Ileocecal tuberculosis is the most common site of gastrointestinal tuberculosis, which in turn is the third most common site of extrapulmonary tuberculosis.
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Pathology
Three morphological types of ileocecal tuberculosis are known:
- ulcerative
- hypertrophic
- ulcerohypertrophic
Radiographic features
Ultrasound
Ultrasound is non-specific but may show cecal wall thickening and/or lymphadenopathy.
Fluoroscopy
Barium study
- acute-to-subacute stage
-
Fleischner sign:
- narrowing of the terminal ileum
- thickening and gaping of the ileocecal valve
- thickening and hypermotility of the cecum
- Stierlin sign: acute-on-chronic
-
Fleischner sign:
- chronic stage
- ileocecal valve appears fixed, rigid and incompetent
- cecum appears conical in shape and shrunken in size
- pulled-up cecum (away from the right iliac fossa) due to fibrotic changes in the mesocolon
CT
- circumferential wall thickening of terminal ileum and cecum
- asymmetric thickening of the ileocecal valve
- mesenteric lymphadenopathy with central low attenuation areas
- involvement of other organs (e.g. lung)
Differential diagnosis
General imaging differential considerations include:
-
Crohn disease
- more terminal ileal involvement compared with tuberculosis, which has more pronounced cecal involvement
- less/no ascites
- vascular engorgement and fibrofatty proliferation of mesentery
- cecal carcinoma (colorectal carcinoma)
- eccentric cecal wall thickening
- evidence of metastatic disease
-
small bowel lymphoma
- very thick (>2 cm thickness) bowel wall
- lack of stricturing
- associated lymphadenopathy +/- hepatosplenomegaly
- amoebic colitis
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