TB Peritonitis

TB Peritonitis
swallowing of sputum with direct seeding, hematogenous

spread,ingestion of milk from cows affected by bovine TB.
• Although any portion of the gastrointestinal tract may be affected, the
terminal ileum and the cecum are the sites most commonly involved.
• Abdominal pain and swelling, obstruction, hematochezia, and a
palpable mass in the abdomen are common findings at presentation.
Fever, weight loss, anorexia, and night sweats are also common. With
intestinal-wall involvement, ulcerations and fistulae may simulate
Crohn's disease; the differential diagnosis with this entity is always
difficult. Anal fistulae should prompt an evaluation for rectal TB.
• As surgery is required in most cases, the diagnosis can be established by
histologic examination and culture of specimens obtained
intraoperatively.
• Tuberculous peritonitis follows either the direct spread of tubercle
bacilli from ruptured lymph nodes and intraabdominal organs (e.g.,
genital TB in women) or hematogenous seeding. Nonspecific
abdominal pain, fever, and ascites should raise the suspicion of
tuberculous peritonitis. The coexistence of cirrhosis (Chap. 307) in
patients with tuberculous peritonitis complicates the diagnosis. In
tuberculous peritonitis, paracentesis reveals an exudative fluid with
a high protein content and leukocytosis that is usually lymphocytic
(although neutrophils occasionally predominate). The yield of direct
smear and culture is relatively low; culture of a large volume of
ascitic fluid can increase the yield, but peritoneal biopsy (with a
specimen best obtained by laparoscopy) is often needed to establish
the diagnosis
Acute Peritonitis
• Peritonitis is an inflammation of the peritoneum; it may be
localized or diffuse in location, acute or chronic in natural
history, and infectious or aseptic in pathogenesis. Acute
peritonitis is most often infectious and is usually related to a
perforated viscus (and called secondary peritonitis). When no
intraabdominal source is identified, infectious peritonitis is
called primary or spontaneous. Acute peritonitis is associated
with decreased intestinal motor activity, resulting in distention
of the intestinal lumen with gas and fluid (adynamic ileus). The
accumulation of fluid in the bowel together with the lack of oral
intake leads to rapid intravascular volume depletion with effects
on cardiac, renal, and other systems.
Etiology
• Infectious agents gain access to the peritoneal cavity through a
perforated viscus, a penetrating wound of the abdominal wall, or
external introduction of a foreign object that is or becomes infected
(e.g., a chronic peritoneal dialysis catheter). The conditions that most
commonly result in the introduction of bacteria into the peritoneum are
ruptured appendix, ruptured diverticulum, perforated peptic ulcer,
incarcerated hernia, gangrenous gall bladder, volvulus, bowel infarction,
cancer, inflammatory bowel disease, or intestinal obstruction.
• Bacterial peritonitis can also occur in the apparent absence of an
intraperitoneal source of bacteria (primary or spontaneous bacterial
peritonitis). This condition occurs in the setting of ascites and liver
cirrhosis in 90% of the cases, usually in patients with ascites with low
protein concentration (<1 g/L).
• aseptic peritonitis may be due to peritoneal irritation by
abnormal presence of physiologic fluids (e.g., gastric
juice, bile, pancreatic enzymes, blood, or urine) or sterile
foreign bodies (e.g., surgical sponges or instruments,
starch from surgical gloves) in the peritoneal cavity or as
a complication of rare systemic diseases such as lupus
erythematosus, porphyria, or familial Mediterranean
fever. Chemical irritation of the peritoneum is greatest
for acidic gastric juice and pancreatic enzymes.
Secondary bacterial infection is common in chemical
peritonitis
Clinical Features
• The cardinal manifestations of peritonitis are acute
abdominal pain and tenderness, usually with fever. The
location of the pain depends on the underlying cause and
whether the inflammation is localized or generalized.
Localized peritonitis is most common in uncomplicated
appendicitis and diverticulitis, and physical findings are
limited to the area of inflammation. Generalized peritonitis is
associated with widespread inflammation and diffuse
abdominal tenderness and rebound. Rigidity of the
abdominal wall is common in both localized and generalized
peritonitis. Bowel sounds are usually but not always absent.
• Tachycardia, hypotension, and signs of dehydration are
common. Leukocytosis and marked acidosis are common
laboratory findings. Plain abdominal films may show dilation of
large and small bowel with edema of the bowel wall.
• Free air under the diaphragm is associated with a perforated
viscus. CT and/or ultrasonography can identify the presence of
free fluid or an abscess. When ascites is present, diagnostic
paracentesis with cell count (>250 neutrophils/L is usual in
peritonitis), protein and lactate dehydrogenase levels, and
culture is essential. In elderly and immunosuppressed patients,
signs of peritoneal irritation may be more difficult to detect.
Therapy
• Treatment relies on rehydration, correction of
electrolyte abnormalities, antibiotics, and
surgical correction of the underlying defect.

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TB Peritonitis

swallowing of sputum with direct seeding, hematogenous

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