirubin before reaching the liver.

Details: Elevated indirect bilirubin can indicate excessive red blood cell breakdown (hemolysis), certain genetic conditions like Gilbert’s syndrome, or impaired bilirubin processing by the liver. It is typically assessed alongside total and direct bilirubin to differentiate between liver-related and non-liver-related causes of jaundice.

8. Albumin

Purpose: Albumin is the main protein synthesized by the liver.

What It Indicates: Low albumin suggests chronic liver disease, malnutrition, or kidney problems. Since albumin has a long half-life, reduced levels indicate long-standing liver dysfunction rather than acute injury.

9. Total Protein

Purpose: The total protein test measures the combined amount of albumin and globulins in the blood. These proteins are essential for maintaining fluid balance, transporting nutrients and hormones, supporting immune function, and ensuring proper blood clotting. Because the liver produces most blood proteins, total protein levels provide valuable insight into overall liver performance, nutritional status, and immune health.

Details:

Low Total Protein: May indicate chronic liver disease, kidney disorders (protein loss), malnutrition, or gastrointestinal conditions affecting absorption.

High Total Protein: Can suggest chronic inflammation, infections, or certain blood disorders like multiple myeloma.

Clinical Use: Often evaluated alongside albumin and globulin levels or the albumin-to-globulin (A/G) ratio to pinpoint the cause of abnormal protein values.

10. Prothrombin Time (PT/INR)

Purpose: Evaluates how quickly blood clots. The liver produces clotting factors necessary for this process.

What It Indicates: Prolonged PT or high INR suggests severe liver dysfunction, vitamin K deficiency, or effects of certain medications like warfarin. It’s a critical indicator of advanced liver disease.

11. Lactate Dehydrogenase (LDH) (less commonly used)

Purpose: LDH is an enzyme present in many tissues, including the liver.

What It Indicates: Elevated LDH is non-specific but may support other findings of liver injury or tissue damage elsewhere in the body.

Why Doctors Order LFTs

Diagnosis: To detect liver conditions such as hepatitis, fatty liver, or cirrhosis.

Monitoring: To track liver health when using medications or during treatment for liver disease.

Symptom Evaluation: To investigate jaundice, abdominal pain, fatigue, or unexplained weight loss.

Routine Screening: To assess liver function during annual health checkups or pre-surgery evaluations.

Summary

Liver function tests provide a detailed picture of liver health by measuring key enzymes, proteins, and pigments. Interpreting these results alongside symptoms, imaging, and medical history ensures accurate diagnosis and treatment planning. Regular LFT monitoring can detect liver issues early, improving outcomes and preventing complications.

 

 

Fibromyalgia

 What is Fibromyalgia?

Fibromyalgia is a long-term pain condition that leads to widespread discomfort in the muscles and soft tissues. It is often accompanied by fatigue, sleep difficulties, and problems with memory or focus (commonly called “fibro fog”). Unlike diseases that damage joints or tissues, fibromyalgia changes the way the brain and nervous system process pain signals, making normal sensations feel much more painful.

Common Symptoms

• Widespread Pain – Aching, throbbing, or burning pain felt throughout the body, which may shift from place to place.
• Fatigue – Constant exhaustion, even after adequate rest.
• Sleep Problems – Difficulty falling asleep, frequent waking, or sleep that doesn’t feel refreshing.
• Cognitive Issues (“Fibro Fog”) – Poor concentration, forgetfulness, and mental sluggishness.
• Other Symptoms – Headaches, digestive problems such as IBS, sensitivity to temperature, light or noise, as well as anxiety and depression.

Causes and Risk Factors

The exact cause is unclear, but several factors are thought to play a role:

• Central sensitization – the brain and nerves become overly sensitive to pain signals.
• Genetic tendency – fibromyalgia may run in families.
• Possible triggers – physical injury, infections, stress, or other health problems.
• Risk factors – more common in women, usually diagnosed between ages 20–50, and seen more often in people with conditions such as rheumatoid arthritis or lupus.

How It’s Diagnosed

There isn’t a single test for fibromyalgia. Doctors typically make the diagnosis by:

• Confirming widespread pain lasting more than 3 months.
• Checking for tender points in multiple areas of the body.
• Ruling out other conditions such as thyroid disorders or arthritis.

Management and Treatment

Fibromyalgia cannot be cured, but symptoms can be reduced and controlled with a mix of treatments:

Medications

• Pain relievers – such as acetaminophen, NSAIDs, or tramadol.
• Antidepressants – including duloxetine and amitriptyline, and other SSRI which may ease pain and improve sleep.
• Anti-seizure medications – like pregabalin and gabapentin, which help reduce nerve pain.

Lifestyle Strategies

Regular exercise – gentle activities like walking, swimming, or yoga.

Better sleep habits – keeping a consistent schedule, creating a restful environment, and limiting caffeine.

Stress reduction – techniques such as meditation, mindfulness, or cognitive behavioral therapy (CBT).

Healthy diet – emphasizing anti-inflammatory foods while cutting back on sugar and excessive caffeine,

Avoid smoking, over thinking.

Conclusion

Fibromyalgia is a long-term condition that, while not life-threatening, can significantly affect daily life due to persistent pain, fatigue, and cognitive issues. Early recognition, proper management, and lifestyle adjustments can greatly improve quality of life. With the right support and treatment, people living with fibromyalgia can manage symptoms effectively and maintain a healthier, more active life.

 Left Lower Quadrant Abdominal Pain

Abdominal pain is one of the most frequent complaints in clinical practice, and when the discomfort is localized to the left lower quadrant (LLQ), it often points toward conditions involving the colon, urinary tract, or reproductive organs. A clear understanding of the anatomy and careful evaluation help in reaching the right diagnosis and guiding effective management.

 Structures Found in the LLQ

The organs and tissues located in the LLQ include:

Digestive tract: Descending colon, sigmoid colon, rectum, and sometimes portions of the small intestine.

Urinary tract: Left ureter and part of the bladder.

Reproductive system (female): Left ovary, left fallopian tube, and surrounding ligaments.

Other tissues: Blood vessels, lymph nodes, and abdominal wall muscles.

 Main Causes of LLQ Pain

 Digestive System Disorders

Diverticulitis: The most frequent cause in adults. It occurs when small pouches in the colon (diverticula) become inflamed or infected, leading to steady LLQ pain, fever, and bowel habit changes.

 

Irritable Bowel Syndrome (IBS): A functional disorder that produces recurrent abdominal pain, bloating, diarrhea, or constipation without structural disease.

 

Colitis: Inflammation of the colon from infections, ischemia, or chronic inflammatory conditions such as Crohn’s disease or ulcerative colitis. Often associated with diarrhea(some times mix with blood) and cramps.

 

Colon polyps: rectal bleeding, alteration in bowel habits, cramping.

  

 Constipation or Fecal Impaction: Can trigger cramp-like pain and abdominal fullness.    

Hernias: Inguinal or femoral hernias may cause localized LLQ discomfort, especially if strangulated.

    Urinary Tract Causes

Kidney/Ureter Stones: Cause sharp, colicky pain radiating to the groin, sometimes with blood in the urine.

Urinary Tract Infection (UTI): May produce burning urination, urgency, frequency, and suprapubic or LLQ discomfort.

    Gynecological Causes (Women)

Ovarian Cyst (torsion or rupture): Presents with sudden, intense LLQ pain, often with nausea or vomiting.

Ectopic Pregnancy: A dangerous condition when a fertilized egg implants in the fallopian tube. Symptoms include severe pain, vaginal bleeding, and shock if ruptured.

 

Pelvic Inflammatory Disease (PID): Infection of the reproductive organs that causes pelvic pain, fever, and abnormal vaginal discharge.

    Other Causes

Musculoskeletal Issues: Abdominal wall strain can mimic visceral pain.

Referred Pain: Problems such as testicular torsion, hip disorders, or even chest conditions may radiate pain to the LLQ.

Mesenteric ischemia    

  Diagnose LLQ Pain

   A structured evaluation helps identify the root cause:

History – Character of pain, duration, associated symptoms (fever, bowel or urinary changes, menstrual history).

Physical Exam – Abdominal palpation, pelvic exam (in women), and rectal exam for tenderness or bleeding.

 

Tests and Imaging:

Blood tests: CBC, CRP,ESR, blood sugar, renal function,

Urine tests: Check for infection or blood.

Pregnancy test (β-hCG): Essential in women of childbearing age.

Ultrasound: Useful for pelvic or urinary causes.

CT abdomen/pelvis: Gold standard for diverticulitis, stones, or abscesses.

MRI: Sometimes used in pregnancy or complex pelvic disease.

    Management Strategies

     Digestive Causes

Diverticulitis: Antibiotics, rest, clear liquid diet for mild cases; hospitalization and surgery for complications.

Colon polyps: colonoscopy, surgery.

IBS: Diet changes (fiber-rich or low-FODMAP diet), stress reduction, antispasmodics.

Colitis: Treatment depends on cause—antibiotics for infection, steroids for IBD, IV fluids for ischemic colitis.

Constipation: Increased fiber and fluids, laxatives, enema if required.

    Urinary Causes

UTIs: Treated with antibiotics, pain relief, and hydration.

Stones: Managed with painkillers, hydration, and medications to aid passage; surgery or lithotripsy for  large stones.

    Gynecological Conditions

Ovarian cyst complications: Urgent surgical evaluation.

Ectopic pregnancy: Emergency treatment surgery

PID: Antibiotic, analgesic therapy, sometimes requiring hospital admission.

    Supportive Care

 

Adequate hydration, IV fluid. urinary catheter.

Pain control with NSAIDs or paracetamol.

Nutritional support during recovery.

Close monitoring for complications like perforation, abscess, or sepsis.

 When to Seek Emergency Care

    Immediate medical help is required if any of the following occur:

Sudden, severe, or worsening LLQ pain.

High fever or chills.

Vomiting that prevents fluid intake.

Blood in stool or urine.

Dizziness, fainting, or signs of shock.

Positive pregnancy test with abdominal pain.

 Summary

Pain in the left lower quadrant can stem from digestive, urinary, or reproductive conditions, ranging from mild constipation to life-threatening emergencies such as ectopic pregnancy or perforated diverticulitis. A systematic approach with history, examination, and targeted investigations is essential. Early diagnosis and tailored management not only relieve pain but also prevent serious complications.