Blackwell Science, LtdOxford, UKJGHJournal of Gastroenterology and Hepatology0815-93192005 Blackwell Publishing Asia Pty LtdXXX 2005206906909Review ArticleTuberculous peritonitisAC

Tanrikulu et al.

Journal of Gastroenterology and Hepatology (2005) 20, 906–909 DOI: 10.1111/j.1400-1746.2005.03778.x

GASTROENTEROLOGY

Clinical review of tuberculous peritonitis in 39 patients in

Diyarbakir, Turkey

A CETIN TANRIKULU,* MUSTAFA ALDEMIR, † FUAT GURKAN, ‡ ALI SUNER, §

CANAN EREN DAGLI* AND AYDIN ECE ‡

Departments of *Chest Diseases, †General Surgery, ‡Pediatrics and §Internal Medicine, Faculty of Medicine,
Dicle University, Diyarbakir, Turkey

Abstract Abdominal tuberculosis (TB) is a rare manifestation, which can be overlooked on long-last-
ing and non-specific findings unless a high index of suspicion is maintained. The purpose of the present
study was to investigate the diagnostic features of 39 patients hospitalized with tuberculous peritonitis
(TBP) in Dicle University Hospital, Turkey between January 1994 and August 2003. Twenty-two
patients were male; patient age ranged between 1 and 59 years (mean: 16.2 ± 14.4 years). There were 21
patients (54%) under 15 years of age. Thirteen children had a history of familial TB and seven adults had
prior history of TB. Six (29%) of 21 pediatric cases had bacille Calmette-Guerin (BCG) scars and
results of 5-tuberculin units (TU) tuberculin test were positive in seven children (18%). Of all cases, the
most common presenting findings were abdominal pain (95%), ascites (92%) and abdominal distention
(82%). Five of the patients had accompanying pulmonary TB, and six patients (15%) had intestinal TB
who were admitted to emergency service with acute abdomen, of whom three (8%) had perforation and
three (8%) had ileus. Histopathologically 20 cases (51%) were proven on abdominal ultrasonography,
and computed tomography revealed most commonly ascites and thickening of peritoneum. No micro-
biologic evidence was obtained except three positive culture results for Mycobacterium tuberculosis. As a
result, TBP should be considered for diagnosis, in patients with non-specific symptoms of abdominal
pain, wasting, fever, loss of appetite, abdominal distension and even symptoms of acute abdomen,
because early diagnosis and effective treatment will decrease morbidity and mortality.
© 2005 Blackwell Publishing Asia Pty Ltd

Key words: clinical finding, diagnosis, peritoneal tuberculosis.

INTRODUCTION spread hematogenously and less frequently directly

from other organs.2–6
Tuberculous peritonitis (TBP) continues to be a prob- In the laboratory analysis, the characteristics of the
lem in populations with high incidence of tuberculosis peritoneal fluid may be important, but acid-fast bacilli
(TB). According to the World Health Organization (AFB) are rarely positive and less than half of the cases
(WHO) reports, one-third of the world’s population is are culture positive.3,5 Ultrasonography (USG) and
at risk for TB, and in the 1990s, particularly in Asia and computed tomography (CT) findings may help in the
Africa, more than 30 million people died of TB.1 diagnosis.
Abdominal TB is one of the most common forms of Because of the lack of specific symptoms and labora-
extrapulmonary TB. tory findings, diagnosis of TBP may usually be late.
Diagnosis of the disease is difficult due to lack of spe- However, early diagnosis is important for an effective
cific symptoms and patognomonic findings. Patients treatment and for decrease of morbidity and mortality.
may present with non-specific symptoms such as fever, In the present study we aimed to investigate the char-
abdomainal pain and weight loss. Infection is usually acteristics of the present patients with TBP including

Correspondence: Dr Fuat Gurkan, Department of Pediatrics, Faculty of Medicine, Dicle University, Diyarbakir, Turkey. Email:
fgurkan@dicle.edu.tr, fuatgurkan@hotmail.com
Accepted for publication 9 June 2004.
Tuberculous peritonitis 907

their admission symptoms and demographic findings in Table 1 Clinical symptoms

order to contribute to early diagnosis.
Symptoms n %

Abdominal pain 37 95
METHODS Fever 25 64
Fatigue 23 59
Official files of pediatric and adult patients hospitalized
Lack of appetite 23 59
with TBP at Dicle University Hospital between January
Weight loss 21 54
1994 and August 2003 were evaluated retrospectively. A
total of 39 patients, 21 children (<15 years of age) and Night sweating 13 33
18 adults (≥15 years of age) were included. Nausea and vomiting 7 18
Patient characteristics including admission symp- Cough and sputum 6 15
toms, physical examination findings, familial and past Dispnea 3 8
history of TB were recorded. Mantoux tuberculin skin Diarrhea 3 8
tests of 5 tuberculin units (TU) were done at presenta-
tion in all pediatric cases. Laboratory investigations in
all cases included complete blood count (CBC), periph-
Table 2 Patient characteristics
eral smear, erythrocyte sedimentation rate (ESR), rou-
tine biochemical analysis, chest X-ray, USG and CT
n %
findings, microbiological results and biochemical and
cytologic peritoneal fluid evaluations. Case definition Age (years)
for the diagnosis of TBP included histopathologic,
≥15 18 46
microbiologic or clinical criteria.7 Microbiologic case
<15 21 54
definition was isolation of Mycobacterium tuberculosis
Sex (male) 22 56
(M. tuberculosis) from the ascitic fluid. All adult patients
were histopathologically diagnosed. This process was Family history of TB 13 33
not available for 16 of 21 pediatric cases because of Past Diagnosis of TB 7 18
practical reasons at the hospital. Clinical case definition Positive biopsy 20 51
was made in 16 children in whom the dignosis was Positive culture for M. tuberculosis 3 8
based on consistent clinical findings (long-lasting Elevated ESR 34 87
abdominal symptoms, ascites etc.), radiological results Chest X-rays
(chest X-ray, abdominal USG, CT), ascitic fluid abnor- Fibrocalcific lesion 6 15
malities, Mantoux skin test and discovery of adult Pleural effusion 5 12
source case with contagious TB. Abdominal USG and CT
Patients were treated with isoniazide (INH; 15 mg/kg Ascites with fine septations 36 92
per day, maximum 300 mg/day), and rifampisin Thickening of peritoneum 30 77
(15 mg/kg per day, maximum 600 mg/day) for Thickening of mesentery and omentum 12 31
9 months and pyrazinamide (30 mg/kg per day, maxi- Intra-abdominal lymphadenopathy 9 23
mum 2 g/day) and ethambutol (20 mg/kg per day, max- Hepatomegaly 6 15
imum 1.5 g/day) or streptomycin (30 mg/kg per day, Splenomegaly 3 8
maximum 1 g/day) for the first 2-month period. All
cases were followed up by routine controls every month CT, computed tomography; ESR, erythrocyte sedimenta-
during the treatment period. tion rate; TB, tuberculosis; USG, ultrasonography.

RESULTS Elevated ESR was demonstrated in 34 patients

Among the overall 39 patients, 22 (56%) were male and
17 (44%) were female. The mean age of all patients was
16.2 ± 14.4 years (range: 1–59 years). Of the 21 pedi-
atric cases the mean age was 5.9 ± 3.4 years ranging
between 1 and 14 years. Of all cases, 13 children (33%)
gave a family history of TB, and seven adults (18%) had
a history of past diagnosis with TB.
The most frequent symptoms and clinical findings at
admission were abdominal pain in 37 patients (95%),
ascites in 32 (82%), fatigue in 23 (%59), fever in 25
(64%), lack of appetite in 23 (%59) and loss of weight
in 21 patients (54%; Table 1). Six patients (15%) with
intestinal TB were surgically operated on for suspicion
of acute abdomen at their first admission to the emer-
gency room.
(87%), anaemia in 14 (36%), increased lactate dehy-
drogenase levels in 13 (33.3%), hypoalbuminemia in 11
(28%), hyponatremia in seven (18%) and increased
liver function tests in four patients (10%).
In the laboratory investigation of the ascitic fluid,
exudate and predominance of lymphocytes were
present, but no malignant cells or acid-fast bacilli were
detected. The diagnosis was confirmed microbiologi-
cally by production of M. tuberculosis at Löwenstein
Jensen medium in the ascitic fluid of three patients (8%;
Table 2).
Chest X-rays were evaluated: six (15%) had fibrocal-
cific lesion and five (12%) had pleural effusion and infil-
tration (Table 2). Abdominal USG and CT revealed
ascites with fine septations as the most common finding
in 36 patients (92%), thickening of peritoneum in 30
908
patients (77%), thickening of mesentery and omentum
in 12 (31%), intra-abdominal lymphadenopathy in nine
(23%), hepatomegaly in six (15%) and splenomegaly in
three patients (8%; Table 2).
In the evaluation of bacille Calmette-Guerin (BCG)
scars and the endurations of 5-TU tuberculin test in
pediatric patients, seven had positive tuberculin test
>10 mm and >15 mm in cases without BCG (15 chil-
dren) and with BCG (six children), respectively. Con-
committant pulmonary TB was diagnosed in five
children, tuberculous meningitis was diagnosed in one
child, tuberculous pericarditis in one adult and tuber-
culous ovaritis in another. Other accompanying diseases
in adults were chronic renal failure in one case and ade-
nocarcinoma of the colon in another. All patients were
subjected to antituberculous therapy and clinical recov-
ery was obtained after 9 months of treatment in all cases
without any complications.
DISCUSSION
Tuberculosis infections have increased significantly dur-
ing recent years due to several factors such as poor
socioeconomic status, much ill-informed diagnosis and
treatment, and HIV infection. However, abdominal
TB is relatively infrequent particularly in developed
countries.
Tuberculous peritonitis usually occurs secondary to
the rupture of caseous lesions of the adjacent lymph
nodes and less frequently by direct invasion from the
intestinal focus; or by the hematogenous route.8
Abdominal TB is usually overlooked due to changing
and non-specific findings at differential diagnosis of
abdominal diseases. Some investigators recommend
considering TBP when patients have abdominal pain,
weight loss and ascites in regions of high TB
insidence.5,6
Three steps can be used to assess the diagnosis of
abdominal TB. The first two steps are evaluation of the
clinical and radiological findings, which supply indirect
information. The last step includes invasive techniques
following peritoneal biopsy, which is usually needed for
confirmation of the diagnosis.6,9,10 In the present study
more than half of the patients (51%) were diagnosed by
peritoneal biopsy. Bayramicli et al. have reported a ratio
of histopathologically proven diagnosis in 61% of their
patients in another series in Turkey.10 Sotoudehmanesh
et al. reported the method of diagnosis to be laparatomy
and laparoscopy in 50 (74%) of their patients.11 Lap-
aroscopic examination and peritoneal biopsy should be
the preferred method of diagnosis,12 but in most series
there are some patients treated with antituberculous
therapy without biopsy, but only after a careful evalua-
tion of all other findings. Long-lasting abdominal symp-
toms, familial history of exposure to TB, having no prior
BCG vaccination, positive tuberculin skin test, elevated
ESR and findings of USG and CT have all contributed
well to the diagnosis.
Patients with abdominal TB frequently have history
of TB in the past or family history of TB,13 which may
alert the physician. In the present study, 13 children had
AC Tanrikulu et al.
family history of TB and seven adult patients had prior
diagnosis of TB.
The most common symptoms are fever, abdominal
pain, abdominal distension and weight loss in TBP.3,6,7,9
In the present study, abdominal pain was seen in 37
(95%), abdominal distention in 32 (82%), fever in 25
(64%), and weight loss in 21 patients (54%) in accor-
dance with previous studies. Most patients would not
have presented to a hospital unless abdominal disten-
tion and ascites were evident.
The most common USG and CT findings have been
reported to be ascites, lymphadenopathy and thickness
of mesenterium and peritoneum.4,7 Abdominal USG
and CT of the present patients revealed ascites with fine
septations as the most common finding in 36 patients
(92%), and thickening of peritoneum in 30 (77%).
However, intra-abdominal lymphadenopathy was seen
in nine patients (23%).
Culture and AFB positivity of the peritoneal fluid are
rarely seen.3,5,9,14 In the present study, no patients had
AFB positivity in the microscobic evaluation of the
ascitic fluid and only three patients (8%) had culture
positivity for M. tuberculosis.
The most common complication of the abdominal
TB is intestinal obstruction with an incidence of 20%.
The mechanism is the thickening of the intestinal wall
secondary to the inflamation.15,16 Intestinal perforation
and fistule may be seen in 5% of the patients.17 In the
present study, six (15%) of our patients were admitted
to the emergency service with acute abdomen, among
whom three (8%) had intestinal perforation (Fig. 1),
and three (8%) had ileus. Generally in the emergency
services, abdominal TB is not considered in patients
presenting with acute abdomen.
In conclusion, although Turkey is not a high-preva-
lence country for TB (27/100 000 population),18
abdominal TB is frequently seen in this country; and in
the regions where TB is endemic this rate should be
even higher. To our knowledge there are a limited num-
ber of large series reported that are similar to the
present series. Long-lasting symptoms with abdominal
pain and distention are the major symptoms and these
should alert the doctor to a suspicion of TBP, but in the
Figure 1 Macroscopic pathological view of tuberculoma
and ulcerative lesions of a patient who underwent right hemi-
colectomia after multiple colon and intestinal perforations.
Tuberculous peritonitis
present series 15% of the patients were surgically oper-
ated on for a suspicion of acute abdomen at their first
visit to the emergency room, which demonstrates the
difficulty in early diagnosis. The microbiological confir-
mation of diagnosis by ascitic fluid was obtained only in
three patients; and abdominal USG and CT findings
contribute well to the diagnosis in children for whom
laparoscopic examination and peritoneal biopsy were
not available. Early diagnosis and treatment will
decrease the mortality and morbidity of the disease.
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