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SEMINAR
Peritoneal tuberculosis
La tuberculose péritonéale
a
Service de chirurgie générale, CHU Habib Bourguiba, 3029 Sfax, Tunisia
b
Service des maladies infectieuses, CHU Hédi Chaker, 3029 Sfax, Tunisia
c
Service d’anatomie pathologique, CHU Habib Bourguiba, 3029 Sfax, Tunisia
Summary The peritoneum is one of the locations outside the most common pulmonary tuber-
culosis. Peritoneal tuberculosis poses a public health problem in endemic regions of the world.
The phenomenon of migration, the increased use of immunosuppressive therapy and the epi-
demic of AIDS have contributed to a resurgence of this disease in regions where it was previously
controlled. The aim of this review is to expose the clinical, biologic end radiologic futures of
the peritoneal tuberculosis and to present the methods of diagnosis and treatment. The diag-
nosis of this disease is difficult and still remains a challenge because of its insidious nature,
the variability of presentation and limitations of available diagnostic tests. The disease usually
presents a picture of lymphocytic exudative ascites. There are many complementary tests with
variable sensitivities and specificities to confirm the diagnosis of peritoneal tuberculosis. Isola-
tion of mycobacteria by culture of ascitic fluid or histological examination of peritoneal biopsy
ideally performed by laparoscopy remains the investigation of choice. The role of PCR, ascitic
adenosine deaminase, interferon gamma and the radiometric BACTEC system can improve the
diagnostic yield. An antituberculous treatment with group 1 of the WHO for 6 months is sufficient
in most cases.
© 2010 Elsevier Masson SAS. All rights reserved.
Résumé Le péritoine est l’une des localisations extrapulmonaire les plus fréquentes de
la tuberculose. La tuberculose péritonéale pose un problème de santé publique dans cer-
taines régions endémiques du monde. Le phénomène de migration, l’utilisation plus fréquente
d’immunosuppresseurs et l’épidémie du sida ont contribué à une réapparition de cette maladie
dans les régions où elle était précédemment contrôlée. Le but de cette mise au point est de
dégager les particularités cliniques, biologiques et radiologiques de la tuberculose péritonéale
et de présenter les moyens de diagnostic et les modalités thérapeutiques. Le diagnostic de
cette maladie est difficile et demeure un défi en raison de sa nature insidieuse, de la variabilité
0399-8320/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.gcb.2010.07.023
Peritoneal tuberculosis 61
Table 2 Sensitivity, specificity and threshold values of ADA in some studies reported in the literature.
for induration at the injection site, if the subject is Gene amplification by ligase chain reaction (LCR)
ill [64]. It is a molecular amplification test recently introduced into
The positivity of the TST is not specific for active tubercu- medical practice. According to Gamboa et al. [73], this
losis, but merely reflects an awareness by prior contact with method has a sensitivity of 77.7%, specificity of 98.7% and a
the MT. Its interpretation varies depending on the immune negative predictive value of 95.2% for the diagnosis of extra
status of patients, history of vaccination, contagion or pri- pulmonary tuberculosis; its diagnostic effectiveness is then
mary infection. Similarly, the sensitivity of this test is low; significantly higher than that of PCR. Unfortunately, this test
false negatives are reported in 15% to 60% in the literature is still very expensive and therefore difficult to insert in
[65,66]. practice especially in endemic countries.
Figure 1 Free high-density ascites with thickening of the pari- Figure 2 Tuberculous granuloma consisting in giant cells of
etal peritoneum (arrow). Langhans-type, epithelioid cells, histiocytes and eosinophils.
• the ascites, which typically has a high density (25 to 45 However, face to atypical macroscopic PT, we should
HU) [82,83], but at an early stage it may have a fluid always evoke the peritoneal carcinomatosis, which typi-
density [84,85] (Fig. 1); cally includes peritoneal nodules of varying sizes, irregular,
• lymph nodes, which usually have hypodense center [84] inverted, retractable, preferably located on the diaphragm
corresponding to the caseating with hyperdense rim but and/or in the pelvis with a non-inflammatory peritoneum.
can also be calcified [86];
• thickening of the mesentery and omentum [87—89];
The pathological study of biopsies
• regular and uniform thickening of the peritoneum [84,89]
Histologically, typical lesions of tuberculosis is represented
(Fig. 1);
by the tuber, which corresponds to caseating epithe-
• agglutination of the intestinal loops [85,89].
lioid granuloma containing multi-nucleated giant cells
‘‘Langhans-type’’, epithelioid histiocytes and lymphocytes
The surgical biopsies forming a ring surrounding a central area of caseous necrosis
(Fig. 2).
Surgical approach
They remain the ultimate means to confirm the diagnosis Percutaneous biopsy
of PT-related histological proof. These biopsies are typ-
ically done by laparotomy or in recent years ideally by
Liver biopsy
laparoscopy. They must interest the peritoneum zones,
A granulomatous liver disease may be associated with peri-
which contain nodular lesions. The feasibility of laparoscopy
toneal involvement in varying proportions ranging from 25%
in the exploration of ascites is well established [90—93].
to 48% [38,72,95]. For some authors, liver biopsy must be
Cumulative data from 402 patients in 11 studies, reported
systematic face to any suspicion of PT, it would provide,
at a recent systematic review, showed rates of sensitivity
in some cases, the only evidence of tuberculous etiology
and specificity of 93% and 98% respectively [22]. In addition,
without resorting to invasive procedures [96].
laparoscopy is a surgical approach that gives less parietal
prejudice and less postoperative pain than laparotomy. It
also allows the reduction of hospital stay and quicker reha- Peritoneal biopsies
bilitation. This is a new minimally invasive method with little or no
The complications rate of laparoscopy biopsies is around complications and could allow to obtain very good results.
2.7%; the most common are intestinal perforations and Vardareli et al. [47] reported 19 cases of PT with ascites
bleeding from wounds of large vessels [11,93] especially (fibro-adhesive forms excluded) of which 18 were diag-
in the fibro-adhesive forms [24]. Therefore the diagnostic nosed by peritoneal biopsy under percutaneous radiological
laparoscopy in case of exudative ascites should be entrusted guidance. Thus, this method could avoid the drawbacks
to an experienced surgeon. of surgery, and preliminary results seem very encouraging.
Studies on a larger scale trials will help to confirm the contri-
bution of this new diagnostic procedure.
Macroscopic findings
The macroscopic appearance of PT is typical when we find
regular white granules with equivalent sizes (1 to 3 mm), Treatment
numerous nodules, dispersed and friable at biopsy, hyper-
emia of the peritoneum, filamentous (or rope) peritoneal The treatment of PT is medical. The delay in initiating treat-
adhesions and clumping of bowel loops with fibrin deposition ment may increase mortality. Chow et al. [35] reported a
[94]. significant deterioration in clinical status of over 80% of
66 A. Guirat et al.
patients during the exploration period. The overall mortality because of its clinical polymorphism. Assays of LDH, SAAG
in this study was 35%, whereas in the subgroup of patients and glucose have a specificity that is too low. PCR tests
with underlying cirrhosis mortality reached 73%. The aver- are expensive and have low sensitivity. The research of MT
age mortality rate according to the cumulative data from in the ascites fluid is insensitive; culture in liquid media
18 studies, which included more than 800 patients was 19% such as BACTEC radiometric system improves the diagnos-
[14]. This underlines the importance of establishing appro- tic sensitivity in a reasonable timeframe. The dosage of
priate treatment as soon as possible. the ADA is a quick test, reproducible with excellent sen-
The antituberculosis drugs were classified into first and sitivity and specificity for the diagnosis of PT. It should
second line. Currently, WHO has divided them into five be used routinely in endemic countries. It is the same for
groups. The first-line drugs are a group 1 of WHO: isoniazid gamma interferon, which has a very high sensitivity and
(INH), rifampicin (RIF), pyrazinamide (PZA), ethambutol specificity. The determination of CA-125 would allow the
(EMB). Those of second-line bring together groups 2 to 5 assessment of therapeutic response. The ideal peritoneal
of the WHO [97]. biopsies performed by laparoscopy can confirm the diag-
The currently recommended protocol combines four nosis while avoiding the disadvantages of laparotomy. The
drugs INH, RIF, PZA and EMB given daily for 2 months, interventional radiology seems promising for the realization
relayed by 4 months of combination therapy INH and RIF of peritoneal biopsies. Treatment involves antituberculosis
[98]. Although the recommended duration of treatment of drug of group 1 according to the WHO during 6 months.
PT is 6 months, some authors have reported treatment dura-
tion to 12 months [29]. There is however no evidence to
Conflict of interest statement
hold a treatment time beyond 6 months. Some retrospec-
tive series have used different regimens of 6 or 9 months,
and found that the majority of their patients has responded The authors have not declared any conflict of interest.
to treatment similarly [43,47]. One study compared two dif-
ferent durations of treatment (9 months and more than 12 Acknowledgments
months) and found no significant difference in terms of ther-
apeutic response in either group [99]. The authors would like to thank Pr Ben Amar
The favorable response to treatment results in the res- Mohamed (benammed@yahoo.fr) and Mrs Ahlem Fendri
olution of symptoms and the disappearance of ascites. (ahlem fendri@yahoo.fr) for their precious help in the
Laboratory abnormalities in favor of disease activity will usu- translation of the manuscript and for her constant support.
ally normalize within 3 months after starting the treatment
[22].
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