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Clinics and Research in Hepathology and Gastroenterology (2011) 35, 60—69

SEMINAR

Peritoneal tuberculosis
La tuberculose péritonéale

A. Guirat a,∗, M. Koubaa b, R. Mzali a, B. Abid a, S. Ellouz c, N. Affes a,


M. Ben Jemaa b, F. Frikha a, M. Ben Amar a, M.I. Beyrouti a

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

Available online 6 January 2011

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

∗ Corresponding author. BP 12 bureau de poste, Jadida, 3027 Sfax, Tunisia.


E-mail address: ahmedguirat@yahoo.fr (A. Guirat).

0399-8320/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.gcb.2010.07.023
Peritoneal tuberculosis 61

de sa présentation et des limites des examens de diagnostic disponibles. Cette pathologie se


manifeste habituellement par un tableau d’ascite exsudative à prédominance lymphocytaire.
Il existe une panoplie d’examens complémentaires dont la sensibilité et la spécificité sont
variables pour confirmer le diagnostic de tuberculose péritonéale. L’isolement d’une mycobac-
térie par culture du liquide d’ascite ou de la biopsie péritonéale idéalement réalisée par voie
laparoscopique représente l’examen de choix. Le rôle de la PCR, l’adénosine désaminase asc-
itique, l’interféron gamma et le système radiométrique de BACTEC permettent d’améliorer le
rendement diagnostique. Un traitement pendant six mois avec des antituberculeux du groupe
1 de l’OMS est suffisant dans la plupart des cas.
© 2010 Elsevier Masson SAS. Tous droits réservés.

Introduction the peritoneum. An immune response occurs usually and


the evolution is generally towards healing. However, some
Described for the first time in 1843 [1], peritoneal tuber- bacteria remain quiescent in the peritoneum for months
culosis (PT) is due to the development of Koch’s Bacillus or years. Several causes may reduce the defenses of the
(KB) in the peritoneum. It is a disease that poses a public organism and can cause the reactivation of the bacilli and
health problem in endemic areas. The PT risks to evolve into their multiplication [5,6];
complications such as septicemia, acute intestinal occlu- • by ruptured retroperitoneal and mesenteric lymph, which
sion and infertility in women. The diagnosis of this disease nodes into the peritoneal cavity resulting in the formation
is a challenge; the absence of specific clinical signs, the of caseous foci partitioned by fibrosis in places adhering to
lack of paraclinical tests with high predictive value and the the intestinal loops. These secondary foci are formed fol-
pauci-bacillary nature of this disease make the diagnosis of lowing the ingestion of the bacteria crossing the intestinal
tuberculosis often based on histological study of biopsies of mucosa to the lymph of the peritoneal cavity or following
peritoneum performed ideally by laparoscopy. hematogenous spread as the first mechanism [7—9];
• from lesions in adjacent organs such as intestine or the
fallopian tubes [10—12];
Pathogenesis • by direct contamination of the peritoneum in patients
with chronic renal failure under peritoneal dialysis [13].
Pathogenic agent

PT is caused by several species of Gram-positive bacteria


known as Mycobacterium tuberculosis complex (M. tuber- Mechanism of ascites formation
culosis, M. africanum, M. bovis, M. caprae, M. microti, M.
pinnipedi. . .). They are united in the same unit for genetic In PT, ascites usually results from peritoneal lymphatic
similarities reasons. These bacteria belong to the family of obstruction caused by a blocking of the peritoneal fluid
Mycobacteriacea and the order of Actinomycetales: they are reabsorption [14]. Rarely, ascites may result from portal
characterized by a thick wall, which is rich in fat giving them hypertension secondary to portal vein compression by tuber-
special dyeing properties and a relative resistance to many culous lymph nodes but the characteristics of ascites are so
antiseptics (soda, acid, detergent. . .). The mycobacterium different [10,15,16].
is 2 to 5 microns in length, very sensitive to heat but resis-
tant to cold and desiccation, colored red by the fuchsin, not Epidemiology
discolored by nitric acid or alcohol from where the nomina-
tion of acid-fast bacillus-resistant (AFB). It grows in aerobic
In recent years, there has been an increase in the total
strictly between 35 and 37 C on enriched media including
number of new cases of tuberculosis. The World Health Orga-
that of Lowenstein-Jensen [2].
nization (WHO) has estimated that the number of new cases
‘‘Atypical’’ mycobacteria are bacteria present in the
of PT disease in 2007 was about 9.27 million. This repre-
environment and usually non-pathogenic, but which may be
sents an increase from 9.24 million cases in 2006, 8.3 million
responsible for peritoneal mycobacteriosis. Mycobacteruim
cases in 2000 and 6.6 million cases in 1990. Most of the esti-
avium complex is the most common cause of mycobacterio-
mated cases in 2007 were recorded in Asia (55%) and Africa
sis in immunosuppressed patients (AIDS) [3,4].
(31%), a small proportion of cases in the Eastern Mediter-
ranean Region (6%), the European Region (5%) and Region of
Modes of contamination the Americas (3%). Of the 9.27 million new cases in 2007, an
estimated 1.37 million (15%) were suffering from AIDS, 79%
Mycobacteria can infect the peritoneum by different mech- of these patients came from the African Region and 11% of
anisms: the Southeast Asia Region [17].
The PT remains a public health problem in endemic areas.
• hematogenous spread of bacilli from a primary pulmonary It represents 1% to 2% of all localizations of tuberculosis
site of tuberculosis infection to secondary foci such as [18] and 31% to 58% of abdominal localizations [19—21]. It
62 A. Guirat et al.

is associated with pulmonary tuberculosis in 3.5% of cases


Table 1 Frequency of various clinical signs of peritoneal
[22]. As in pulmonary tuberculosis where the incidence is
tuberculosis according to the literature.
higher among younger subjects between 25 and 44 years
in developing countries [23], the PT is typically observed in Clinical Signs Frequency (%)
young adults between the third or fourth decade [22,24]. For Ascites 35—100
some authors, the average age is even younger than 28 years [29—32,35,38,43,47,95,103]
[25]. A frequency among women was found in most published Abdominal pains 49—100
series. Neither pathogenic nor physiological explanation is [6,27,30,31,35,38,43,47,103]
advanced for this frequency. Isolated fever 52—76.1
[27,29,30,35,38,43,47,50,103,104]
Contributing factors Abdominal distension 62.5—73 [38]
Abdominal tenderness 47.7 [22]
Constipation 7.1—31 [32,35,38—40,44,99]
The factors favoring overall tuberculosis disease are:
Diarrhea 4.7—1.4
[22,29,30,39,40,44,99,103]
• the pandemic infection of acquired immunodeficiency
Hepatomegaly 2.3—8.2
virus [26,27]: about 9% of new cases of PT (31% in Africa)
[22,29,36,40,44,72,94,99,105,106]
had occurred among AIDS patients [25];
Splenomegaly 2.3—4.3
• the prolonged corcticosteroid [28];
[22,29,36,47,94,99,105]
• the low socio-economic conditions of poor living, poor
hygiene and overcrowding. The literature data suggest
that the incidence of the disease is particularly high in
[39,40]. The sedimentation rate is always increased but the
rural areas [22,29];
values do not exceed 60 mm per hour in more than half of
• treatment with TNF␣ (tumor necrosis factor) [30—32].
the cases [39].
Other predisposing factors for the occurrence of PT have
been reported in the literature such as: Analysis of ascetic fluid

• chronic renal failure on peritoneal dialysis [33]; Macroscopic


• the BCG therapy: use in bladder instillation of Bacil- In PT, ascites is usually yellow citrine. This characteristic is
lus Calmette-Guérin in the treatment and prevention of found in 77% to 91% of the cases [39,41]. The ascites fluid
recurrent superficial bladder carcinoma has been impli- may also take a cloudy appearance, chylous or hematic.
cated in outbreaks of PT [34];
• alcoholism and alcoholic cirrhosis [35,36]. Protein content
In PT, the exudative ascites is a quasi-constant [42], usually
with protein content higher than 30 g/l.
The clinical manifestations
Cellularity
PT is a subacute disease and its symptoms often evolve over
The ascites fluid of PT is often rich in cells (> 400 E/ml) with
a period of several weeks to months. The average consulta-
lymphocyte predominance (> 60%) [22,43]. A recent meta-
tion time compared to the first symptom varied between 2
analysis that included 39 English sets about PT has found a
and 4 months [29].
lymphocytic predominance in 68.3% of cases [22]. The pre-
This disease can be manifested by different clinical
dominance of neutrophils is sometimes found especially in
forms. The presenting symptoms of PT are unspecific, which
case of concomitant renal failure or in case of infection of
makes the diagnosis a challenge. Some clinical signs are
ascites with another common germ [22]. Thus, an exudative
frequently found in most series, such as ascites (most com-
ascites rich in lymphocytic cells is suggestive but not specific
mon clinical sign), abdominal pain, night sweats, fever and
of PT.
abdominal distension (Table 1). In most cases, the discovery
of PT is done during the waning of ascites. PT is diagnosed
in 6.6% of the ascites cases [37]. This rate can reach 65.5% Cytological study
during exploration of exudative ascites in an endemic area Cytological examination of the ascitic fluid must always
[38]. be performed to look for neoplastic cells indicating the
existence of carcinomatous ascites, which is the main dif-
ferential diagnosis of PT.
The diagnostic approaches
Biochemical of ascitic fluid
Assessment standard blood The literature review shows that no biochemical marker is
useful for the diagnosis of PT.
The standard blood test abnormalities are non-specific and LDH essay. Normally the rate of LDH in ascites is less than
therefore they have a low diagnostic value. A mild nor- half that of serum. In case of tuberculosis, a rate of LDH
mocytic normochromic anemia and thrombocytosis are the greater than 90 IU/l has a sensitivity ranging between 77%
main abnormalities [11,36,39]. The white blood cells rate and 90%, but a low specificity (14%) [22].Serum amino-acid
is generally normal, however lymphocytosis is often found gradient (SAAG)
Peritoneal tuberculosis 63

This gradient is calculated by measuring the difference CA-125 determination


between the concentrations of albumin in serum and in
ascites collected on the same day. It reflects the charac- Some authors have found that rates of CA-125 were high
teristic of exudative ascites when its value is greater than in both serum and ascites in the majority of patients with
11 g/l and portal hypertension when its value is greater exudative ascites whatever the etiology [53,54]. Other stud-
than 11 g/l [44]. This specificity for portal hypertension ies have reported high levels of this marker in both serum
is estimated at 97% [45]. A low gradient less than 11 g/l and ascites of patients with PT [55,56] and can therefore
was found in 100% of tuberculosis patients [43,46,47], be confused with ovarian carcinoma at an advanced stage.
but this sensitivity decreases in patients having an asso- Thus, a high rate of CA-125 should always evoke PT in differ-
ciated cirrhosis reaching values ranging from 29% to 88% ential diagnosis of ovarian carcinoma mainly among women
[26,43]. Besides specificity, it is low. Indeed, SAAG less living in endemic areas. In addition, the finding of a high CA-
than 11 g/l is also found in patients having carcinomatosis 125 in ascites rich in proteins in a woman may lead to a false
[43,47,48]. diagnosis of ovarian cancer and tuberculosis underrate.
Glucose determination. A low concentration of glucose in Moreover, several studies have noted that under quadru-
the ascites fluid may be in favor of PT [22,40]. However, data ple anti-tubercular drugs, after histological confirmation of
are insufficient to decide about the value of a systematic the PT diagnosis, the rate of CA-125 decreased gradually
assay. and returned to normal even after 1 to 2 months on average
Thus, assays of LDH, SAAG and glucose have a speci- [22,53,54,56,57]. Thus, the determination of CA-125 seems
ficity too low to be recommended for the diagnosis of useful for evaluating the therapeutic response of PT. This
PT. feature remains to be confirmed by prospective studies.

Microbiological study The determination of the activity of adenosine


Microscopy: search of Mycobacterium tuberculosis (MT). deaminase in ascites (ADA)
The microscopic diagnosis on a single smear made from the
crushed uses dye specific property of the wall of mycobac- Several studies have reported an increase of ADA in some
teria, which is acid-alcohol resistance. This is a quick body fluids in disorders that involve an immune reaction cell
technique that is also accessible. Due to the pauci-bacillary type such as tuberculosis, empyema, rheumatoid arthritis
nature of PT, microscopic examination has a sensitivity of and malignant lymphomas [58,59].
less than 10% [22,35,38,46,49]. In PT, the increase of adenosine deaminase may be the
Culture. The isolation of MT in the culture of ascitic fluid result of activation of T cells in response to mycobacterial
or in cell homogenates of biopsies confirm the diagnosis of antigens, on the threshold of 30 U/l and in the absence of
PT. immunosuppression or cirrhosis, this test has a sensitivity of
Solid culture medium. This test requires 10 to 50 ml of 96%, a specificity of 98% (Table 2), positive predictive value
ascites, ultra-centrifuged and then cultured on Lowenstein- of 95% and a negative predictive value of 98% [22,60,61]. It
Jensen medium. This method has a sensitivity of around 35% is a cheap and reproducible test.
[35,50]. The major drawback of culture is the time needed According to the recommendations of the Society of
to obtain the result. Indeed, the average time of bacterio- Pneumology in the French language for the management of
logical results is 45 days [22], which is not conforming to the tuberculosis in France published in 2004, the utility of the
requirements and urgent diagnosis. peritoneal assay of ADA depends more on economic and epi-
Liquid culture medium. The use of automated BACTEC demiological criteria than on its sensitivity or its specificity:
is a recent method allowing for more rapid detection of in endemic area where invasive techniques like laparoscopy
MT in an average of 14 to 27 days [22,35]. It is a radio- are not available or costly, the ADA is helpful. Elsewhere, the
metric system allowing the acceleration of the discovery ADA will be useful if positive, it confirms a clinical suspicion
of MT by reducing the culture time by half [51]. The of TB for inoperable patient [62].
time of bacteriological results is shortened to 15 days but In a recent meta-analysis that included four prospective
requires one liter of ascites ultra-centrifuged. This method studies reporting 264 cases of ascites, Riquelme et al. have
has a large positivity rate, which varies from 66% to 83%. shown that for a rate between 36 and 40 IU/L, the ADA has a
A comparative study of its use, compared to Lowenstein- sensitivity of 100% and a specificity of 97% for the diagnosis
Jensen medium on any type of sample showed a higher of PT [63]. The authors concluded that the determination
sensitivity of detection of MT as atypical mycobacteria of the ADA is a rapid and accurate test for the diagnosis
(100% versus 51.7%), a better specificity (94.7% versus of PT. In case of high rate, the introduction of empirical
78.9%) and a higher negative predictive value (100% ver- antituberculosis treatment is justified while waiting for the
sus 78.9%) [48]. However, this method is more expensive results of mycobacteria culture or biopsy [63].
than the solid culture medium, and it uses a radioactive
material, which poses a problem of manipulation. To over- Immunological tests
come these drawbacks, other non-radioactive culture media
have been developed with the same advantages of rapid Tuberculin skin test (TST)
growth [52]. These environments are used manually (BBL® The TST is testing cell memory response to mycobacterial
tube, MGITTM , MB Redox system) or via automated systems antigens. It explores the capacity of memory lympho-
(BP BACTECTM , 9000MB, BACTECTM MGITTM 960 Bac T/Alert cytes in the patient after stimulation with these antigens,
3DTM ). to secrete cytokines (IFN-gamma especially) responsible
64 A. Guirat et al.

Table 2 Sensitivity, specificity and threshold values of ADA in some studies reported in the literature.

Series Year Number Sensitivity (%) Specificity (%) Value (U/L)


Voigt et al. [107] 1989 41 100 96 112.6
Bhargava et al. [108] 1990 87 100 97 36
Ribera et al. [109] 1991 86 100 97 40
Soliman et al. [110] 1994 50 94.4 100 28
Sathar et al. [68] 1995 93 96 96 30
Brant et al. [111] 1995 44 100 92 31
Burgess et al. [60] 2001 178 94 92 30
El Abkari et al. [24] 2006 123 96 98 —
Riquelme et al. [63] 2006 264 100 97 39
Sharma et al. [112] 2006 119 97 94 58
Dewivedi [113] 2008 49 100 96.6 33

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.

Determination of gamma interferon Radiological explorations


It is a quantitative test that assesses the cell-mediated
immune response against MT. It is based on the fact that Abdominal ultrasounds
T cells secreting gamma interferon were necessarily aware Abdominal ultrasound can evoke some signs in favor of PT
in advance [22]. This assay has a sensitivity of 89% for the but cannot confirm diagnosis [74], and can follow the evo-
diagnosis of latent forms of PT [67]. Some authors advocate lution under treatment. The ascites is the most frequent
the measurement of gamma interferon coupled with that ultrasound sign (45% to 100% of cases) [75,76]. It is free in
of adenosine deaminase, thereby increasing their respec- most cases and appears as trans-sonic images in which the
tive sensitivity and specificity for the positive diagnosis of bowel loops float. Ascites may take echogenicity related to
tuberculosis [68]. According to Sathar et al. [68], the gamma its exudative nature [77]. Sometimes, the ascites is par-
interferon assay has a sensitivity of 93% and a specificity of titioned, which is an argument in favor of its tubercular
98% when the rate was 3.2 IU/ml, the sensitivity of adeno- origin and could predict technical difficulties during diag-
sine deaminase is 93% and its specificity is 96%, when the nostic laparoscopy. Other signs suggestive of PT can be
rate is 30 IU/l. Unfortunately this is not a common practice highlighted, such as the thickening of the peritoneum, the
test. Thus, the dosage of interferon gamma may be an alter- clumping of bowel loops side by side each other or to the
native diagnosis compared to surgery in countries with high anterior abdominal wall [78], peritoneal nodules that are the
endemic TB. equivalent of granulations sitting at the visceral and parietal
peritoneum [75,78,79], adhesions visualized as hypoechoic
linear structures in thin strips and floating in the tuberculosis
Determination of specific immunoglobulin peritoneal effusion [78,80], and the deep lymph nodes often
A recent review on the immunological diagnosis of tuber- described as hypoechoic multiple masses and sometimes
culosis has shown that the determination of IgG antibody confluent [75,76,80]. All these echographic signs taken sep-
response to 43-kDa antigen of MT in ascites had a high sen- arately have no diagnostic value in the PT. On the contrary,
sitivity approaching 100% and a specificity of 95.7% [69]. It their association should suggest the diagnosis [75]. How-
is a very expensive test performed in specialized centers. ever, the problem of differential diagnosis with peritoneal
carcinomatosis remains.

The molecular genetics


Computed tomography (CT)
Testing the polymerase chain reaction (PCR) This examination is often done through the assessment of
The reaction of gene amplification by PCR is a rapid test exploration of exudative ascites isolated in order to find a
to isolate the MT between 24 to 48 hours [70]. The use in primary tumor such as advanced ovarian cancer, the main
clinical practice of this technique is limited by high cost and differential diagnosis of PT [56,81].
low sensitivity (60% to 80%) [71,72]. The major CT signs suggestive of PT are:
Peritoneal tuberculosis 65

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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