- Valerie Byrnes, MRCPI, MD, MMSc
Valerie Byrnes, MRCPI, MD, MMSc
- Consultant Gastroenterologist
- National University of Ireland, University College Hospital Galway
- Sanjiv Chopra, MD, MACP
Sanjiv Chopra, MD, MACP
- Editor-in-Chief — Gastroenterology/Hepatology
- Section Editor — General Hepatology
- Section Editor — Gallbladder and Biliary Tract Disease
- Professor of Medicine
- Harvard Medical School
- Senior Consultant in Hepatology
- James Tullis Firm Chief
- Beth Israel Deaconess Medical Center
Peritoneal tuberculosis is an uncommon site of extrapulmonary infection caused by Mycobacterium tuberculosis (TB). The risk is increased in patients with cirrhosis, HIV infection, diabetes mellitus, underlying malignancy, following treatment with anti-tumor necrosis factor (TNF) agents, and in patients undergoing continuous ambulatory peritoneal dialysis [1-5].
Infection occurs most commonly following reactivation of latent tuberculous foci in the peritoneum that were established from hematogenous spread from a primary lung focus . It can also occur via hematogenous spread from active pulmonary or miliary TB. Much less frequently, the organisms enter the peritoneal cavity transmurally from an infected small intestine or contiguously from tuberculous salpingitis .
As the disease progresses, the visceral and parietal peritoneum become increasingly studded with tubercles. Ascites develops secondary to "exudation" of proteinaceous fluid from the tubercles, similar to the mechanism leading to ascites in patients with peritoneal carcinomatosis. More than 90 percent of patients with tuberculous peritonitis have ascites at the time of presentation, while the remainder present with a more advanced "dry" phase, representing a fibroadhesive form of the disease [7,8].
Approximately 70 percent of patients have symptoms for more than four months before the diagnosis is established [9,10]. This is due in part to the insidious onset of the disease and because the diagnosis is frequently unsuspected. In patients with renal failure, symptoms and signs typically develop within the first year of beginning continuous ambulatory peritoneal dialysis (CAPD) and are usually indistinguishable from bacterial peritonitis. Tuberculous (TB) peritonitis should be added to the differential diagnosis of any patient presenting with several weeks of abdominal pain, fever, and weight loss.
One of the largest contemporary series included 60 patients who were identified during a 12-year period at a center in Hong Kong . The mean age at presentation was 55 with an approximately equal gender distribution. Risk factors (in descending order of frequency) included cirrhosis, CAPD, diabetes mellitus, underlying malignancy, use of systemic corticosteroids, and AIDS. However, 20 percent of patients had no risk factor.
- Mehta JB, Dutt A, Harvill L, Mathews KM. Epidemiology of extrapulmonary tuberculosis. A comparative analysis with pre-AIDS era. Chest 1991; 99:1134.
- Braun MM, Byers RH, Heyward WL, et al. Acquired immunodeficiency syndrome and extrapulmonary tuberculosis in the United States. Arch Intern Med 1990; 150:1913.
- Rieder HL, Snider DE Jr, Cauthen GM. Extrapulmonary tuberculosis in the United States. Am Rev Respir Dis 1990; 141:347.
- Aguado JM, Pons F, Casafont F, et al. Tuberculous peritonitis: a study comparing cirrhotic and noncirrhotic patients. J Clin Gastroenterol 1990; 12:550.
- Chow KM, Chow VC, Hung LC, et al. Tuberculous peritonitis-associated mortality is high among patients waiting for the results of mycobacterial cultures of ascitic fluid samples. Clin Infect Dis 2002; 35:409.
- Tang LC, Cho HK, Wong Taam VC. Atypical presentation of female genital tract tuberculosis. Eur J Obstet Gynecol Reprod Biol 1984; 17:355.
- Manohar A, Simjee AE, Haffejee AA, Pettengell KE. Symptoms and investigative findings in 145 patients with tuberculous peritonitis diagnosed by peritoneoscopy and biopsy over a five year period. Gut 1990; 31:1130.
- Bhargava DK, Chopra P, Nijhawan S, et al. Peritoneal tuberculosis: laparoscopic patterns and its diagnostic accuracy. Am J Gastroenterol 1992; 87:109.
- Lisehora GB, Peters CC, Lee YT, Barcia PJ. Tuberculous peritonitis--do not miss it. Dis Colon Rectum 1996; 39:394.
- Gitt S, Haddad F, Levenson S. Tuberculous peritonitis: an overlooked diagnosis. Hosp Pract (Off Ed) 1992; 27:224.
- Jakubowski A, Elwood RK, Enarson DA. Clinical features of abdominal tuberculosis. J Infect Dis 1988; 158:687.
- Demir K, Okten A, Kaymakoglu S, et al. Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems. Eur J Gastroenterol Hepatol 2001; 13:581.
- Tanrikulu AC, Aldemir M, Gurkan F, et al. Clinical review of tuberculous peritonitis in 39 patients in Diyarbakir, Turkey. J Gastroenterol Hepatol 2005; 20:906.
- al-Quorain AA, Satti MB, al-Freihi HM, et al. Abdominal tuberculosis in Saudi Arabia: a clinicopathological study of 65 cases. Am J Gastroenterol 1993; 88:75.
- Lee CT, Hung KH, Lee CH, et al. Chronic hypercalcemia as the presenting feature of tuberculous peritonitis in a hemodialysis patient. Am J Nephrol 2002; 22:555.
- Ilhan AH, Durmuşoğlu F. Case report of a pelvic-peritoneal tuberculosis presenting as an adnexial mass and mimicking ovarian cancer, and a review of the literature. Infect Dis Obstet Gynecol 2004; 12:87.
- Aliyu MH, Aliyu SH, Salihu HM. Female genital tuberculosis: a global review. Int J Fertil Womens Med 2004; 49:123.
- Namavar Jahromi B, Parsanezhad ME, Ghane-Shirazi R. Female genital tuberculosis and infertility. Int J Gynaecol Obstet 2001; 75:269.
- Chavhan GB, Hira P, Rathod K, et al. Female genital tuberculosis: hysterosalpingographic appearances. Br J Radiol 2004; 77:164.
- Parikh FR, Nadkarni SG, Kamat SA, et al. Genital tuberculosis--a major pelvic factor causing infertility in Indian women. Fertil Steril 1997; 67:497.
- Liomba NG, Chipangwi JD. Female Genital Tuberculosis in Malawi--a report of 90 cases. J Obstet Gynaecol East Cent Africa 1982; 1:69.
- Sutherland AM. Gynaecological tuberculosis since 1951. J Obstet Gynaecol 1997; 17:119.
- Tripathy SN, Tripathy SN. Infertility and pregnancy outcome in female genital tuberculosis. Int J Gynaecol Obstet 2002; 76:159.
- Sanai FM, Bzeizi KI. Systematic review: tuberculous peritonitis--presenting features, diagnostic strategies and treatment. Aliment Pharmacol Ther 2005; 22:685.
- Inadomi JM, Kapur S, Kinkhabwala M, Cello JP. The laparoscopic evaluation of ascites. Gastrointest Endosc Clin N Am 2001; 11:79.
- Marshall JB. Tuberculosis of the gastrointestinal tract and peritoneum. Am J Gastroenterol 1993; 88:989.
- Chahed J, Mekki M, Mansour A, et al. Contribution of laparoscopy in the abdominal tuberculosis diagnosis: retrospective study of about 11 cases. Pediatr Surg Int 2010; 26:413.
- Shukla HS, Bhatia S, Naitrani YP, et al. Peritoneal biopsy for diagnosis of abdominal tuberculosis. Postgrad Med J 1982; 58:226.
- Bastani B, Shariatzadeh MR, Dehdashti F. Tuberculous peritonitis--report of 30 cases and review of the literature. Q J Med 1985; 56:549.
- Uzunkoy A, Harma M, Harma M. Diagnosis of abdominal tuberculosis: experience from 11 cases and review of the literature. World J Gastroenterol 2004; 10:3647.
- Chow KM, Chow VC, Szeto CC. Indication for peritoneal biopsy in tuberculous peritonitis. Am J Surg 2003; 185:567.
- Rana SS, Bhasin DK, Srinivasan R, Singh K. Endoscopic ultrasound-guided fine needle aspiration of peritoneal nodules in patients with ascites of unknown cause. Endoscopy 2011; 43:1010.
- Kocaman O, Danalioğlu A, İnce AT, et al. Diagnosis of tuberculous peritonitis using endoscopic ultrasound-guided fine-needle aspiration biopsy of the peritoneum. Turk J Gastroenterol 2013; 24:65.
- Bai Y, Qiao WG, Zhu HM, et al. Role of transgastric natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin (with videos). Gastrointest Endosc 2014; 80:807.
- Candocia SA, Locker GY. Elevated serum CA 125 secondary to tuberculous peritonitis. Cancer 1993; 72:2016.
- Mas MR, Cömert B, Sağlamkaya U, et al. CA-125; a new marker for diagnosis and follow-up of patients with tuberculous peritonitis. Dig Liver Dis 2000; 32:595.
- Younossian AB, Rochat T, Favre L, Janssens JP. Ascites and highly elevated CA-125 levels in a case of peritoneal tuberculosis. Scand J Infect Dis 2006; 38:216.
- Koc S, Beydilli G, Tulunay G, et al. Peritoneal tuberculosis mimicking advanced ovarian cancer: a retrospective review of 22 cases. Gynecol Oncol 2006; 103:565.
- Runyon BA. Malignancy-related ascites and ascitic fluid "humoral tests of malignancy". J Clin Gastroenterol 1994; 18:94.
- Demirkazik FB, Akhan O, Ozmen MN, Akata D. US and CT findings in the diagnosis of tuberculous peritonitis. Acta Radiol 1996; 37:517.
- Akhan O, Pringot J. Imaging of abdominal tuberculosis. Eur Radiol 2002; 12:312.
- Vázquez Muñoz E, Gómez-Cerezo J, Atienza Saura M, Vázquez Rodriguez JJ. Computed tomography findings of peritoneal tuberculosis: systematic review of seven patients diagnosed in 6 years (1996-2001). Clin Imaging 2004; 28:340.
- Takalkar AM, Bruno GL, Reddy M, Lilien DL. Intense FDG activity in peritoneal tuberculosis mimics peritoneal carcinomatosis. Clin Nucl Med 2007; 32:244.
- Shimamoto H, Hamada K, Higuchi I, et al. Abdominal Tuberculosis: peritoneal involvement shown by F-18 FDG PET. Clin Nucl Med 2007; 32:716.
- Quantrill SJ, Woodhead MA, Bell CE, et al. Peritoneal tuberculosis in patients receiving continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 2001; 16:1024.
- Gupta N, Prakash KC. Asymptomatic tuberculous peritonitis in a CAPD patient. Perit Dial Int 2001; 21:416.
- Kim NJ, Choo EJ, Kwak YG, et al. Tuberculous peritonitis in cirrhotic patients: comparison of spontaneous bacterial peritonitis caused by Escherichia coli with tuberculous peritonitis. Scand J Infect Dis 2009; 41:852.
- Poyrazoglu OK, Timurkaan M, Yalniz M, et al. Clinical review of 23 patients with tuberculous peritonitis: presenting features and diagnosis. J Dig Dis 2008; 9:170.
- Hillebrand DJ, Runyon BA, Yasmineh WG, Rynders GP. Ascitic fluid adenosine deaminase insensitivity in detecting tuberculous peritonitis in the United States. Hepatology 1996; 24:1408.
- Singh MM, Bhargava AN, Jain KP. Tuberculous peritonitis. An evaluation of pathogenetic mechanisms, diagnostic procedures and therapeutic measures. N Engl J Med 1969; 281:1091.
- Pfyffer GE, Kissling P, Jahn EM, et al. Diagnostic performance of amplified Mycobacterium tuberculosis direct test with cerebrospinal fluid, other nonrespiratory, and respiratory specimens. J Clin Microbiol 1996; 34:834.
- Lye WC. Rapid diagnosis of Mycobacterium tuberculous peritonitis in two continuous ambulatory peritoneal dialysis patients, using DNA amplification by polymerase chain reaction. Adv Perit Dial 2002; 18:154.
- Shen YC, Wang T, Chen L, et al. Diagnostic accuracy of adenosine deaminase for tuberculous peritonitis: a meta-analysis. Arch Med Sci 2013; 9:601.
- Riquelme A, Calvo M, Salech F, et al. Value of adenosine deaminase (ADA) in ascitic fluid for the diagnosis of tuberculous peritonitis: a meta-analysis. J Clin Gastroenterol 2006; 40:705.
- Huang HJ, Yang J, Huang YC, et al. Diagnostic feature of tuberculous peritonitis in patients with cirrhosis: A matched case-control study. Exp Ther Med 2014; 7:1028.
- Kim SH, Choi SJ, Kim HB, et al. Diagnostic usefulness of a T-cell based assay for extrapulmonary tuberculosis. Arch Intern Med 2007; 167:2255.
- Tinelli A, Malvasi A, Vergara D, et al. Abdominopelvic tuberculosis in gynaecology: laparoscopical and new laboratory findings. Aust N Z J Obstet Gynaecol 2008; 48:90.
- Alrajhi AA, Halim MA, al-Hokail A, et al. Corticosteroid treatment of peritoneal tuberculosis. Clin Infect Dis 1998; 27:52.
- Wang HK, Hsueh PR, Hung CC, et al. Tuberculous peritonitis: analysis of 35 cases. J Microbiol Immunol Infect 1998; 31:113.
- CLINICAL MANIFESTATIONS
- Routine laboratory studies
- Tuberculin skin testing
- Radiologic imaging
- Peritoneal fluid analysis
- - Polymerase chain reaction
- - Adenosine deaminase
- T-cell based testing for mycobacterium tuberculosis (ELISPOT)
- SUMMARY AND RECOMMENDATIONS