Tuberculous
peritonitis
Acute
tuberculous peritonitis
Tuberculous peritonitis sometimes has an onset
that resembles so closely acute peritonitis that the abdomen is opened. Straw-coloured
fluid escapes and tubercules are seen scattered over the peritoneum and greater
omentum. Early tubercles are greyish and translucent. They soon undergo
caseation, and appear white or yellow and are then less difficult to distinguish
from carcinoma. Occasionally they appear like patchy fat necrosis. On opening
the abdomen and finding tuberculous peritonitis the fluid is evacuated, some
being retained for bacteriological studies. A portion of the diseased omentum is
removed for histological confirmation of the diagnosis and the wound closed
without drainage.
At
other times,
although acute abdominal symptoms arise, the presence of ascites makes diagnosis
of acute tuberculous peritonitis reasonably evident.
Chronic
tuberculous peritonitis
Although the incidence of tuberculous
peritonitis has declined in Britain, in many parts of the world where measures
for eradicating tuberculosis (especially the disease in cows) are enforced less
strictly, the condition still occurs. The condition presents with abdominal pain
(90 per cent of cases), fever (60 per cent), loss of weight (60 per cent),
ascites (60 per cent), night sweats (37 per cent) and abdominal mass (26 per
cent).
Origin
of the infection
Infection originates from:
• tuberculous mesenteric lymph nodes;
• tuberculosis of the ileocaecal region;
•
a tuberculous pyo salpinx;
•
blood-borne infection from pulmonary tuberculosis, usually the
‘miliary’ but occasionally the ‘cavitating’ form.
Varieties
of tuberculous peritonitis
There are four varieties of tuberculous
peritonitis: ascitic, encysted, fibrous and purulent.
Ascitic
form
The peritoneum is studded with tubercules and
the peritoneal cavity becomes filled with pale, straw-coloured fluid. The onset
is insidious. There is loss of energy, facial pallor and some loss of weight.
The patient is usually brought for advice because of enlargement of the abdomen.
Pain is often completely absent; in other cases there is considerable abdominal
discomfort which may be associated with constipation or diarrhoea. On
inspection, dilated veins can be seen coursing beneath the skin of the abdominal
wall. Shifting dullness can be elicited readily. In the male child congenital
hydroceles sometimes appear, due to the patent procesus vaginales becoming
filled with ascitic fluid from the peritoneal cavity. Because of the increased
intra-abdominal pressure an umbilical hernia commonly occurs. On abdominal
palpation a transverse solid mass can often be detected. This is rolled-up
greater omentum infiltrated with tubercules.
Diagnosis
is seldom difficult except when it
occurs in an
acute form or when it first appears in an adult, in which case it has to be
differentiated from other forms of ascites, especially from malignant
secondary deposits. A positive Mantoux test in a child with ascites strongly
suggests, and a negative test is good evidence against, tuberculosis. In adults
this test is of negligible value. Laparoscopy is useful by allowing inspection
of the peritoneal cavity, where the appearance is often diagnostic. Areas of
caseation can be biopsied for histology and microbiological studies. The
‘open’ (Hassan) technique of trocar insertion should be used because of the
risk of adhesions to the abdominal wall. The diagnosis of tuberculous
peritonitis having been made, it is always important to look for tuberculous
disease elsewhere. The possibility of tuberculous salpingitis in females
should be remembered. A chest X-ray should always be
taken before laparoscopy or laparotomy is performed.
The
ascitic fluid is pale yellow, usually clear and rich in lymphocytes. The
specific gravity is comparatively high, often 1.020 or over. Even after
centrifugation, rarely can M.
tuberculosis be
found, but its presence can be demonstrated by culture or by guinea-pig
inoculation.
Treatment.
See guidelines, Chapter 8. If the general condition is good, the patient can
return home and, if an adult, to light work, before the course of chemotherapy
has been completed.
Encysted
form
Encysted (syn. loculated) form is similar to
the above, but one part of the abdominal cavity alone is involved. Thus, a
localised intra-abdominal swelling is produced which gives rise to difficulty in
diagnosis. In a female above the age of puberty when the swelling is in the
pelvis, an ovarian cyst will probably be diagnosed. In the case of a child it is
sometimes difficult to distinguish the swelling from a mesenteric cyst. For
these reasons laparotomy is often performed, and if an encapsulated collection
of fluid is found, it is evacuated and the abdomen is closed. The general
treatment already detailed is required, but the response to this treatment is
more rapid. Late intestinal obstruction is a possible complication.
Fibrous
form
Fibrous (syn. plastic) form is characterised by
the production of widespread adhesions, which cause coils of intestine,
especially
the ileum, to become matted together and distended. These distended coils act as
a ‘blind loop’ and give rise to steatorrhoea, wasting and attacks of
abdominal pain. On examination, the adherent intestine with omentum attached,
together with the thickened mesentery, may give rise to a palpable swelling or
swellings. The first intimation of the disease may be subacute or acute
intestinal obstruction. Sometimes the cause of the obstruction can be remedied
easily by the division of bands. Lateral anastomosis between an obviously
dilated loop and a collapsed loop of small intestine should not be done, as the
‘blind loop’ syndrome is a certain outcome. If the adhesions are
accompanied by fibrous strictures of the ileum as well it is best to excise the
affected bowel, provided not too much of the small intestine needs to be
sacrificed. If adhesions only are present a plication may be performed (see
Chapter 58). Chemotherapy after adequate surgery will rapidly cure the
condition.
Purulent
form
The purulent form is rare. When it occurs,
usually it is secondary to tuberculous salpingitis. Amidst a mass of adherent
intestine and omentum, tuberculous pus is present. Sizeable cold abscesses often
form, and point on the surface, commonly near the umbilicus, or burst into the
bowel. In addition to prolonged general treatment, operative treatment
Peritoneal
bands and adhesions
Congenital bands and membranes. Congenital
bands and membranes occur in the peritoneum at various sites as described in
textbooks of anatomy. Intestinal obstruction is rarely seen except by an
obliterated vitellointestinal duct.
Peritoneal
adhesions. Peritoneal
adhesions are abnormal deposits of fibrous tissue that form after peritoneal
injury. They follow operation or peritonitis and are the commonest cause of
small bowel obstruction and secondary female infertility in developed countries.
They are discussed in detail in Chapter 58.
Talc
granuloma. Talc (silicate of magnesium) should never be used as a lubricant for
rubber gloves for it
is a cause of
peritoneal adhesions and granulomas in the Fallopian tubes. Potassium bitartrate
which is completely soluble is free from these serious complications.
Starch
peritonitis. Like talc, starch powder has found disfavour as a surgical glove
lubricant. In a few starch-sensitive patients it causes
a painful ascites, fortunately of limited duration. Should laparotomy be
performed any small granulomas in, say, the omentum will be found to contain
birefringent starch particles. Starch-free surgical gloves are now widely
available