Laparoscopic diagnosis of abdominal tuberculosis

A Case of Peritoneal Tuberculosis Mimicking Ovarian Cancer in a Young Female

Background

Tuberculosis causes significant morbidity and mortality globally. Peritoneal tuberculosis can have a similar presentation to ovarian cancer.

Case

We present a case of a 42-year-old female referred to gynecology oncology with imaging findings of enlarged right ovary, omental caking, and elevated CA-125 (1289 U/mL). A diagnostic laparoscopy revealed diffuse studding of intraperitoneal surfaces. Histopathological examination of omental and abdominal wall biopsies showed granulomas, but stains and cultures for mycobacteria were negative. Antimicrobial treatment for tuberculosis was initiated. Within eight weeks, there was clear clinical and radiographic improvement, consistent with a diagnosis of peritoneal tuberculosis.

Conclusion

This case highlights the importance of including peritoneal tuberculosis in the differential diagnosis when evaluating for ovarian cancer in women with epidemiologic risk factors for tuberculosis.

Diagnosis of abdominal tuberculosis: lessons learned over 30 years: pectoral assay

Diagnosing abdominal tuberculosis remains a great challenge even for experienced clinicians. It is a great mimicker that has unusual presentations. A high index of suspicion is essential for reaching its diagnosis. Clinical and radiological findings of abdominal tuberculosis are non-specific. Herein, we report the lessons we have learned over the last 30 years stemming from our own mistakes in diagnosing abdominal tuberculosis supported by illustrative challenging clinical cases. Furthermore, we report our diagnostic algorithm for abdominal tuberculosis. This diagnostic algorithm will help in reaching the proper diagnosis by histopathology or microbiology. Our diagnostic workup depends on categorizing the clinical and radiological findings of abdominal tuberculosis into five different categories including (1) gastrointestinal, (2) solid organ lesions, (3) lymphadenopathy, (4) wet peritonitis, and (5) dry/fixed peritonitis. The diagnosis in gastrointestinal tuberculosis and dry peritonitis can be reached by endoscopy. The diagnosis in solid organ lesions can be reached by ultrasound-guided aspiration. The diagnosis in wet peritonitis and lymphadenopathy can be reached by ultrasound-guided aspiration followed by laparoscopy if needed. Diagnostic laparotomy should be kept as the last option for achieving a histological diagnosis. Capsule endoscopy and enteroscopy were not included in the diagnostic algorithm because of the limited data of using these modalities in abdominal tuberculosis. They need special expertise, and rarely used in low- and middle-income countries. Furthermore, capsule endoscopy may cause complete intestinal obstruction in small bowel strictures. A definite diagnosis can be reached in only 80% of the patients. Therapeutic diagnosis should be tried in the remaining 20%.

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.

Peri and post-menopausal women with complex adnexal masses, ascites, and raised CA-125: Is it ovarian cancer or tuberculosis?

Pelvic and peritoneal tuberculosis may resemble advanced ovarian cancer due to the presence of ascites, complex adnexal masses, peritoneal deposits and raised CA-125 level, especially in peri- and postmenopausal women. Other common features among women with these two conditions are abdominal pain and distension, weight loss and reduced appetite. As the treatment of pelvic-peritoneal tuberculosis is completely different from that of ovarian cancer, it is important to reach a correct diagnosis. Sometimes women with pelvic-peritoneal tuberculosis may be subjected to a laparotomy for suspected ovarian cancer which is likely to increase their morbidity. In the present article, we report ten women in the peri- and post-menopausal age group where this diagnostic dilemma arose of whom seven were diagnosed only after a laparotomy had been performed for suspected ovarian cancer due to adnexal masses with ascites and raised CA-125 level. Ascitic fluid showing lymphocytic predominance, raised ADA level and absence of malignant cells are pointers to consider the possibility of pelvic- peritoneal tuberculosis, especially in endemic countries like India. In such situations, an effort should be made to obtain a cytological or histopathological diagnosis of either condition by ultrasound guided needle biopsy or laparoscopically obtained biopsy rather that proceeding with laparotomy for suspected ovarian cancer.

Tuberculosis peritonitis with features of acute abdomen in HIV infection

This case report introduces a 26-year-old male IV drug abuser with fever, abdominal pain and distension referred to the emergency ward. According to these findings, abdominal tenderness and involuntary guarding, an explorative laparotomy was performed. Multiple biopsies of omentum, peritoneum and liver were taken. Pathologic assessment of multiple biopsies confirmed intra-abdominal TB infection.

Tuberculous peritonitis presenting as an acute abdomen: a case report

Female genital tuberculosis is relatively rare and difficult to diagnose. Often it is mistaken for ovarian malignancy. We report a case of a young immigrant woman with acute abdominal pain.

Pitfalls of diagnostic laparoscopy in abdominal tuberculosis

BACKGROUND

Diagnostic laparoscopy currently is emerging as an important tool in the diagnostic armamentarium for abdominal tuberculosis (TB). However, the laparoscopic view may be deceiving even to the most experienced eyes, and it is not uncommon for TB to be diagnosed erroneously before the final histologic confirmation is received.

METHODS

A retrospective review of 20 diagnostic laparoscopies was conducted. The cases erroneously diagnosed at laparoscopy were collected and analyzed.

RESULTS

Five cases (20%) were identified. For two patients, the laparoscopic findings were thought to be those of carcinomatosis, but histology showed TB. For the other three patients, TB was suspected laparoscopically, but the final diagnoses were carcinomatosis, spontaneous bacterial peritonitis, and panniculitis. Two patients died: one due to delayed diagnosis and treatment of abdominal TB and the other due to carcinomatosis.

CONCLUSION

For a percentage of patients, the laparoscopic features of abdominal TB at diagnostic laparoscopy may be mistaken for other pathologies. Caution should be exercised before disclosure of the provisional diagnosis to the patient based on laparoscopy alone without histologic confirmation.

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.

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.

Peritoneal tuberculosis--an uncommon disease that may deceive the gynecologist

OBJECTIVES

To document women with peritoneal tuberculosis mimicking ovarian malignancy and to review pertinent literature.

STUDY DESIGN

The records of women with peritoneal tuberculosis who were managed at the Soroka Medical Center, Beer-Sheva, Israel between January 2000 and December 2001 were reviewed.

RESULTS

Four patients with peritoneal tuberculosis mimicking ovarian malignancy were encountered. Two presented with the classical symptomatology of advanced-stage ovarian carcinoma including ascites, abdominopelvic masses and elevated serum CA-125, and two presented with lower abdominal pain and adnexal mass. Laparoscopy in one patient and laparotomy in three patients revealed peritoneal tuberculosis and no malignancy. Of the three patients who had laparotomy, two underwent unnecessary extended surgery including total hysterectomy, bilateral salpingo-oophorectomy, omentectomy and bilateral pelvic lymphadenectomy, and one had conservative surgery including unilateral salpingo-oophorectomy. All patients were postoperatively treated with quadruple anti-tuberculosis chemotherapy.

CONCLUSIONS

Medical awareness of peritoneal tuberculosis is still lacking and many women with this disease are initially thought to have ovarian malignancy and undergo unnecessary extended surgery. Laparoscopy including biopsies seems to be a sufficient and safe method to provide diagnosis of peritoneal tuberculosis. If laparoscopy is not feasible, laparotomy should be performed. If no malignancy is detected and the diagnosis of peritoneal tuberculosis is confirmed, unnecessary extended surgery is avoided and anti-tuberculosis treatment is started.

Peritoneal tuberculosis: diagnostic options

BACKGROUND

Extrapulmonary tuberculosis has vague symptoms and few signs. It is essential to recognize and diagnose this curable disease prior to performing definitive surgery. Newer tests such as DNA or RNA amplification allow for early diagnosis but have limitations.

CASE

We report a case of peritoneal tuberculosis in an immigrant woman. She had vague symptoms of low-grade fever, mild abdominal pain, obstipation, and bloating. Diagnostic laparoscopy was performed to establish the diagnosis. Tuberculosis was confirmed by DNA extraction from the frozen section specimen with subsequent analysis using polymerase chain reaction.

CONCLUSION

Peritoneal tuberculosis is a disease that often simulates malignancies. With the increasing prevalence of human immunodeficiency virus in developed countries, tuberculosis is also on the rise and should be considered in the differential diagnosis of a patient with an abdominal/pelvic mass and ascites.

Peritoneal tuberculosis: diagnostic options

BACKGROUND

Extrapulmonary tuberculosis has vague symptoms and few signs. It is essential to recognize and diagnose this curable disease prior to performing definitive surgery. Newer tests such as DNA or RNA amplification allow for early diagnosis but have limitations.

CASE

We report a case of peritoneal tuberculosis in an immigrant woman. She had vague symptoms of low-grade fever, mild abdominal pain, obstipation, and bloating. Diagnostic laparoscopy was performed to establish the diagnosis. Tuberculosis was confirmed by DNA extraction from the frozen section specimen with subsequent analysis using polymerase chain reaction.

CONCLUSION

Peritoneal tuberculosis is a disease that often simulates malignancies. With the increasing prevalence of human immunodeficiency virus in developed countries, tuberculosis is also on the rise and should be considered in the differential diagnosis of a patient with an abdominal/pelvic mass and ascites.