Case Report

Abdominal-Peritonitis TB
dr. Regi Rinaldy Billjudika
RSUD MIMIKA 2019
CASE
Identity
Name : Ny. L
Age : 26 yo
Register number : 207265
Entry date : 12/9/2019
Anamnesis

Chief complaint
• Pain and enlarged abdomen after 3rd childbirth 22 Aug 2019 (20 days)
• Nausea (+) Vomiting (+), vaginal bleeding (-)

Past history
• Progressive enlargement of abdomen after childbirth
• DM, HT, Liver disease, TB denied

Family history
• Same complaint none
Anamnesis

Obstetric history
• 1st childbirth 2014
• 2nd childbirth 2016
• 3rd childbirth 22 Aug 2019, male, 3100 gram, in lbor
clinic
• No history of abortion, abnormal
discharge/bleeding after childbirth
Physical examination

• Vital sign
• Heart rate : 145 bpm
• Blood pressure : 110/80mmHg
• Respiratory rate : 22 times/ minute
• Temperature : 38,8 C
• SpO2 : 97 %
• VAS :4/10
Status General

• KU / Kes : TSS / CM
• Head and neck : Ca +/+ , Ikt -/- , isochor pupil 3mm/3mm
• Pulmo : V/V , Rh -/-, Wh -/-
• Cor : S1S2 single, regular, murmur (-)
• Abdomen : convex abdomen, peristaltic (+), shifting dullness
(+) , pain at lower segment of abdomen
• Extremity : Warm, CRT <2 s
Status local

• VT : no cervical opening, no vaginal bleeding or discharge

• USG: ascites (+)

Lab results

Parameter Jumlah Satuan Batas normal

WBC 3.93 103/uL 3,37 -10.0
RBC 5.23 106/uL L: 4.5-6.5, P: 4.0-5.5
HGB 10.9 g/dL L: 13.0-18.0, P: 11.5-16.5
HCT 20.1 % L: 40-54, P: 36-47
MCV 68.1 fL 80.0-97.0
MCHC 30.6 g/dL 32.0-36.0
PLT 288 103/uL 150-450
NEUT% 89.3 % 50-70
LYMPH% 5.9 % 20-40
MONO% 4.3 % 4.3-10
EO% 0.0 % 0.6-5.4
BASO% 0.5 % 0.3-1.4
Lab Result

Parameter Jumlah Satuan Batas normal

Natrium 130 mmol/L 135-147
Kalium 3.15 mmol/L 3.5-5.5
Chlorida 92.3 Mmol/L 95-103

PT 14.3 Detik 9.7-13.1

INR 1.31
Kontrol PT 10.7 Detik
APTT 33.3 Detik 23.9-39.8
Kontrol APTT 23.4 Detik
Diagnosis

Ovarium Cyst suspect Tumor

P3-3 post partum day 20
Treatment

• IVFD RL 1500 ml/24 h

• Ondancentron 4 mg/ 8 h/iv
• Paracetamol 500mg/8h/iv
• Ceftriaxone 1 g/12 h/iv
• Metronidazol 500mg/8h/iv
 Follow Up

S : Abdominal pain (+), enlarged abd (+)

O: BP: 100/60 , HR 100 bpm, ascites (+)
A: Ovarium cyst susp Tumor + post partum day 21
P: USG in poli, check Ur/Cr, HBsAg, SOGT/SGPT
13.15

Surg dept
12 Sep. 19 S: + diarrhea from 3 days ago, 2-3 x/ day
USG: Hiperechoic Intraabdominal mass from CD, vesico O: HR 132 bpm, BP 100/60 , RR 30
uteri, to upper abdomen + Solid mass Rg ubilical uk ascites (+), abdominal pain
8cm. A: Abdominal pain ec Enteritis + susp abdominal tumor
+ Septic shock ec acute enteritis dd peritonitis TB+
Plan : Consul Surgery dept Electrolyte imbalans
P: Resuscitation and optimmalisasi KU
Lab Result

Parameter Jumlah Satuan Batas normal

BUN Urea 47 mg/dL 5-45

Creatinine 1.59 mg/dL 0.6-1.2

SGOT 31.2 U/L 0-50

SGPT 7.3 U/L 5-50

Alb 3.55 g/dL 3.4-4.8

 Follow Up
Interna dept
Not typical for TB, rather Bacterial infection non
TB,
P: meropenem and advice to do Laparotomy

17.36

12 Sep. 19, 15.35

VS: BP 95/65 , HR 80, RR 21, SP02 99%

P: Norepinephrine titration dose till Systolic BP
target 100 or more
Septic cause cannot be determined until laparoscopy
is done
 Follow Up
S: weakness, abdominal pain
O: somnolens. BP 100/60 on NE,HR 130 bpm, RR 22
ascites (+), cold extremity
GDS : 38, UOP 0,12 cc/bw/h, NGT residu dark green
A: + Hipoglycemia ec sepsis + AKI
P: bolus D40% , transfer to ICU
08.30

13 Sep. 19, 07.00

Surgical dept:
Optimalisasi KU and Laparotomy CITO
with risk DOT
Surgery Report

Procedure

●
Exp Laparotomy + Adhesiolisis + Necrotomy & Darinage

Findings

●
Seropurulent fluid 4500cc
●
Adhesion of all GIT with necrotic peritonium
●
Multiple diffuse sarcoidosis in all abdominal wall and omentum, consistent with peritonitis TB description
●
Uterus normal

Diagosis

●
Peritonitis ec bowel TB with total adhesion GIT gr V + Necrotic peritonium (Severe sepsis)
Follow Up

HR 278 bpm. ECG: SVT HR 242 bpm, ECG: SVT

Surgery done, on ventilator
P: Caridoversion 120 J -> ECG AF -> P: Cardioversion 150 J -> S tach
Plan to do TPN and transfusion
13 Sep. 19, 16.40 Amiodarone 300 mg
19.05 Amiodaron 60mg/h
19.35
Follow Up

BP: 77/50, HR 105 , RR 33, Temp

HR 103, BP 95/37, RR 24, GDS 134
41 HR 255 bpm. ECG: SVT
Cold extremity
Plan to postponed transfusion, P: Cardioversion
Plan to start
14 OAT
higher NE, and21.46
PCT drip 22.28 Sep 19, 08.00
Follow Up

BP: 60/30, HR 77, cold GDS 32, plan to bolus D40 2 GDS 42 after bolus 5 flac of Passed away, COD: Cardiac
extremity flac D40 arrest ec multi organ failure
14 Sep. 19, 11.15 12.45 13.35 14.00
LITERATURE REVIEW
Preview

Clinical Take home

Introduction Diagnosis Treatment
presentation massage
Introduction1-6

Rare

●
30-50% of all abdominal TB, often overlap with GI TB
●
Abdominal TB -> 10-30% of all extrapulmonary TB
●
13% comes with pulmonary TB

Difficult to diagnose

●
Subacute and indolent nature
●
Nonspecific and variant complaints
●
No specific examination modalities

High Mortality

●
60% if treatment not initiated
●
Higher in patient with concomitant disease (AIDS, malnourish, DM, etc)
Abdominal TB spread from1,2,3:

1. Haematogenous spread
2. Ingestion of infected sputum
3. Direct spread from infected contiguous
lymph nodes
Peritonitis TB after childbirth4,5

Very rare

●
Physician tends to explore obstetrics problems first
●
Peritonitis TB mimic obstetric problem such as PID and ovarian cyst/carcinoma

Harder to diagnosis

●
twice as likely to develop TB to nonpregnant women
●
Immunosuppressive state of pregnancy + postpartum reversal response

High risk of TB in postpartum women

Poor prognosis

Lahbabi et al. Tuberculosis peritonitis in pregnancy, a case report. Journal of Medical Case Reports; 8:3. 2014
Shinohara et al. Disseminated tuberculosis after pregnancy progressed to paradoxical response to treatment: reportof two cases. BMC Infectious Diseases; 16:284. 2016
 Pregnancy Post Partum
Th2/Th3 enhanced Th2/Th3 suppressed
• Immunosuppressive & anti- • Immunosuppressive & anti-
inflammatory enhanced inflammatory suppressed
Th1 suppressed Th1 enhanced
• Pro inflammatory suppressed • Pro inflammatory enhanced

Preventing maternal immune Reversal of immune system

system from assaulting fetus

Asymptomatic Active disease, mostly

mycobacterial extrapulmonary or
infection disseminated
Shinohara et al. Disseminated tuberculosis after pregnancy progressed to paradoxical response to treatment: report of two cases. BMC Infectious Diseases; 16:284. 2016
 Nonspecific and mimics
other abdominal disease or
Obstetric problem (ex:
ovarian carcinoma, PID, etc)

Clinical
Presentation Sub acute : 3-4 month before
symptomatic

30% present with acute

abdomen
 No Symptom Numbers
Common sign
and symptom 1. Abdominal pain 76%

2. Ascites 60%

3. Fever 30%-50%

4. Abdominal mass 30%

5. Weight loss Nonspecific, often misleading

6. Bowel habit changes Nonspecific , often misleading

Weledji EP et al . Abdominal tuberculosis: Is there a role for surgery?. World J Gastrointest Surg August 27; 9(8): 174-181.2017
Bolognesi M. Case report: Complicated and delayed diagnosis of tuberculosis peritonitis. Am J Case Rep;14: 104-112. 2013
Yeh Hsiu et al. Tuberculosis peritonitis: Analysis of 211 cases in Taiwan. Digestive and Liver Disease; 44: 111-117. 2012
Diagnosis

Neither
clinical signs, laboratory, radiological and endoscopic methods nor
bacteriological and histopathological findings
provide a gold standard by themselves in the diagnosis of abdominal TB

Clinical awareness and high index

of suspicion is a primary

Weledji EP et al . Abdominal tuberculosis: Is there a role for surgery?. World J Gastrointest Surg August 27; 9(8): 174-181.2017
Diagnosis

Anamnesis

●
Subacute symptoms
●
History of TB, contact, and treatment
●
Other concomitant disease

Physical examination

●
Nonspecific
●
Sign of acute abdomen
Differential Diagnosis1,2,3

Intestinal TB Peritoneal TB
Crohn’s disease Bacterial peritonitis
Intestinal carcinoma Chronic liver disease
Bacterial infection Ovarian carcinoma
Lab Findings often unhelpful1,3,6
Findings % of patient
Elevated ESR 79%
Anemia (mild normocytic and common
normochromic)
Leukocytosis common
Hypoalbuminemia Common in ascites patient , LFT normal
Sputum AFB stain Common in pulmonary TB
Direct AFB stain from ascites <5% , up to 40% if cultured
High mortality for patient who waiting for
culture
Ascites fluid findings high protein content, a low glucose and
low SAAG (<1.1)
Imaging6,7

X-ray

● Not helping in intestinal TB, my help in diagnosis of peritonitis or pulmonary TB

Ultrasound

● Ascites, hepatomegaly, and or enlarged nodes

CT-scan and MRI

● Most common use in US (88%)

● Suggestive: Omental stranding (50%), ascites (37%), Retroperitoneal lymphadenopathy (31%)
Srivasta U et al. Tuberculosisi peritonitis. Radiology case report;9: 3.2014
Rocha et al. Abdominal tuberculosis: a radiological review with emphasis on computed tomography and magnetic resonance imaging findings. Radiol Bras.
Mai/Jun;48(3):181–191. 2015
Rocha et al. Abdominal tuberculosis: a radiological review with emphasis on computed tomography and magnetic resonance
imaging findings. Radiol Bras. Mai/Jun;48(3):181–191. 2015
Histology

• Obtaining biopsy specimen

• Ascites
• Colonoscopy
• Laparoscopy
• Laparotomy (diagnosis and treatment)
Bolognesi M. Case report: Complicated and delayed diagnosis of tuberculosis peritonitis. Am J Case Rep;14: 104-112. 2013
Laparoscopy

Emerging gold standard

●
Reliable and minimal invasive (75% accuracy)
●
Macroscopic and microscopic (culture and histology)

Weakness

●
Costly, operator dependent, and not available in many poorer areas where TB is endemic

Suggestive macroscopic findings

●
Small whitish tubercles
●
Inflammatory adhesion
●
Fibrous band “stalactic”

A Mohamed, N Bhat, M Abukhater, M Riaz. Role of Laparoscopy in Diagnosis of Abdominal Tuberculosis. The Internet Journal of
Infectious Diseases; 8:2. 2009
A Mohamed, N Bhat, M Abukhater, M Riaz. Role of Laparoscopy in Diagnosis of Abdominal Tuberculosis. The Internet Journal of
Infectious Diseases; 8:2. 2009
Treatment1,3,9

Pharmacology

●
Respond well to anti tuberculosis regiment
●
No difference with pulmonary TB regiment
●
Systemic steroid is considered in post partum TB

Regiment

●
Cat 1 : 2HRZE/4 (HR)3
●
Cat 2 : 2 (HRZE)S/ HRZE/ 5 (HR)3E3
●
TB RO
Surgical Treatment1,2,3

Reserved for patient with surgical complication

●
Perforation, massive bleeding, complete obstruction, or obstruction not responding to medical management

High mortality rate

●
14-51% in developing country, up to 37% in developed country

Exploratory laparotomy

●
Lifesaving for patient with unchecked bacteremia and uncontrolled intraabdominal sepsis
●
Removal of Infected/necrotic structures and conserved of normal organs/tissue
Take Home Message

Abdomin High Hard to

al- index of diagnose
peritoniti suspicion cause
s TB is a and delayed
rare symptom treatmen
extrapul recognitio t and
monary n is high
TB needed mortality
Reference

1. Weledji EP et al . Abdominal tuberculosis: Is there a role for surgery?. World J Gastrointest Surg August 27; 9(8):
174-181.2017
2. Bolognesi M. Case report: Complicated and delayed diagnosis of tuberculosis peritonitis. Am J Case Rep;14: 104-
112. 2013
3. Yeh Hsiu et al. Tuberculosis peritonitis: Analysis of 211 cases in Taiwan. Digestive and Liver Disease; 44: 111-117.
2012
4. Lahbabi et al. Tuberculosis peritonitis in pregnancy, a case report. Journal of Medical Case Reports; 8:3. 2014
5. Shinohara et al. Disseminated tuberculosis after pregnancy progressed to paradoxical response to treatment:
reportof two cases. BMC Infectious Diseases; 16:284. 2016
6. Srivasta U et al. Tuberculosisi peritonitis. Radiology case report;9: 3.2014
7. Rocha et al. Abdominal tuberculosis: a radiological review with emphasis on computed tomography and magnetic
resonance imaging findings. Radiol Bras. Mai/Jun;48(3):181–191. 2015
8. A Mohamed, N Bhat, M Abukhater, M Riaz. Role of Laparoscopy in Diagnosis of Abdominal Tuberculosis. The
Internet Journal of Infectious Diseases; 8:2. 2009
9. Kemenkes.Pedoman Nasional Pengendalian Tuberkulosis. Kemenkes RI. 2011
10. Anggarwal K dan Amrita S. Case approach puerperal peritonitis. AODG bulletin vol 18. 2019
THANK YOU