Value of diagnostic laparoscopy in tuberculous peritonitis

Visual Diagnosis of Pleural Tuberculosis and its Association with Tissue Biopsy, Culture and Xpert Assay

INTRODUCTION

 The diagnosis of pleural tuberculosis remains a clinical challenge due to the paucibacillary nature of disease. Medical thoracoscopy remains the gold standard in diagnosing tuberculous pleuritis.

OBJECTIVE

 To establish the diagnostic yield of sago-seed thoracoscopic appearance of pleura in tuberculosis and its correlation with histopathology, tissue AFB culture and tissue Xpert MTB/Rif assay.

METHODS

 All consecutive patients with lymphocytic exudative pleural effusion, who fulfilled inclusion criteria of the study underwent medical thoracoscopy under local anesthesia and pleural tissue was sent for histopathology, AFB culture and Xpert MTB/Rif assay. Chronic granulomatous inflammation on histopathology and response to anti-tuberculous treatment was taken as reference standard for diagnosis of tuberculous pleurisy.

RESULTS

 A total of 249 patients were included in the study, out of which 168 had effusion secondary to tuberculosis. Sago-like nodules visualized on thoracoscopy had a sensitivity of 58.9 %, specificity of 92.6 % and diagnostic accuracy of 69.88 % for pleural tuberculosis. There is a strong association between the presence of sago-like nodules and detection of mycobacterium tuberculosis on Xpert MTB/Rif assay and AFB culture of pleura (p-value 0.007).

CONCLUSION

 Sago seed nodules on pleura have a high positive predictive value for tuberculous pleurisy. In high endemic countries patients with this finding on thoracoscopy can be commenced on anti-tuberculous treatment before histopathology or culture results are available.

Diagnosis of Abdominal Tuberculosis: The Importance of Laparoscopy

Abdominal tuberculosis (TB) tends to present with non-specific features and can be hard to diagnose. In the University Hospitals of Leicester, which serve a large immigrant population, 36 patients had this diagnosis between 1995 and 2001. We examined their records to identify features, including history, clinical presentation, investigations and diagnostic procedures, that might help with diagnosis of future cases. 32 of the patients were of Asian origin, predominantly from the Indian subcontinent. The most common presenting complaints were abdominal pain and weight loss. On clinical examination the findings were non-specific. Only 2 patients were found to have concurrent pulmonary TB. The most consistent laboratory finding (>90%) was a low haemoglobin with a raised C-reactive protein. The tuberculin test (Mantoux) was positive in only 7 patients (22%), and Ziehl-Neelsen staining of ascitic fluid was negative in all 11 patients in whom it was examined. An ultrasound scan of the abdomen revealed findings consistent with TB in 9/28 patients and a CT scan was helpful in 6/11. Laparoscopy, although usually performed as a last resort, proved the most effective investigation, yielding the diagnosis in 23 (92%) of the 25 patients in whom it was performed. In patients with the relevant background and clinical history, laparoscopy is the investigation of choice.

Role of ascites adenosine deaminase in differentiating between tuberculous peritonitis and peritoneal carcinomatosis

AIM: To investigate the usefulness of tumor markers and adenosine deaminase in differentiating between tuberculous peritonitis (TBP) and peritoneal carcinomatosis (PC).

METHODS: A retrospective analysis of data was performed on consecutive patients who underwent peritoneoscopic and abdominal computed tomography (CT) evaluations. Among 75 patients at the Seoul National University Hospital from January 2000 to June 2010 who underwent both tests, 27 patients (36.0%) and 25 patients (33.3%) were diagnosed with TBP and PC, respectively. Diagnosis was confirmed by peritoneoscopic biopsy.

RESULTS: Serum c-reactive protein (7.88 ± 6.62 mg/dL vs 3.12 ± 2.69 mg/dL, P = 0.01), ascites adenosine deaminase (66.76 ± 32.09 IU/L vs 13.89 ± 8.95 IU/L, P < 0.01), ascites lymphocyte proportion (67.77 ± 23.41% vs 48.36 ± 18.78%, P < 0.01), and serum-ascites albumin gradient (0.72 ± 0.49 g/dL vs 1.05 ± 0.50 g/dL, P = 0.03) were significantly different between the two groups. Among tumor markers, serum and ascites carcinoembryonic antigen, serum carbohydrate antigen 19-9 showed significant difference between two groups. Abdominal CT examinations showed that smooth involvement of the parietal peritoneum was more common in the TBP group (77.8% vs 40.7%) whereas nodular involvement was more common in the PC group (14.8% vs 40.7%, P = 0.04). From receiver operating characteristic (ROC) curves ascites adenosines deaminase (ADA) showed better discriminative capability than tumor markers. An ADA cut-off level of 21 IU/L was found to yield the best results of differential diagnosis; sensitivity, specificity, positive predictive value, and negative predictive value were 92.0%, 85.0%, 88.5% and 89.5%, respectively.

CONCLUSION: Besides clinical and radiologic findings, ascitic fluid ADA measurement is helpful in the differential diagnosis of TBP and PC.

Pelvic tuberculosis mimicking advanced ovarian malignancy

We sought to identify the characteristic features of pelvic tuberculosis (TB) in women with symptoms and sonogaphic findings which were otherwise consistent with an ovarian malignancy. This study is a retrospective analysis of 138 women who underwent an operation and had a preoperative diagnosis of ovarian malignancy at the Government Medical College Hospital, Chandigarh, from January 2004 to January 2008. Among these 138 women, seven cases (5.7%) of pelvic TB were identified. Abdominal pain and distension were the most common presenting symptoms. All patients had a pelvic mass, six had ascites (85%) and five had a fever (71%). The mean cancer antigen (CA) 125 level was 295 IU (13-529). Pelvic TB can present with symptoms and signs which mimic ovarian malignancy. Therefore, a high-index of clinical suspicion should be maintained when treating patients in countries with a high prevalence of TB.

The spectrum of abdominal tuberculosis in a developed country: a single institution's experience over 7 years

BACKGROUND

The incidence of human immunodeficiency virus (HIV) infection is rising, and as a result, tuberculosis (TB) has become a resurgent problem in many developed countries.

OBJECTIVES

The aim of this study was to review the spectrum of abdominal TB and its surgical management in our institution.

METHODS

A retrospective review of all abdominal TB cases notified to the health authorities by our institution from Jan 01 to Oct 07 was performed.

RESULTS

There were 57 patients (37 men) with abdominal TB, with a median age of 47 (range 14-74) years. Active pulmonary TB was present in 27 patients (47%). Positive HIV status was present in 30% and untested in 58%. The majority of patients underwent computed tomography scans (n = 50, 88%). The main radiological findings included bowel thickening, lymphadenopathy, ascites, free gas suggestive of perforation, and abscesses. The diagnosis of TB was confirmed on microbiological and/or histological examination in 72%, while the remaining 28% were diagnosed based on the clinical presentation and radiological imaging. All patients were commenced on anti-tuberculous therapy. TB involved the small or large bowel in 33 patients, mesenteric lymphadenopathy in 24, peritoneum in 13, spleen in seven, pancreas in two, anus in two, and the liver in two. Disseminated (including pulmonary) TB occurred in 27 patients (47%), while isolated intra-abdominal TB occurred in the remaining 30 patients (53%). Twenty-five patients (44%) underwent surgery--16 laparotomies (six perforated viscus, five intestinal obstruction, three suspected malignancies, and two for suspected acute abdomen), five laparoscopic procedures (four diagnostic, one gastrojejunostomy bypass for gastric outlet obstruction), two appendectomies, one drainage of abscess, and one anal fistulotomy.

CONCLUSIONS

Although TB is eminently treatable medically, surgery is still often required for suspected or confirmed abdominal TB presenting with acute complications or as atypical diagnostic problems. The role of laparoscopy is likely to be more significant in future in the management of abdominal TB.

Clinical review of 23 patients with tuberculous peritonitis: presenting features and diagnosis

OBJECTIVE

To better identify which clinical, laboratory, radiological and invasive procedures were most useful in diagnosing tuberculous peritonitis and to assess the methods in order to reach the diagnosis in future cases.

METHODS

Tuberculous peritonitis cases diagnosed between 2000 and 2006 were reviewed retrospectively. Their clinical presentation, physical examination, laboratory and diagnostic methods were evaluated.

RESULTS

Twenty-three cases oftuberculous peritonitis were diagnosed. The mean age of the patients were 30 +/- 11 years and 16 were women. The mean duration of symptoms prior to diagnosis was 3.6 months. All patients presented with abdominal pain. Abdominal swelling (91.3%), loss of appetite (87%) and weight loss (82.6%) were the other commonest symptoms. The major physical findings were ascites (78.3%) and fever (60.9%). The serum ascites albumin gradient was < 1.1 g/dL in all. An ascites fast bacilli smear was positive in 12 (52.2%) patients. Skin tests with purified protein derivative, adenosine deaminase and polymerase chain reaction were performed in seven, four and five patients, respectively. The tuberculous culture was positive in only two. The most common radiological findings were ascites (100%) and omental involvement (65.2%). A laparoscopy was performed in nine of 23 patients. A total of 22 patients completed anti-tuberculous therapy successfully and were cured, except one with cirrhosis.

CONCLUSION

Tuberculous peritonitis may be fatal but is medically cured if diagnosed in a timely fashion. Although both non-invasive and invasive tests have additional benefits, clinician suspicion is still the first step for the diagnosis of tuberculous peritonitis.

Systematic review: tuberculous peritonitis--presenting features, diagnostic strategies and treatment

The peritoneum is one of the most common extrapulmonary sites of tuberculous infection. Peritoneal tuberculosis remains a significant problem in parts of the world where tuberculosis is prevalent. Increasing population migration, usage of more potent immunosuppressant therapy and the acquired immunodeficiency syndrome epidemic has contributed to a resurgence of this disease in regions where it had previously been largely controlled. Tuberculous peritonitis frequently complicates patients with underlying end-stage renal or liver disease that further adds to the diagnostic difficulty. The diagnosis of this disease, however, remains a challenge because of its insidious nature, the variability of its presentation and the limitations of available diagnostic tests. A high index of suspicion is needed whenever confronted with unexplained ascites, particularly in high-risk patients. Based on a systematic review of the literature, we recommend: tuberculous peritonitis should be considered in the differential diagnosis of all patients presenting with unexplained lymphocytic ascites and those with a serum-ascites albumin gradient (SAAG) of <11 g/L; culture growth of Mycobacterium of the ascitic fluid or peritoneal biopsy as the gold standard test; further studies to determine the role of polymerase chain reaction, ascitic adenosine deaminase and the BACTEC radiometric system for acceleration of mycobacterial identification as means of improving the diagnostic yield; increasing utilization of ultrasound and computerized tomographic scan for the diagnosis and as a guidance to obtain peritoneal biopsies; low threshold for diagnostic laparoscopy; treatment for 6 months with the first-line antituberculous drugs (isoniazid, rifampicin, ethambutol and pyrazinamide) in uncomplicated cases.

TUBERCULOUS PERITONITIS IN NO RISK PATIENTS: DIAGNOSTIC APPROACH

BACKGROUND

Incidence of tubercoulosis is increasing in Western countries particularly in immigrants from endemic areas and in patients with HIV or immunocompromised. The disease is unusual in patients without risk factors. In these conditions the diagnosis of tuberculous peritonitis is often delayed, resulting in high morbidity and mortality.

METHODS

We describe a case of tuberculous peritonitis in a man suffering from ascites referred for presumed peritoneal carcinosis. The finding of no malignancies in the peritoneal fluid must rise the suspect of tuberculosis that, if misdiagnosed, is fatal. The patient was submitted to diagnostic videolaparoscopy and multiple biopsies were done. The definitive histological diagnosis was chronic granulomatous flogosis with giant cells, focally necrotizing, caused by peritoneal tubercolosis.

RESULTS

The patient was submitted to chemotherapy with isoniazide, rifampicine, piazafoline, ethambutol and streptomycine which determined the resolution of the clinical picture.

CONCLUSIONS

We believe the diagnostic procedure of choice is videolaparoscopy when tubercolous peritonitis is suspected. This technique allows to obtain selective biopsies of peritoneal nodules and to collect samples for specific cultural and cytohistological exams. The operation is safe, reliable with few complications and permits a prompt diagnosis necessary to cure the patient.

Laparoscopic diagnosis of peritoneal tuberculosis

BACKGROUND

The value of laparoscopy in diagnosing peritoneal tuberculosis (TB) is well described by gastroenterologists but infrequently by surgeons. This report describes a single surgeon's experience with laparoscopic diagnosis of peritoneal TB.

METHODS

A total of 21 consecutive patients with peritoneal TB diagnosed at laparoscopy from January 1995 to December 2002 were prospectively reviewed. Their clinical data, laparoscopic findings, and outcome are described.

RESULTS

There were 11 females and 10 males; the mean age was 36.6 years. Fever (81%) and ascites (66.7%) were the most common clinical features. Laparoscopy under general anesthesia was successful in all patients, and there was no laparoscopy-related mortality. Histology confirmed TB in 17 patients; the remaining four had nonspecific inflammation. All had satisfactory response to anti-TB therapy except one patient with systemic lupus erythematosus, who died after initiation of treatment.

CONCLUSIONS

Laparoscopy is safe and readily establishes the diagnosis of peritoneal TB.

Tuberculose péritonéale de l'enfant : à propos de deux cas

Peritoneal tuberculosis is an uncommon presentation of extra-pulmonary tuberculosis in children. It usually presents as ascites, abdominal pain, anorexia and weight loss.

CASES REPORT

We report two adolescent patients who presented with ascites, fever, weight loss and abdominal distension. In one case, the diagnosis was late, and confirmed by ascites culture. In the second case, a laparoscopy was performed and showed whitish nodules involving the entire abdominal cavity, compatible with peritoneal tuberculosis, later confirmed bacteriologically.

CONCLUSION

Peritoneal tuberculosis presents with nonspecific symptoms. Because laboratory investigations may not be helpful, diagnosis may be difficult. Peritoneal-fluid adenosine deaminase (ADA) determination and coelioscopy seem to be the best way to make a rapid diagnosis.

Tuberculous peritonitis of the wet ascitic type: clinical features and diagnostic value of image-guided peritoneal biopsy

BACKGROUND

Abdominal tuberculosis is still a medical problem in developing countries.

AIMS

To analyse the clinical, laboratory, ultrasonography and computed tomography findings and to discuss the diagnostic approach of 19 patients with peritoneal tuberculosis.

PATIENTS

Nineteen patients diagnosed in our department, with peritoneal tuberculosis (8 female, 11 male; mean age: 47.89 +/- 4.3 years) between 1996 and 2002, were studied retrospectively.

METHODS

All clinical, laboratory, radiological findings, and diagnostic methods were reviewed.

RESULTS

The most common symptoms and signs of the disease in these patients were abdominal pain, ascites, weight loss and night sweats. On conducting skin test, eight patients (42%) were found to be positive, while all the patients had elevated serum cancer antigen 125 levels, but acid-resistant bacilli could not be demonstrated on the direct preparation. In three patients (15.78%), the ascitic fluid culture was positive. The most common ultrasonographic and computed tomographic findings were ascites, septation in the ascites, peritoneal thickening, mesenteric and omental involvement. An abnormal chest X-ray, suggestive of previous tuberculosis was present in three patients. Diagnosis was made by image-guided percutaneous peritoneal biopsy in 18/19, and by histological examination of biopsy specimens obtained via laparoscopy in 1/19. Laparoscopy was only performed in 1 of the 19 patients due to lack of sufficient material for histological diagnosis by percutaneous biopsy. Of the biopsy specimens, 84% revealed caseating granulomas, while 16% were non-caseating. Acid-fast bacilli were seen on the Ziehl-Neelsen stain in 18 patients.

CONCLUSIONS

Peritoneal tuberculosis should be considered in the differential diagnosis of exudative ascites. Image-guided percutaneous peritoneal biopsy seems to be a sufficient, safe and inexpensive method for diagnosis of peritoneal tuberculosis.

Diagnosis of abdominal tuberculosis: the importance of laparoscopy

Abdominal tuberculosis (TB) tends to present with non-specific features and can be hard to diagnose. In the University Hospitals of Leicester, which serve a large immigrant population, 36 patients had this diagnosis between 1995 and 2001. We examined their records to identify features, including history, clinical presentation, investigations and diagnostic procedures, that might help with diagnosis of future cases. 32 of the patients were of Asian origin, predominantly from the Indian subcontinent. The most common presenting complaints were abdominal pain and weight loss. On clinical examination the findings were non-specific. Only 2 patients were found to have concurrent pulmonary TB. The most consistent laboratory finding (>90%) was a low haemoglobin with a raised C-reactive protein. The tuberculin test (Mantoux) was positive in only 7 patients (22%), and Ziehl-Neelsen staining of ascitic fluid was negative in all 11 patients in whom it was examined. An ultrasound scan of the abdomen revealed findings consistent with TB in 9/28 patients and a CT scan was helpful in 6/11. Laparoscopy, although usually performed as a last resort, proved the most effective investigation, yielding the diagnosis in 23 (92%) of the 25 patients in whom it was performed. In patients with the relevant background and clinical history, laparoscopy is the investigation of choice.

Indication for peritoneal biopsy in tuberculous peritonitis

BACKGROUND

With the introduction of effective antituberculous chemotherapy, the clinical outcome of tuberculous peritonitis depends much on the diagnostic accuracy of this disease entity. This review summarizes the current state-of-the-art thinking regarding the protean manifestation and diagnostic modalities of this major infectious disease.

DATA SOURCES

This review was compiled after an extensive search of the current and historical literature, comprising 1,070 cases of tuberculous peritonitis. A number of important areas were highlighted, with emphasis on the diagnostic value and clinical impact of peritoneal biopsy.

CONCLUSIONS

We believe an aggressive diagnostic approach, particularly with peritoneal biopsy, is warranted for the diagnosis and timely treatment of tuberculous peritonitis.

A peritoneal dialysis patient with fatal culture-negative peritonitis. Case Discussion

Culture-negative peritoneal inflammation accounts for between 5 and 20% of cases of peritonitis in peritoneal dialysis patients. Diagnostic yields may be enhanced considerably by reculturing dialysate effluents using appropriate collection methods and optimal laboratory techniques (including prolonged low-temperature and anaerobic incubations). In patients with persistent culture-negative peritonitis, consideration should be given to the possibilities of unusual or fastidious microorganisms (especially fungi and mycobacteria) and non-infective causes (especially drug reactions, malignancy, visceral inflammation and retroperitoneal inflammation). In this paper, an illustrative case of persistent culture-negative peritonitis is presented followed by a discussion of the investigative approach to such patients, with particular emphasis on differential diagnosis and the limitations of currently available tests.

Tuberculous peritonitis-associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples

We identified 60 cases of tuberculous peritonitis during the past 12 years at our health care center. Most of the patients had severe underlying medical conditions, such as cirrhosis, renal failure, diabetes mellitus, and malignancy. Abnormal chest radiograph findings, ascitic fluid lymphocytosis, and biochemical findings for exudates could only identify 33%, 37%, and 53% of the cases, respectively. On the other hand, peritoneal biopsy allowed early definitive diagnosis for 9 patients. Thirty-one patients died, 26 of whom died < or =6 weeks after their initial presentation, often before the result of mycobacterial culture was available. Only 8 patients died of advanced disease after antituberculous therapy was started. Univariate analysis showed that advanced age, underlying diagnosis, and delayed initiation of therapy were associated with higher mortality rates. Standard antituberculous chemotherapy is highly effective. However, conventional microbiologic diagnostic methods are slow and not sensitive enough for establishing a diagnosis of tuberculous peritonitis.

Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems

OBJECTIVE

To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis.

METHODS

Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features.

RESULTS

The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment.

CONCLUSION

Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.