Tuberculous peritonitis. Identification difficulties

Aim. To study forms of the course of the disease, variations of clinical and morphological manifestations and diagnostics of tuberculous peritonitis with determination of optimal examination and surgical tactics algorithm. Materials and methods. In the period from 2009 to 2018 in the Tuberculosis surgery department of the Moscow Research and Clinical Center for Tuberculosis Control 58 patients with tuberculous peritonitis were examined and operated. Among the hospitalized patients, males prevailed (males - 39; 67.2%, females - 19; 32.8%), while the patients' age ranged from 20 to 63 years (median - 37.2 years). The complex examination of patients included diagnostic radiology methods (MSCT and ultrasonography) of the abdominal cavity and chest, diagnostic video laparoscopy, laboratory and morphological methods. Results and discussion. According to the clinical and morphological picture of peritoneal tuberculosis, all patients were divided into three groups: patients with the predominant syndrome of fluid accumulation in the abdominal cavity (37, 63.8%), patients with the prevailing enterocolitis syndrome and intestinal obstruction (19, 32.8%), patients with symptoms of peritonitis and abdominal sepsis (2, 3.4%). Anamnestic data on the timing of occurrence and course of the disease allowed to speak of the extreme variability in the course and duration of tuberculous peritonitis. Non-invasive diagnostic radiology methods showed a high level of informativeness in visualization of free fluid in the abdominal cavity (more than 90% positive results), but its detection with MSCT or ultrasonography can only serve as indirect evidence of tuberculous peritonitis, as it is observed in a wide range of diseases. Accumulations of fluid in the abdominal cavity in the presence of thickened and layered areas of the peritoneum, as well as signs of partial or complete small bowel obstruction detected with MSCT may be markers of peritoneal tuberculosis in 81% of cases, but laboratory confirmation of the process etiology is always required. The examination of exudates in only one third of cases allowed to identify the pathogen with PCR (29.3%), bacteriological examination showed bacterial growth of the MBT after 8-9 weeks in only 8.6% of patients. Only a peritoneal biopsy with bacterioscopic and histological examination of the biopsy specimen showed the highest confidence rates in the detection of Acid-Resistant Mycobacterium (74.1%) and specific granulomas (93.1%) or their equivalents in cases of HIV infection. Conclusion. With all the variety of clinical and morphological pictures of tuberculous peritonitis, the only highly informative diagnostic method is surgical involvement with a peritoneal biopsy followed by bacterioscopic and histological examination of biopsy specimen.

abdominal tuberculosis, peritoneal tuberculosis, peritonitis, biopsy, video laparoscopy