Tuberculous Peritonitis Notes

Tuberculous Peritonitis

It can be of two types:

Acute and chroniBasically, it produces the following pathological changes:

1. Intense exudation which causes ascitic form
2. Exudation with minimal fibroblastic reaction— loculated form
3. Extensive fibroblastic reaction—plastic form
4. Fibroblastic with secondary infection—purulent form
   • In most of the cases, tuberculous peritonitis results from reactivation of latent primary peritoneal focus

Tuberculous Peritonitis Types

1. Ascitic form (generalised variety):

• It is common in children and young adults. The child is brought to the hospital with abdominal distension.
• Omentum can be felt as a rolled-up transverse mass, which is nodular due to extensive fibrosis. Abdomen has a doughy feel with fluid giving rise to shifting dullness.
• Aspiration of peritoneal fluid reveals exudate, which is rich in lymphocytes.
• The peritoneal cavity contains pale-straw-coloured fluid and the peritoneal surface is studded with tubercles.
• Umbilical hernia or congenital hydrocele appears in children due to increased intra-abdominal pressure.

2. Loculated or encysted form:

• In this variety, ascitic fluid is present in one quadrant of the abdomen which is sealed off by matted intestinal coils surrounded by omentum. It gives rise to localised swelling. These patients have no shifting dullness.
• It commonly presents in adults.
• Differential diagnosis: Other cystic swellings in the abdomen such as pseudocyst of the pancreas, mesenteric cyst, and retroperitoneal cyst.

3. Fibrous peritonitis (plastic):

• In this variety, there are no ascites but there is extensive fibrosis which results in dense adhesions between the coils of intestines. Intestines are matted, distended and not able to empty properly due to adhesions and bands. It is associated with strictures.
• This gives rise to blind loop with steatorrhoea and emaciation.
• Usually, it presents with intestinal obstruction at a later date due to fibrous band which needs to be divided to relieve the obstruction. In some occasions, it is not possible to enter the peritoneal cavity, due to dense adhesions.
• It is not uncommon to create openings in the bowel at laparotomy and end with a helpless situation wherein one will not be able to close the perforation. The net result is fistula formation.

4. Purulent variety:

• Seen in females as a complication of genitourinary tuberculosis (tuberculous salpingitis).
• The spread occurs through the female genital tract and there is always secondary infection.
• It presents with acute peritonitis at laparotomy, the peritoneal cavity is seen studded with tubercles, cold abscesses and pus.
• Laparotomy, drainage of pus, followed by antituberculous treatment is the choice of therapy.
• It carries poor prognosis because of complications such as toxaemia and faecal fistula formation.
• Tuberculous peritonitis can be associated with infections of pleural space and pericardial space (effusion). It is called polyserositis syndrome.

Tuberculous Mesenteric Lymphadenitis:

Tuberculous Mesenteric Lymphadenitis Clinical Presentation:

1. As a calcified lesion along the line of mesentery, which extends from L2 vertebra, at the left of vertebral column to the right sacroiliac joint. In 50% of cases, there is no active infection but in the remaining, there is infection. If the symptoms are that of tuberculosis, antituberculous treatment should be given. The shadows caused by lymph nodes are round to oval, mottled and may be regular or irregular.

2. Acute mesenteric lymphadenitis

• Common in children, clinically mimics acute appendicitis.
• Pain in the right iliac fossa, vomiting, fever, rigidity can be present.
• On palpation, tender mass of swollen lymph nodes can be felt in the right iliac fossa.
• Laparotomy, appendicectomy and biopsy of the lymph node is the procedure of choice.

3. Chronic lymphadenitis in children presents as failure to thrive. Fever, loss of weight, loss of appetite, emaciation and pallor are present. Abdomen is protuberant. On deep palpation, nodes can be felt in the right iliac fossThese nodes have to be differentiated from nodes that enlarge due to lymphoma.

4. Pseudomesenteric cyst

• This is due to caseation of mesenteric lymph nodes confined within two leaves of the mesentery.
• Due to adhesions, intestines can get kinked or twisted causing intestinal obstruction.

Tuberculous Mesenteric Lymphadenitis Treatment:

• Antituberculous treatment (details in medicine books).