 Hello everyone, this is Dr. Ushaal Kumar and today I will be speaking on an important disease abdominal tuberculosis, the great masquerader and USG to the rescue. Let's go in for some data first. In 2018, WHO reported 10.2 million cases of TB. The death figure was around 1.2 million. Interesting part is India has approximately one fourth of the disease burden as per 2018 data. So India is one of the leading countries affected by tuberculosis. Abdominal tuberculosis compounds to about 10 to 20 percent of total load. Objective of this presentation is to highlight the important role of ultrasound in diagnosing abdominal cox, which is a great masquerader. Many patients are often left undiagnosed due to the lack of proper diagnostic work up or follow. Tuberculosis is endemic in Asia and Africa and it is reemerging in the western world along with HIV AIDS. The rates are rising, are consistent with the overall trend. TB poses a diagnostic challenge because many a times features are non-specific, they can lead to diagnostic delays and can lead to multiple complications too. So a high index of suspicion is an important factor for early diagnosis. Abdominal involvement can occur in the GI tract, the peritoneum, the lymph nodes or the phallid wethera which is rare. The spread is further aided by poverty, overcrowding and drug resistance. So again early diagnosis is the key. Most patients which are diagnosed and are put on AKT respond very well and surgeries required in minority of the case only. One more telling ground reality in the Indian subcontinent is the lack of resources and affordability to carry out diagnostic tests. Therefore today in this scenario I propose the liberal use of ultrasound and ultrasound guided procedures as the first line of diagnostic repertoire. Ultrasound technology has moved from leaps and bounds, excellent high frequency linear probes and unparalleled resolution even at greater depths are now the USP of most machines. Good spatial resolution, cost effectiveness, reproducibility and being easily available even in the remotest areas gives ultrasound an edge. To maximize the ultrasound machine capability we have to just take care of these 4-5 factors. These are the transducer frequency, proper adjustment of the depth, focus, gain and the most important factor is spatial compounding. Most common abdominal symptom is abdominal pain, constipation, diarrhea, fever and aneroxia also are very important systemic complaints. Now classification of tuberculosis, I won't go into the details of these. I'll just go into the peritoneal classification. Peritoneal classification is divided into three types. The wet acetic type where there is copious amount of free fluid and can be loculated to. The fixed fibrotic type where you can get multiple plaques and you can also get loculations and septae. The dry and the plastic type where you get fibrotic strands which are irregular but there is no free fluid generally. I'll just go into 4-5 commonly seen types of abdominal tuberculosis at my clinic. Symmetrical thickening of the peritoneum and misentry, acitis which it can be clear, echogenic or loculated. Symmetrical bowel wall thickening, most commonly the IC junction involvement. Enlargement of lymph nodes with low attenuation that is hypoechoic and occasionally there can be multiple matted lymph nodes which can be seen as the hallmark of cox many a times. Multiple plaques or nodular lesions in the misentry can also be seen with complicated cox and rarely surface nodularity or visceral organ involvement mainly deliver. Misentric disease is an important manifestation of early stage of abdominal cox. Initially it is thickened with few discrete lymph nodes. In the latest stage however there could be irregular inflammatory masses with increased ecogenicity. Ultrasound offers a distinct advantage in demonstrating features with adequate visualization of the normal and disease misentry. Misentric lymph nodes generally show hypo attenuating features which could suggest areas of necrosis which are classic to granular matters disease but they are not specific because they can be seen in necrotic metastasis. The momentum involvement can also be cake like or nodular and may appear similar to peritoneal carcinomatosis which is one of the differential diagnosis. In the list of differential diagnosis of peritoneal disease things which come close to misentric cox can be misinus carcinomatosis, pseudomixoma peritoneal, peritoneal meds, misentric fibromatosis and sclerosis misentritis. I would not like to go into the details of all these. Whenever the gastrointestinal tract is involved, neural thickening of the IC junction is the most common sight that is a textbook picture we have learned all our lives. However, circumferential bowel wall thickening which can involve the ilium or the IC junction is not uncommon in cox and can mimic diseases like Crohn's disease which is common differential diagnosis. So, how would you like to differentiate the two? Mostly in cox there is multiple enlarged lymph nodes which can be necrotic, there is a mental involvement which can be a cogenic and thickened or cake like and there is a cytos. All these which are go in favor of cox and also IC junction involvement is more common in cox whereas, secom involvement is rare in Crohn's disease. Four figures which show the circumferential wall thickening of the terminal ilium and the secom. There is an atypical case case and routine where the secom as well as the proximal ascending colon was involved and the diagnosis was confirmed in colonoscopy to be cox. Mated lymph nodes with internal breakdown, this is case one. Here you can see multiple hypoechoic lymph nodes which are in close vicinity to each other and interspaced hyper echoic misentry suggestive of mated lymph nodes. Classic of cox. Here is case number two. In this case we can see there are multiple mated small bowel and as you can see there is copious amount of acitis and multiple small loculated areas of acitis with multiple septae also. The third case is an interesting case where you can see all the things which are common in cox. Echogenic misentry, abnormal nodes, thickened bowel loop which are inflamed and acitis. So all features of a cox in one case. This is very interesting case. If you can see there is minimal free fluid. However, the diagnosis which was clinched on this lining which was abnormal along the peritoneum, thickened peritoneum. We discussed cake like nodularity. This is one case where there was extreme amount of acitis and multiple areas of cake like echogenic areas arising from the misentry suggestive of omental nodularity seen with cox. We discussed iliocecal cox. Now this image is a panoramic view of a classic icy junction cox where we can see the thickened cecum the terminal ilium classic cox. These upper two images show sub hepatic and intra hepatic involvement in proven case of cox. The lower set of three images. The first two show hypo attenuating lymph nodes. The first one showing internal breakdowns of necrosis. The last image showing inflamed peritoneum also a feature of cox. These are two panoramic again panoramic images of diffuse ecogenic omental thickening seen in the entire abdomen in the space between the cell small bowel with associated free fluid. Both were proven case of cox. Two common differential diagnosis of ecogenic misentry are omental infarct appendicitis loike and divertic loites which is a very uncommon differential diagnosis. This is a case where there is focal ecogenic omentum in close proximity to the distal end of the descending colon. As it is seen very close to the colon diagnosis of appendicitis epiploic was suggested. There are no other signs of tuberculosis in the abdomen. This was a case of appendicitis epiploic close to the descending colon. The site is very important descending colon. Okay this case there is similar finding of ecogenic omentum but it is close to the liver and the right kidney. So it is in the right hypochondrium. It is a lady who is a 40-year-old lady with focal pain in the right hypochondrium. This is a classic case of omental infarct. There is no other differential diagnosis. So I had reviewed basically retrospectively 43 patients from January 2017 to July 2018 who had signs of abdominal cox who were diagnosed on ultrasound. Most of them were proven on ultrasound guided intervention or other biochemical or surgical tools. So this study showed definitive diagnosis was reached in 38 cases. There were five who were treated empirically. Common features in abdominal cox of these patients were free fluid omental thickening lymphodionopathy and omental flux. Okay, diagnosis was reached in most of these cases commonly by ascetic tapping, biopsy and FNA. Very few of them required either a colonoscopy, surgery or biochemistry. So being a real-time test, ultrasound guided procedures like ascetic tapping, nodal and omental biopsies can help in getting a tissue diagnosis. I will just show a few cases I have done. This is a case of abnormal ecogenic omentum with free fluid but true fluid was not tapable. So I did omental biopsies. Okay, you can see here the gun. This is the case where there is a very small pocket of fluid. So very acutely I took a spinal needle and tried to aspirate everything which was there in the pelvis. Came out to be cox. Okay, third case is interesting because though it's a simple cox node, it is in very close proximity to the right kidney. So had to be careful but ultimately could get a good chunk of the node and we could get to a diagnosis of cox. Okay, one important thing whenever we tap fluid from the pelvis and if there is omental thickening or the fluid is in the deep pocket, try using a spinal needle, put it entirely into the ascetic fluid, remove the distillate and try to aspirate. Now I'll just give you a small example. If there is a small pelvic collection, free fluid, omental plaque or omental disease or a peritoneal node, here a USG guided procedure would be more helpful and advisable than use of profession. So for example, a patient turns at 3 p.m. to do a USG. You had a clear cut free fluid, say free fluid in the pelvis. We call up the consultant. Please go ahead with the aspiration. You do a guided aspiration to get a result faster and it is cost effective. Okay, one note I would like to put here is whenever you do for elderly patients with comorbidities or biopsy or FNA, try getting the bleeding and clotting times first before you go to make it. One more important tip, if you are suspecting abdominal coughs and you might not get enough material from the abdominal for diagnosis, always scan the CP angles and the neck before you let the patient go. You might get a sizable effusion or a large node where you can get a sample from. To conclude, I would say ultrasound still remains the most robust initial modality of choice. Diagnose abdominal coughs including nodal and peritoneal disease. Its ubiquitous availability improved resolution as a cost effective tool in the primary diagnosis of abdominal coughs without overuse of cross-section. Advancement in probe technology has also given unparallel resolution in diagnosing equivocal cases with pinpoint accuracy.