Saudi Journal of Gastroenterology
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ORIGINAL ARTICLE Table of Contents   
Year : 2007  |  Volume : 13  |  Issue : 3  |  Page : 133-135
Role of laparoscopy in the diagnosis of abdominal tuberculosis


Department of Surgery, Guilan University of Medical Sciences, Iran

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Date of Submission10-Mar-2007
Date of Acceptance15-May-2007
 

   Abstract 

Background : Tuberculosis continues to be a common disease in Iran and one of its presentations is abdominal tuberculosis. Histopathological confirmation of abdominal tuberculosis is difficult because of suboptional, noninvasive access to the pathology. Laparoscopy provides minimally invasive access to the peritoneum. AIM : The aim is to evaluate the role and importance of laparoscopy in the diagnosis of tuberculous peritonitis (TP). Materials and Methods : A retrospective study on laparoscopiy in Razi hospital of Rasht (in northern Iran) over a period of ten years showed that diagnostic laparoscopy was performed in 290 patients with abdominal pain, with or without ascites. Most cases revealed malignancy and we found 28 cases of abdominal tuberculosis. Results : Macroscopic findings of TP were whitish granulations over both peritoneal layers, inflammatory adhesions on the visceral or parietal surface, thickening, hyperemia and retraction of the greater omentum and stalactic band which is characteristic of TP. Pathology confirmed TP in 28 cases and all patients had excellent response to medical therapy. Conclusion : Although other diagnostic methods of TP such as imaging, culture of ascitis and polymerase chain reaction (PCR) are used today, laproscopy with tissue biopsy provided rapid and correct diagnosis of abdominal tuberculosis.

Keywords: Laparoscopy, tuberculous peritonitis

How to cite this article:
Safarpor F, Aghajanzade M, Kohsari MR, Hoda S, Sarshad A, Safarpor D. Role of laparoscopy in the diagnosis of abdominal tuberculosis. Saudi J Gastroenterol 2007;13:133-5

How to cite this URL:
Safarpor F, Aghajanzade M, Kohsari MR, Hoda S, Sarshad A, Safarpor D. Role of laparoscopy in the diagnosis of abdominal tuberculosis. Saudi J Gastroenterol [serial online] 2007 [cited 2019 Dec 13];13:133-5. Available from: http://www.saudijgastro.com/text.asp?2007/13/3/133/33465


Each year tuberculosis (TB) results in the death of three million people globally. In 2000-2020, an estimated one billion people will be infected, 200 million people will become sick and 35 million will die from TB. TB is still a common disease in Iran with an annual incidence of 30/100000. [1] Case rates vary according to sex, race, age, geographic location and socioeconomic factors, which are important in the prevalence of disease.

It has been reported that up to 5% of TB patients may have abdominal tuberculosis and of these, 25-60% may have peritoneal involvement. [2] Concomitant active pulmonary TB associated with abdominal TB has been reported to range from 20-50%. [3] Peritoneal tuberculosis can originate from mesenteric lymph nodes or through hematogenous spread or from tuberculous salpintigtis.

Abdominal lymph nodal and peritoneal tuberculosis may occur without gastrointestinal involvement in about one third of the cases. Symptoms are usually insidious with abdominal pain, swelling, fever, night sweats, anorexia and weight loss. [4] Symptoms may even be absent in some patients. Clinicians should maintain a high index of suspicion for TB peritonitis as missing the diagnosis can result in significant morbidity and mortality.


   Materials and Methods Top


Razi hospital of Guilan university (northern Iran) is a referral center for laparoscopic procedures. During a retrospective study spanning ten years, we documented 290 cases with ascites and abdominal pain. Most diagnostic laparoscopic findings were of malignancy. The other valuable findings of our investigation consisted of pelvic inflammatory disease (PID) in 17 cases, ovarian tumor origin in 28 cases, pancreatic tumor origin in 25 cases, visceral and parietal carcinomatosis, omental cake without known origin in 176 cases, cirrhosis in eight cases, abdominal tuberculosis in 28 cases whereas we could not find any obvious pathology in eight cases.

Of 28 patients with peritoneal tuberculosis, 18 were female and the age range was 17-62 years. Most patients were from low socioeconomic state and five patients were opium abusers. All patients were admitted with ascites and abdominal pain and were evaluated until the diagnosis became evident. In the majority of cases, there was no evidence of an active TB infection on admission or when the diagnosis was made. Chest X-ray was negative in 22 patients and TB was suspected only in six patients. TB skin test was negative and unremarkable in most cases.

Most patients presented with abdominal pain and ascites (22 cases), abdominal pain without ascites (four cases) and mixed forms of fibroadhesive type with multiple interloop cysts (two cases). Pain and fever (low grade) in six cases and chronic wasting illness were observed in 22 cases. Ultrasound examination of the abdomen was helpful in 21 cases and showed mesenteric lymphadenopathy in 11 patients and mesenteric thickening in five patients. Computed tomographic (CT) scan showed circumferential thickening in eight patients with central necrosis, lymphadenopathy and ascites in 12 cases and omental thickening seen as an omental cake in two patients.

Paracentesis for acid-fast bacterial (AFB) smear was positive in two patients but we did not perform ascitis fluid culture and polymerase chain reaction (PCR). Routine blood examination was not helpful. Only sedimentation rate was elevated in 25 patients. Laparoscopy was performed and tissue biopsy (peritoneum) confirmed tuberculosis in 28 patients. Culturing was not done for any of the patients. The routine diagnostic laparoscopic technique is similar to therapeutic laparoscopic procedures. In two cases, because of dense adhesion and fear of bowel perforation; we opened the peritoneum by making a simple, small incision infraumblically.

The pelvic cavity was inspected first and in suspected cases, liquid was aspirated for cytological exam or peritoneal washing with 150 mm saline after which the upper abdominal portion was visualized. The pelvic cavity, liver surface, gastrohepatic and gastrocolic ligaments, right and left paracolic spaces, the inferior surface of the transverse mesocolon and mesenteric root were examined. All peritoneal and liver-related lesions were biopsied for pathologic demonstration. Additionally, all accessible suspicious lymph nodes were biopsied. The pathologic findings included granulomatous reactions composed of epithelial cell aggregates and lymphocytic rims, admixed with multinucleated giant cells. Caseation necrosis was present in four patients


   Discussion Top


Although the incidence of tuberculosis has decreased over time, there has been a resurgence of this lethal infectious disease in recent years. In Europe and the USA, tuberculosis seems to be an increasingly, important health issue with its vague clinical signs and nonspecific symptoms and has been growing in parallel to the increasing incidence of HIV. TB continues to be a common disease in Iran and one of its presentations is abdominal tuberculosis.

The cornerstone of TB diagnosis is the culture of involved microorganisms, the results of which usually take a long time to obtain. Molecular diagnostic methods such as PCR are also very useful but are not widely available, particulary in less developed areas. Many research studies have been conducted for serological diagnosis of TB but their clinical utility, particularly in extrapulmonary TB, remains to be established. [5]

In TB peritonitis, histopathological examination is an appropriate method both for diagnosing TB and to rule out other diseases such as malignancy. Histopathological confirmation of abdominal tuberculosis because of suboptional, noninvasive access to the pathology is difficult. Laparoscopy provides minimally invasive access to the peritoneum.

Information on the diagnostic yield of this investigation in abdominal tuberculosis is scarce. Tuberculosis can involve any part of the gastrointestinal tract and is the sixth most frequent site of extrapulmonary involvement. The majority of cases of tuberculous peritonitis result from the reactivation of latent tuberculous foci. These foci follow hematogenous dissemination from the primary disease in the lung and remain latent. Tuberculous peritonitis is the result of silent foci reactivation. [6]

The most common site of involvement of gastrointestinal tuberculosis is the ileocecal region and rare clinical presentations include dysphagia and midoesophageal ulcer due to oesophageal tuberculosis, dyspepsia and gastric outlet obstruction due to gastroduodenal tuberculosis and rectal fistula and stricture due to rectal and anal tuberculosis. [6] The most commonly presenting symptoms of abdominal tuberculosis are reported to be abdominal distention (95%), abdominal pain (82%), weight loss (80%), weakness (76%), loss of appetite (75%) and fever (69%).

In the same report, the most common physical findings are ascites (96%), fever (75%) and abdominal tenderness (43%). [7] In our study, most patients presented with abdominal pain and ascites (20 cases; 70%), abdominal pain without ascites (four cases; 14%) and in two (14%) patients, there were mixed forms consisting of fibroadhesive type with small amounts of ascites and multiple interloop cysts. Presenting symptoms in our study were abdominal pain in 24 cases (85%) abdominal distension in 22 cases (78%), weight loss in 20 cases (70%), weakness in 20 cases (70%), loss of appetite in 21 cases (72%) and fever in 6 cases (22%). Chronic wasting illness was present in 22 patients.

Tuberculous peritonitis presents with different symptoms determined by wet and dry clinical phases. The wet phase corresponds to the early phase of the disease. Presenting symptoms are usually abdominal distention secondary to intraabdominal ascites, abdominal pain and weight loss. [8] The dry or fibroadhesive phase characterized by dense intraabdominal adhesions, follows the wet phase. Approximately 3% of the patients present with the fibroadhesive from or late phase. However, in our series, four patients (13%) had the fibroadhesive form, which demonstrates a delay in admission.

Earlier, a minimally invasive surgical procedure such as laparotomy was the only definitive diagnostic approach. But now laparoscopy is more frequently used for this purpose. [9] Macroscopic signs suggestive of abdominal tuberculosis in laparoscopy are small whitish tubercles over the visceral and parietal peritoneum; inflammatory adhesions on the visceral and parietal surface; thickening, hypermia and retraction of the greater omentum and a long fibrous band extending from the parietal to the visceral peritoneum termed "stalactic" which is characteristic of abdominal tuberculosis.

In our study, all patients showed small whitish tubercles (1-3mm) over the visceral and parietal peritoneum and there were four cases of stalactic, which is the best documentation of abdominal tuberculosis till date. There were four cases of dry forms with fibroadhesive bands and 22 cases of wet forms. In two cases, there were mixed forms of fibraodhesive along with ascites and multiple interloop cysts. In two cases, because of the fear of adhesion, before inserting the routine trocar in the laparoscopic procedure, we explored the abdomen with a finger through an ordinary, small infraumblical incision. There were no complications in any of the laparoscopies.

Our results revealed that macroscopic examination by laparoscopy is the most useful method in the diagnosis of abdominal tuberculosis. The macroscopic diagnosis rate by laparoscopy was reported to be 78% in one study. [10] In our series, the macroscopic diagnostic rate was 82%. Although more definite methods for TB diagnosis such as culture or PCR were not utilized in our study, the clinical picture, granulomatous peritonitis finding in pathology, high prevalence of TB in northern Iran and good response to antiTB therapy together seem sufficient to mark these patients as TB peritonitis patients. In all of our patients, antiTB treatment was instituted promptly and the symptoms of all patients disappeared very soon.


   Conclusion Top


Abdominal tuberculosis may be fatal but is medically cured if diagnosed in a timely fashion. It is essential that the clinician suspect the disease in patients presenting with the symptoms discussed earlier. Tests frequently associated with TB are not sensitive in detection of abdominal tuberculosis. CT, PCR and culture of ascitis fluid are the most useful tools of diagnosis but laparoscopy with tissue biopsy provided rapid and correct diagnosis of abdominal tuberculosis. Furthermore, laparascopy with tissue biopsy is the most sensitive and specific diagnostic procedure for abdominal peritonitis.

 
   References Top

1.Personal communication with control center. Tehran. Iran; 1993.  Back to cited text no. 1    
2.Marshall JB. Tuberculosis of gastrointestinal tract and peritoneum. Am J Gastrointest 1993;88:989-99.  Back to cited text no. 2    
3.Chen Ym, Lee DY, Perng PR. Abdominal tuberculosis in Taiwan a report from veterans, general hospital, Taipei. Tuber Lung Dis 1995;76:35-8.  Back to cited text no. 3    
4.Manohar A, Simjee AE, Hafejee AA, Pettegell KE. Symptoms and investigative finding in 145 patient with tuberculose peritonitis diagnosed by peritonoscopy and biopsy over a 5 years period. Gut 1990;31:1130-2.  Back to cited text no. 4    
5.Perkins MD, Conde MB, Martins M, Kritski AL. Serologic diagnosis of tuberculosis using a simple commercial. Chest. 2003;123:107-12.  Back to cited text no. 5    
6.Apaydin B. Paksoy M, Bilir M, Zengin K, Saribeyoglu K, Taskin M. Value of diagnostic laparoscopy in tuberculous peritonitis. Eur J Surg 1999;165:158.  Back to cited text no. 6    
7.Sheer TA, Coyle WJ. Gastrointestinal tuberculosis. Curr Gastroentrerol Rep 2003;5:273-8.  Back to cited text no. 7    
8.Sandikci MU, Colakoglus, Ergun Y, Unal S, Akkiz H, Sandikci S, et al . presentation and role of peritonescopy in the diagnosis of tuberculous peritonitis. J Gastroenterol Hepatol 1992;7:298-301.  Back to cited text no. 8    
9.Jorge AD. Peritoneal tuberculous. Endoscopy 1984;16:102.  Back to cited text no. 9    
10.Apaydin B, Pasoy M, Bilir M, Zengin K, Saribeyoglu K, Taskin M. Value of diagnostic laparoscopy in tuberculous peritonitis. Eur J Surg 1999;165:158-63.  Back to cited text no. 10    

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Correspondence Address:
Faizollah Safarpor
Razi Hospital Rasht, Guilan University of Medical Sciences, Guilan, 41448
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-3767.33465

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