Multimodality imaging of abdominal tuberculosis: a practical guide for radiologists

Abdominal tuberculosis remains diagnostically challenging because its imaging appearances are heterogeneous and frequently overlap with inflammatory and malignant conditions. This review illustrates the spectrum of multimodality imaging abdominal tuberculosis across organ systems and provides practical, pattern-based guidance to support confident radiological suspicion, appropriate differential diagnosis, and selection of confirmatory tests. Across the reviewed literature, abdominal tuberculous lymphadenitis is the most frequent manifestation, which typically appears as lymph nodes with central necrosis and peripheral enhancement on contrast-enhanced CT and MRI. Peritoneal tuberculosis is the second most common presentation and often presents in three patterns: an ascitic (wet) pattern, fibrotic disease, and a less common dry pattern. Gastrointestinal involvement most frequently affects the ileocecal region and is characterised by short-segment concentric mural thickening, a gaping ileocecal valve, and associated necrotic mesenteric lymphadenopathy. Solid organ tuberculosis most often involves the liver and spleen, typically demonstrating miliary microgranulomas or macronodular granulomas. Recognition of characteristic combination, particularly necrotic lymphadenopathy with typical distribution, smooth peritoneal thickening with omental/mesenteric involvement, and preferential ileocecal disease, can substantially increase diagnostic confidence in the appropriate clinical context. Imaging features that favour tuberculosis over key mimics include necrotic nodal disease and peritoneal involvement in the differential diagnosis of Crohn’s disease, and a lack of upstream ductal dilatation in focal pancreatic tuberculosis when compared with pancreatic ductal adenocarcinoma. Imaging plays an important role in mapping disease extent, identifying complications, guiding image-directed sampling, and supporting treatment planning and follow-up, though the evidence underpinning many of these applications derives predominantly from observational series and expert consensus.