Overview of Tuberculous Peritonitis
Tuberculous peritonitis is a chronic diffuse peritoneal infection caused by Mycobacterium tuberculosis. Common symptoms of tuberculous peritonitis include fever, night sweats, abdominal pain, abdominal distension, diarrhea, etc. This disease is caused by Mycobacterium tuberculosis infection. Depending on the condition of the disease, the choice of general treatment, drug treatment, surgical treatment, etc.
Definition
Tuberculous peritonitis is a chronic diffuse peritoneal infection caused by Mycobacterium tuberculosis.
Types
Tuberculous peritonitis can be categorized into 3 types based on pathological features, namely exudative tuberculous peritonitis, adhesive tuberculous peritonitis, and caseous tuberculous peritonitis. The first two types are mostly seen clinically.
Exudative tuberculous peritonitis
This type presents with peritoneal congestion, edema, often covered with fibrin exudate, and tiny yellowish-white or grayish-white nodules. This type tends to have a moderate amount of peritoneal fluid, usually straw-yellow, pale bloody, or celiac.
Adhesive tuberculous peritonitis
This type often presents with significant thickening of the peritoneum and mesentery, which is mainly due to the production of large amounts of hyperplastic fibrous tissue as well as large protein deposits. In some patients, intestinal obstruction may develop due to intestinal adhesions. This type of tuberculous peritonitis may coexist with exudative tuberculous peritonitis.
Caseous tuberculous peritonitis
This type usually evolves from the above two types of peritonitis and may have both of their pathologic features. The pathologic changes are mainly caseous necrotic lesions, which may further form tuberculous abscesses.
Pathogenesis
Tuberculous peritonitis is often a disease secondary to tuberculosis of the lungs or other parts of the body.
Tuberculous peritonitis can occur at any age, but is most common in young and middle-aged people and is about twice as common in women as in men.
Causes
Causes
Tuberculous peritonitis is caused by infection with Mycobacterium tuberculosis.
Typically, tuberculous peritonitis is secondary to tuberculosis elsewhere, such as tuberculosis of the lungs or bone, or in patients with a history of incomplete tuberculosis treatment.
Predisposing factors
Immunocompromised
For immunocompromised patients infected with Mycobacterium tuberculosis, it is easier to infect the peritoneum. Common conditions that cause immunocompromise include prolonged late nights, poor nutrition, insufficient exercise, and long-term use of immunosuppressive drugs.
Presence of tuberculosis in other parts of the body
When tuberculosis exists in other parts of the patient’s body such as pulmonary tuberculosis and bone tuberculosis, Mycobacterium tuberculosis can infect the peritoneum through the blood and lymphatic channels, thus causing tuberculous peritonitis.
Symptoms
Main Symptoms
Most of the patients with tuberculous peritonitis have a slow onset of the disease, and the early symptoms are mild, so it is not easy to be detected; a small number of patients have a rapid onset of the disease, and most of them are mainly characterized by acute abdominal pain or sudden onset of high fever.
Systemic symptoms
The more common ones are low or moderate fever, flaccid fever or episodic fever, accompanied by night sweats in some patients. Some patients may develop high fever with significant toxemia.
Abdominal pain
The nature of the pain is continuous or paroxysmal hidden pain, may occur in the umbilicus, lower abdomen or the whole abdomen. Some patients may have acute abdominal manifestations, mainly caused by caseous necrotic lesion rupture, acute perforation of intestinal tuberculosis, and so on.
Abdominal distension
One of the more common symptoms, patients will have abdominal distension.
Diarrhea and constipation
Stools tend to be paste-like, usually 3 to 4 times / day; some patients have alternating diarrhea and constipation.
Other symptoms
Patients with severe disease may suffer from malnutrition in the later stages of the disease, which is commonly manifested as emaciation, edema, and anemia. Some patients may have intestinal obstruction due to severe intestinal adhesions.
Consultation
Department of Medicine
Gastroenterology
For patients with fever, sweating, abdominal pain, bloating, diarrhea, etc., it is recommended that they consult the Department of Gastroenterology if they do not have tuberculosis in other parts of the body.
Infection Medicine
For patients with tuberculosis or intestinal tuberculosis, it is recommended to consult the Department of Infectious Diseases as they are often contagious.
Preparation
Preparation for consultation: registration, preparation of documents, FAQs
Tips for the doctor
If a patient has recently developed a low-grade fever or night sweats (sweating at night or in the late afternoon while sleeping), it is important to go to the hospital.
If diarrhea is present, it is recommended to record the amount and shape of the diarrhea and take good pictures.
If you have a contagious disease such as tuberculosis, it is recommended that you wear a mask when you go to the hospital.
Checklist for preparing for medical treatment
Symptom list
Its need to focus on the time of symptom onset, special manifestations, etc.
Is there any fever, night sweats (sweating at night or in the late afternoon while sleeping)?
When did the fever start? What was the highest temperature? Does the temperature change over time?
Do you have abdominal pain, bloating, or diarrhea?
When did these symptoms start?
Under what circumstances do these symptoms worsen or resolve?
Medical History Checklist
Is there any tuberculosis or intestinal tuberculosis?
Has anyone in the immediate surrounding close contact population had TB?
Checklist
Test results from the last six months, which can be brought to the doctor’s office
Imaging tests: chest CT, abdominal CT, abdominal MRI, abdominal ultrasound, etc.
Laboratory tests: routine blood test, routine urine test, tuberculin test and gamma-interferon release test, etc.
Diagnosis
Diagnosis is based on
Medical history
Possible history of tuberculosis.
There may be tuberculosis patients among close contacts.
Clinical manifestations
Symptoms
Fever, night sweats, abdominal pain, abdominal distension, diarrhea and other symptoms.
Some patients may present with malnutrition, emaciation, edema, and anemia.
Physical signs
Abdominal wall tenderness or abdominal mass can be palpated in some patients.
Some patients may present with abdominal effusion, abdominal distension, and positive mobile turbid sounds on percussion.
Laboratory Tests
Routine blood tests
Purpose: Blood tests are performed to determine whether the patient has anemia or infection.
Significance: In routine blood tests, some patients have increased white blood cell counts and lymphocytes.
Tuberculin test and γ-interferon release test
Purpose: To check the level of tuberculin and γ-interferon in patients.
Significance: A strong positive tuberculin test and a positive gamma-interferon release test are important for the diagnosis of the disease.
Abdominal fluid examination
OBJECTIVE: To examine the nature of the fluid in the abdominal cavity.
Significance:
An accumulation of fluid in the abdominal cavity, usually a small to moderate amount of fluid is most common. The color of the fluid is usually straw yellow, pale bloody, and occasionally celiac.
The specific gravity is usually more than 1. 018, the protein qualitative test is positive with a quantification of 30 g/L or more, and the leukocytes are high, usually more than 500 × 106/L, and are predominantly lymphocytes or monocytes.
Increased adenosine deaminase (ADA) activity is often detected in the peritoneal fluid of tuberculous peritonitis.
Plain bacterial cultures of the peritoneal fluid should be negative, and if positive for Mycobacterium tuberculosis is detected, this is important for the diagnosis of the disease.
Note: The bladder should be emptied before abdominal puncture.
Imaging
Abdominal X-ray
Purpose: To provide the basis for the preliminary diagnosis of the disease.
Significance: Abdominal X-ray can reveal calcified images of mesenteric lymph nodes. In addition, barium X-ray imaging can help to detect signs of intestinal adhesions and intestinal tuberculosis.
Precautions: Remove metal objects, such as necklaces and earrings, before the examination.
Abdominal CT, Abdominal Magnetic Resonance Imaging (MRI)
Purpose: To provide the basis for the diagnosis of diseases.
Significance: Abdominal CT and abdominal MRI can help to detect thickened peritoneum, abdominal fluid, intra-abdominal masses, etc., and can provide a better view of these lesions.
Precautions: Remove metal objects, such as necklaces and earrings, from the body before the examination.
Chest CT examination
Purpose: To help determine whether the patient has tuberculosis.
Significance: To help determine whether the patient’s tuberculosis is in an active stage.
Precautions: Remove any metal objects, such as necklaces and earrings, before the examination.
Laparoscopy
Purpose: To provide a basis for the diagnosis of the disease.
Significance: It is suitable for patients who have a large amount of fluid in the abdominal cavity, but without peritoneal adhesions. Generally, grayish-white nodules can be seen scattered on the surface of the peritoneum and omentum.
Precautions: Fasting and water should be prohibited before the examination.
Pathologic examination
Purpose: Pathologic examination is of confirmatory value in the diagnosis of tuberculous peritonitis.
Significance:
Exudative tuberculous peritonitis: the peritoneum is seen to be congested and edematous, fibrin exudates are often present on the surface of the peritoneum, and, sometimes, tiny yellowish-white and grayish-white nodules are seen.
Tuberculous peritonitis of the adherent type: significant thickening of the peritoneum and mesentery, which is mainly due to the production of a large amount of hyperplastic fibrous tissue, as well as a large amount of protein deposits.
Caseous tuberculous peritonitis: mainly caseous necrotic lesions with necrosis of mesenteric lymph nodes and further formation of tuberculous abscesses.
Precautions: fasting and water should be prohibited before taking pathological specimens.
Differential diagnosis
Tuberculous peritonitis is often differentiated from abdominal malignant tumors, cirrhosis, and acute peritonitis.
Malignant tumor of the abdominal cavity
Similarities: On abdominal examination, abdominal masses are found in all patients, and in severe cases, abdominal fluid is present, and mobile turbidities are usually positive.
Differences
In patients with tuberculous peritonitis, cancerous cells are often not found in the peritoneal fluid, but Mycobacterium tuberculosis is occasionally detected positively.
In patients with abdominal malignancy, tumor markers tend to rise and cancerous cells may be found on pathology. In the case of metastatic cancer, the patient will often have primary cancer foci in other parts of the body.
Cirrhosis
Similarities: Severe patients will have fluid in the abdominal cavity, and mobile turbidities are usually positive.
Differences
Patients with tuberculous peritonitis will test positive for Mycobacterium tuberculosis in the abdominal fluid.
In patients with cirrhosis, the skin is often jaundiced as well as spider nevi, and varicose veins can be observed on the chest wall as well as the abdominal wall. Most patients have hepatitis and a history of significant alcohol consumption.
Acute pancreatitis
Similarities: Patients will have severe abdominal pain, fever and other symptoms.
Differences
Serum amylase in acute pancreatitis tends to be elevated after the onset of the disease.
Imaging: In patients with acute pancreatitis, pancreatic enlargement can be observed on imaging, and indirect signs such as “sentinel loops” and “colonic cutting sign” can be observed.
Treatment
Aim of treatment: timely diagnosis and treatment, avoiding recurrence and preventing complications as far as possible.
Treatment principle: general treatment, puncture and drainage of abdominal fluid, and reasonable and sufficient course of anti-tuberculosis treatment, and surgery if necessary.
General treatment
Supplementary nutrition
Adjust the diet structure, eat less high oil and high fat food, and supplement more food rich in protein and vitamins.
Lifestyle adjustment
Pay attention to rest, refrain from heavy physical labor, and maintain appropriate daily exercise.
Medication
The principles of drug therapy for tuberculous peritonitis are early, regular, whole course, moderate dosage and combination. The current recommended anti-tuberculosis treatment regimen is rifampicin, isoniazid, pyrazinamide and ethambutol for 2 months, followed by isoniazid and rifampicin for 4 months, for a total course of 6 months.
Oral anti-tuberculosis drugs
Isoniazid
What the drug does: This drug is the single most bactericidal anti-tuberculosis drug in the early stages. It has bactericidal effect on both Mycobacterium tuberculosis inside and outside macrophages.
Medication precautions: Its common drug side effect is liver damage, and should be used under the guidance of a physician.
Rifampicin
Effects of the drug: It has a rapid bactericidal effect on Mycobacterium tuberculosis both inside and outside the macrophage, especially on the C-bacterium group with unique bactericidal effect.
Drug precautions: its common drug side effects are liver damage, should be used under the guidance of a physician.
Pyrazinamide
Effects of the drug: mainly kills the B flora in the acidic environment in macrophages.
Precautions for use: its common adverse drug reactions are high uric acid, liver damage, etc. It should be used under the guidance of a physician.
Ethambutol
The role of the drug: inhibit the reproduction of tuberculosis bacteria.
Precautions for use: common adverse drug reactions for optic neuritis, pediatric patients should be used with caution.
Streptomycin
Effects of the drug: bactericidal effect on Mycobacterium tuberculosis in the alkaline environment outside the macrophage.
Precautions for use: its common adverse reactions are ototoxicity, nephrotoxicity, etc. Use with caution in the elderly, children and pregnant women.
Glucocorticoid
Role of the drug: It mainly plays the role of anti-inflammatory and antitoxicity. It is used for people with serious symptoms of tuberculosis toxicity.
Common drugs: dexamethasone, prednisone and so on.
Precautions for use: Its common adverse reactions are peptic ulcer, osteoporosis, and should be used under the guidance of physicians.
Surgical treatment
Indications
Patients with complete intestinal obstruction.
Patients with mesenteric lymph node rupture.
Patients with perforated intestinal tuberculosis.
Commonly used surgical methods
Drainage of peritoneal fluid: For patients with a large amount of peritoneal fluid, in order to alleviate their symptoms, drainage of peritoneal fluid can be carried out appropriately.
Intestinal adhesion release: For patients with severe intestinal adhesions that lead to intestinal obstruction, intestinal adhesion release should be carried out in time to alleviate the symptoms of abdominal distension, vomiting, constipation, and so on.
Resection of diseased intestinal segment: For patients who have already suffered acute intestinal perforation, surgery should be carried out in time to remove the diseased intestinal segment, so as to improve the patient’s symptoms.
Contraindication
Presence of difficult to correct coagulation dysfunction, with obvious bleeding tendency.
Presence of severe infection with high fever.
Prognosis
Cure
The prognosis of tuberculous peritonitis is related to the patient’s own basic condition and the type of pathology.
In general, the prognosis is relatively good for patients in good health, best for patients with the exudative type, and worst for patients with the caseous type.
Patients with a combination of cirrhosis, AIDS, or long-term hormone therapy have a poorer prognosis.
Daily
Daily Management
Dietary management
In daily life, we should pay attention to a healthy diet and eat more protein-rich foods, such as fish, eggs and milk.
Consume more vitamin-rich fruits and vegetables, such as citrus, dragon fruit and spinach.
It is recommended to consume more foods rich in polyunsaturated fatty acids, such as olive oil and various nuts.
Life Management
Maintain a good routine and ensure sufficient sleep.
Maintain good exercise habits, such as walking and swimming.
Psychological support
Relieve mental stress: Patients are advised to engage in more stress-reducing activities to eliminate their fatigue and release the accumulated pressure.
Family care: Family members should care more about the patient, encourage the patient more and not make fun of the patient.
Maintain a good mindset: be optimistic, love life, and keep a beautiful good mood.
Learn to moderately reduce the pressure on yourself, do not have too much pressure in the daily life;
Learn to control their own emotions and reduce emotional fluctuations.
Health education
Educate patients to take medication regularly and on time as prescribed by the doctor.
Quit smoking and prohibit alcohol.
Prevention
Early diagnosis and active treatment for patients suffering from tuberculosis of the lungs, intestines, mesenteric lymph nodes and fallopian tubes.
Pay attention to your health and have regular medical checkups.
BCG vaccination as scheduled.