Tuberculous peritonitis is a chronic diffuse peritoneal infection caused by Mycobacterium tuberculosis. It is more common in children and young adults. The clinical manifestations are mainly lethargy, fever, abdominal pain and abdominal distension, which can lead to intestinal obstruction, intestinal perforation and fistula formation and other complications.
Etiology and pathogenesis
Tuberculous peritonitis is usually secondary to tuberculous lesions in other organs. The route of infection can be either by direct intra-abdominal spread of tuberculosis or by hematogenous dissemination. The former is more common, such as intestinal tuberculosis, mesenteric lymphatic tuberculosis, and tuberculosis of the fallopian tubes, which can be the direct primary focus of the disease. It is more common in women than in men and may be due to retrograde infection of pelvic tuberculosis.
Pathology
The pathological features of the disease can be of three types, namely exudative, adhesive and caseous types. The adherent type is the most common, the exudative type is the second most common, and the caseous type is the least common. In the process of disease development, one type can be changed to another type, or two or three types can exist simultaneously.
1.Exudative type
Also known as ascites type. There are varying degrees of congestion, edema and large amounts of fibrous exudate in the visceral and mural layers of the peritoneum. The entire peritoneum, including the greater omentum and mesentery, is visible as days of tiny yellowish-white or grayish-white nodules of nodules, which may fuse with each other to form a mass. Plasma exudate accumulated in the peritoneal cavity may form ascites, which is usually straw yellow and sometimes bloody.
2.Adhesive type
The peritoneum has a large amount of fibrous hyperplasia, which is obviously thickened and forms extensive adhesions with nearby organs, resulting in obstruction due to pressure on the intestinal flexure. The greater omentum is also thickened and stiffened by fibrosis, and it curls into a mass, and in severe cases, the abdominal cavity can be completely occluded. This type can be formed after the absorption of ascites from exudative lesions, or it can be an adhesion type at the beginning.
3.Cheese type
This type is dominated by caseous necrotic lesions. The intestinal flexure, large omentum, mesentery or other organs in the abdominal cavity are adhered to each other and separated into many small rooms, and the exudate in the rooms is mostly turbid and purulent, and the mesenteric lymph nodes with caseous necrosis are often involved, forming tuberculous abscesses. In time, the abscess may collapse into the intestinal wall, vagina, or abdominal wall, forming an internal or external fistula. This type of lesion is the most severe, and most often transforms from the other two types.
Clinical presentation
The clinical manifestations of tuberculous peritonitis vary according to the primary lesion, the route of infection, the type of pathology and the reactivity of the organism, and the onset of the disease varies. Most of them have a slow onset, but acute onset is not uncommon. At the onset, the main symptoms are lethargy, fever, abdominal distension and abdominal pain, but there are also cases of sudden onset of chills and high fever. In mild cases, the disease starts in an insidious manner.
1. Systemic manifestations
Fever and night sweats are most common, accounting for 67-95% of cases. In women of childbearing age, menopause and infertility are more common.
2.Abdominal pain
About two-thirds of patients can have abdominal pain of different degrees, mostly persistent vague or dull pain, mostly located around the umbilicus, lower abdomen, and sometimes in the whole abdomen. When patients have acute abdomen, they should consider whether it is caused by acute peritonitis caused by the collapse of mesenteric lymph nodes or other tuberculosis caseous necrotic lesions in the abdomen, or by acute intestinal perforation of intestinal tuberculosis and other causes.
3.Abdominal distension and ascites
Most patients have a feeling of abdominal distension, which can be caused by symptoms of tuberculosis toxicity or intestinal dysfunction associated with peritonitis. About one-third of patients can develop ascites, with small and moderate amounts being the most common. A mobile turbid sound can be detected when the amount of ascites exceeds 1000 ml. A small amount of ascites needs to be examined with the help of ultrasound.
4, abdominal wall tenderness
Tenderness is caused by mild irritation or chronic inflammation of the peritoneum and can be seen in all types of the disease, but is generally considered to be a clinical feature of the adhesive type of tuberculous peritonitis. The vast majority of patients have varying degrees of tenderness, generally mild, with a few having significant tenderness and rebound pain, the latter mostly seen in the case type.
5. Abdominal masses
The abdominal masses of patients with adhesive and caseous types are often palpable and are mostly located in the middle and lower abdomen. The masses mostly consist of thickened large omentum, enlarged mesenteric lymph nodes, adherent intestinal curvature or accumulation of caseous necrotic purulent material, which vary in size and have uneven edges, sometimes in the form of transverse masses or nodular sensation, and mostly have slight tenderness.
6.Other
Some patients may have diarrhea, usually due to inflammatory irritation of the peritoneum, or due to the formation of inter-intestinal fistulae. It is usually 3-4 times a day. In patients with adhesive type, constipation is more common, sometimes alternating between diarrhea and constipation. Hepatomegaly is not uncommon and can be caused by fatty liver due to malnutrition or hepatic tuberculosis. In case of intestinal obstruction, peristaltic waves and hyperactive bowel sounds are seen.
Laboratory and other tests
1. Blood picture, erythrocyte sedimentation rate and tuberculin test
Some patients have mild to moderate anemia, the latter is most often seen in patients with long duration and active lesions, especially in case of caseous type or with complications. The white blood cell count is mostly normal or slightly high, with a few being low. Leukocyte count may be increased in patients with acute spread of abdominal tuberculosis lesions or in patients with the caseous form, and erythrocyte sedimentation rate may be a simple indicator of lesion activity, which is generally increased during the active phase of the disease and gradually normalized when the lesion becomes quiescent.
A strong positive tuberculin test can be helpful in diagnosing the disease, but it can be negative in patients with cornified tuberculosis or severe disease.
2, ascites examination
Ascites is a straw-yellow exudate, which naturally coagulates after resting, and a few are bloody. Occasionally celiac, specific gravity generally exceeds 1.016, protein content in 30g/L, white blood cell count exceeds 5×108/L (500/ul), mainly lymphocytes.
However, sometimes due to hypoproteinemia, the nature of ascites can approach that of leaking fluid and must be analyzed in conjunction with a comprehensive approach. In recent years, it has been advocated that experimental diagnostic indicators should be added to the judgment of infectious ascites. Ascitic fluid glucose <3.4 mmol/L,pH <7.35 indicates bacterial infection, especially when ascitic fluid adenosine deaminase activity is increased, suggesting tuberculous peritonitis. The general bacterial culture of the ascites of this disease is negative, and the chance of finding positive Mycobacterium tuberculosis in concentration is rare, and the positive rate of culture of Mycobacterium tuberculosis is also low, but the positive rate of animal inoculation of ascites can be more than 50%.
3.Gastrointestinal X-ray examination
Barium meal examination such as the discovery of intestinal adhesions, intestinal tuberculosis, intestinal fistula, extra-intestinal luminal masses and other phenomena, the diagnosis of the disease has auxiliary value. Abdominal plain film can sometimes see calcification shadow, mostly mesenteric lymph node calcification.
4.Laparoscopic examination
The examination is contraindicated for those with extensive peritoneal adhesions. It is generally applied to patients with free ascites, and can be seen on the surface of peritoneum, omentum and viscera with scattered or clustered gray-white nodules, plasma membrane losing its normal luster, cloudy and rough, and biopsy has a confirmatory value.
Diagnosis
Diagnosis of typical cases is generally not difficult and is based mainly on the following.
1, young and strong patients with unexplained fever, lasting more than two weeks, accompanied by night sweats, and ineffective by general antibiotic treatment;
2, a history of close contact with tuberculosis or other extra-intestinal tuberculosis;
3, abdominal wall tenderness, ascites or palpable masses;
4, increased blood sedimentation, ascites is exudate;
5.X-ray gastrointestinal barium meal examination found intestinal adhesions and other signs.
Treatment
Treatment principles and drugs can refer to pulmonary tuberculosis, but still need to pay attention to the following points.
1. The efficacy of anti-tuberculosis drugs for this disease is slightly lower than that of intestinal tuberculosis. Therefore, the medication and treatment course should be strengthened or extended appropriately. Generally, the combination of streptomycin, isoniazid and rifadin is preferred, and pyrazinamide or ethambutol can also be added. After the disease is controlled, it can be changed to isoniazid and rifadin or isoniazid orally plus streptomycin twice a week, and the course of treatment should be more than 12 months.
2.For ascites type patients, after the release of ascites, streptomycin and cortisone acetate are injected into the peritoneal cavity once a week, which can accelerate the absorption of ascites and reduce adhesions.
3.For patients with hematogenous dissemination or severe tuberculosis toxemia, on the basis of effective anti-tuberculosis drug treatment, adrenocorticotropic hormone can also be added to reduce toxic symptoms and prevent intestinal adhesions and intestinal obstruction.
4.In view of the fact that this disease is often secondary to other tuberculosis in the body, most patients have already received anti-tuberculosis drugs, therefore, for such patients, drugs that have not been used in the past or used sparingly should be selected and a combined drug regimen should be developed.
5. In case of complicated intestinal obstruction, intestinal perforation, septic peritonitis, surgical treatment is feasible. When there is a real difficulty to identify with intra-abdominal tumor, it is feasible to perform a caesarean section.
Prevention
Tuberculous peritonitis is mostly secondary to infection by direct spread or hematogenous dissemination of tuberculosis from other parts of the body. The diagnosis is not difficult in typical cases, but tuberculous peritonitis varies in severity, and atypical cases are easily misdiagnosed as cirrhotic ascites, intestinal obstruction, typhoid fever, chronic cholecystitis, gastrointestinal tumors, abdominal lymphomas, pelvic tumors, ovarian cysts, etc., so attention should be paid to differentiation.
Tuberculous peritonitis can be treated satisfactorily with rest and anti-tuberculosis treatment, but patients with serious complications such as severe pulmonary tuberculosis or cornual tuberculosis combined with tuberculous meningitis have a poor prognosis. Medication should be administered early, regularly, in combination, in appropriate amounts and throughout the course, and special attention should be paid to drug side effects. Prevention is the fundamental measure to prevent and treat tuberculosis.
Patients with existing tuberculosis should be detected and treated promptly. Patients with open tuberculosis should take effective anti-tuberculosis drugs to make sputum bacteria turn negative as soon as possible to avoid swallowing sputum containing bacteria and causing intestinal infection. Milk must be boiled and consumed.
Tuberculous peritonitis is a chronic peritonitis caused by Mycobacterium tuberculosis and is the most common form of extrapulmonary tuberculosis, with a significantly higher incidence in women than in men, and more often in young women. This is because young women of childbearing age are susceptible to reproductive tuberculosis, which can extend directly from the reproductive organs to the peritoneum, thus causing peritoneal tuberculosis.
Fever is one of the most common or primary symptoms of tuberculous peritonitis. This is followed by pain around the umbilicus, in the lower abdomen, or throughout the abdomen, and pressure pain when the abdomen is pressed, although not all patients have abdominal pain. The third major symptom of tuberculous peritonitis is thickening of the peritoneum, adherence of the intestinal canal and mesentery to each other caused by tuberculosis toxins and intestinal dysfunction, and a kneading sensation on contact with the abdomen or palpation of an abdominal mass.
When the intra-abdominal tuberculosis caseous material penetrates into the intestine, an intestinal fistula can be formed, and when it penetrates outside the abdomen, pus can flow out, and this pus contains a large number of tuberculosis bacilli, and if it is not disinfected, it can become a source of spreading infection and endanger others. In addition to the above symptoms, TB peritonitis can also cause night sweats, anemia, malnutrition, menstrual disorders, and wasting.
Most patients with tuberculous peritonitis are not difficult to diagnose. If a young woman has unexplained fever, abdominal pain, bloating, night sweats, weight loss, menstrual irregularities and other symptoms mentioned above, she should think that she may have tuberculous peritonitis and should go to the hospital for an ultrasound examination and timely abdominal fluid extraction for laboratory tests to confirm the diagnosis. In some cases, the diagnosis can be made by laparoscopy or peritoneal biopsy if the diagnosis is difficult.
Once tuberculous peritonitis is diagnosed, treatment with drugs such as isoniazid, rifampin, streptomycin, pyrazinamide, etc. is available and can achieve significant results.