Abdominal tuberculosis mimicking acute abdomen: the role of laparoscopy

Ernesto Miranda-Cervantes, MD, Jorge Carmona-Cantu, MD, Mauricio Castano-Eguia, MD, Aurora Guillen-Graf, Ulises Caballero-DelaPena, MD, Berenice Medina-Ortiz. Chistus Muguerza Hospital Alta Especialidad / UDEM

INTRODUCTION

Tuberculosis remains a major global health problem, in 2012 it was estimated that there were 8.6 million new cases and 1.3 million deaths from the disease.

In the past 2 decades the rate of active tuberculosis has decreased globally by 37%, but the reduction was primarily in pulmonary tuberculosis, whereas extrapulmonary tuberculosis has remained stable.

The association of peritoneal disease with pulmonary tuberculosis has been reported in 20% to 50% of cases. Peritoneal tuberculosis may originate from lymphatics (mesenteric lymph nodes) or through blood.

Case 1

A 21-year-old female with a four-day history of moderate abdominal pain of diffuse localization. Physical examination revealed a normal contour abdomen, absent peristalsis, tense, and generalized tenderness with a positive Blumberg sign.

Case 2

A 38-year-old male with a two-week history of moderate epigastric abdominal pain and 38ªC fever. Physical examination found pain in the epigastrium followed by rebound tenderness.

Both patients underwent computed tomography (CT), where ascitic fluid with diffuse wall thickening of the peritoneum and omentum was observed. (Figure 1)

During laparoscopy straw-like fluid was found with diffuse implants in the abdominal cavity (Figure 2,3). Pathology results described a granulomatous chronic inflammatory process associated with tuberculosis.

DISCUSSION

Peritoneal tuberculosis continues to be a latent problem in developing countries. Exudative ascites with abdominal pain and fever is the classic presentation, representing 70% of the cases. But, the incidence of tuberculosis as a cause of ascites is reported only in 2% of the patients with this clinical manifestation.

CT characteristics are attenuation values of ascitic fluid of 20-45 HU and nodular and thickened peritoneum.

The previous cases demonstrated these same characteristics with inflammatory ascites and the thickening of the peritoneum.

Detection of Mycobacterium tuberculosis in the ascitic fluid is very difficult and it is positive on direct examination in 5% of cases

CONCLUSION

Laparoscopy is the preferred diagnostic technique, with a sensibility of 93% and specificity of 98%, besides not only does it allow the inspection of the peritoneum but also allows the option of taking biopsies.