Peritoneal Tuberculosis

Julie A. Taub

Epidemiology

Extra-pulmonary Tuberculosis
100
Extra-Pulmonary 17.5 %
Peritoneal 3.3 % Meningeal 4.6 % Miliary 7.3 % Other 9.8 % Bone/Joint 9.8 %

80

Percent

60

Genitourinary 11.9 %

40
Pulmonary 82.5 %

Pleural 23 %

20
Lymphatic 30 %

Adapted from Mandell, et al.

All Cases

All Extra-pulmonary Cases

Results from
Direct spread from
Lymph nodes Intraabdominal organs
small intestine (esp terminal ileum, cecum) fallopian tube

Hematogenous spread from

Primary pulmonary TB Miliary TB
1, 3

Risk Factors
Case series involving 60 patients
38% Cirrhosis 33% Renal Failure with Peritoneal Dialysis 27% Diabetes Mellitus 18% Underlying Malignancy 10% Systemic Corticosteroids 2% AIDS 12% No Risk Factors
4

Clinical Picture

Clinical Presentations
A. Plastic Type:

Tender abdominal masses Doughy abdomen Less common Ascites +/- Peritonitis Mass formation of omentum Matting of bowel loops
7, 9

B. Serous Type:

C. Fibrotic Type:

Clinical Presentation
Ascites Ascites develops from the exudation of proteinaceous fluid from the tubercles Similar mechanism in peritoneal carcinomatosis

Signs/ Symptoms
Case series involving 145 patients
73% Abdominal swelling (ascites) 54% Fever and night sweats 44% Weight loss 36% Abdominal pain

Roughly 50% +PPD 18% both pulmonary & abdominal TB 8

Diagnosis

Laboratory Findings
Anemia
(mild normocytic, normochromic)

Elevated CA-125
Can use to follow treatment response Confused with peritoneal carcinomatosis

3, 6

Ascitic Fluid
Gross Appearance:
Clear, turbid, hemorrhagic, chylous

Protein > 25 SAAG <1.1 RBC 7% WBC 150-4000 (lymphocytosis)

1, 3

Ascitic Fluid
Adenosine Deaminase

Purine-degrading enzyme Assists with maturation and differentiation of lymphoid cells Allows for preliminary diagnosis
2, 3

Ascitic Fluid
Adenosine Deaminase
Cut-off value of 30 U/L 94% Sensitive 92% Specific

Decreased Sensitivity Cirrhosis Decreased Specificity Malignant Ascites

2, 3

Ascitic Fluid
AFB Smear 0-6% Sensitive

AFB Culture 0-8% Sensitive

4, 5

Surgery
Gross Appearance
Diffuse peritoneal, omental and mesenteric involvement (+/-) adnexal mass

Peritoneal Biopsy
85-95% Sensitive Performed by - laparoscopic guidance - minilaparotomy - exploratory laparotomy
4, 10

Case:

Diagnostic Laparoscopy

Acid Fast Staining of the Biopsy

Microbiology:
All specimens are concentrated Fluorescent stain (Auramine Rhodamine)
More sensitive

Pathology:
Small section from biopsy (e.g. 5 microns) Ziehl-Neelsen Stain
Less sensitive

Acid Fast Staining

Auramine Rhodamine
(Microbiology Method)

Ziehl-Neelsen
(Pathology Method)

Microscopic features:
Caseating Granulomas Langerhans Type Giant Cells Rare: Noncaseating Granulomas
Case report
Madhavi et al.

Case series (24 patients with Peritoneal TB)

76% caseating granulomas 20% non-caseating granulomas 4% non-specific findings
5, 6

Case:

Biopsy

Case:

Biopsy

Imaging: CT
Peritoneum
Smooth and uniform thickening If nodular, think Peritoneal Carcinomatosis

Omentum
Smudged, omental cake or nodular

Mesentery
Range from linear soft tissue strands to soft tissue masses

Lymphadenopathy
2/3 of patients with abdominal TB
9

Case

Treatment
Same treatment as pulmonary TB Four drug regimen:
Isoniazid Rifampin Ethambutol Pyrazinamide

Corticosteroids controversial

References
1. 2. Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL. Principles of Internal Medicine, 15th edition. McGraw-Hill, USA, 2001. Burgess LJ, Swanepoel CG, Talijaard JJF. The use of adenosine deaminase as a diagnostic tool for peritoneal tuberculosis. Tuberculosis 2001; 81(3), 243-248. Byrnes V, Chopra S. Tuberculous peritonitis. www.UpToDate.com 2004. Chow KM, et al. Tuberculous peritonitis-associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. Clinical Infectious Disease Aug 2002; 35, 409-413. Demir K, et al. Tuberculous peritonitis reports of 26 cases, detailing diagnostic and therapeutic problems. European Journal of Gastroenterology & Hepatology 2001; 13, 581-585.

3. 4.

5.

References
6. Mahdavi A, Malviya VK, Herschman BR. Peritoneal tuberculosis disguised as ovarian cancer: An emerging clinical challenge. Gynecologic Oncology 2002; 84, 167-170. Mandell GL, Bennett JE, Dolin R. Mycobacterium tuberculosis. Principles and practice of infectious disease, Fourth edition. Churchill Livingston, USA, 1995. Manohar A, et al. Symptoms and investigative findings in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy and biopsy over a five year period. Gut Oct 1990; 31(10), 1130. Suri S, et al. Computed tomography in abdominal tuberculosis. The British Journal of Radiology Jan1999; 72, 92-98. Zaidi ANH, Conner M. Disseminated peritoneal tuberculosis mimicking metastatic ovarian cancer. Southern Medical Journal Dec 2001; 94(12), 1212-1214.

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