Place of Laparoscopy in Peritoneal Tuberculosis

Introduction

Peritoneal tuberculosis (PT) remains a public health problem in endemic regions such as Tunisia. The diagnosis is difficult without specific clinical or laboratory signs. The laparoscopy exploration is actually the gold standard to make the diagnosis by exploring and performing peritoneal biopsies. The confirmation remains with the anatomopathological examination.

Case Reports

We report 4 patients with PT (Table 1), 3 girls and 1 boy. The middle age was 9 years old with extreme ages between 6 and 12 years. A history of nephrotic syndrome has been reported in a single patient. The revealing symptomatology was ascites in all cases. Chronic abdominal pain was observed in 3 cases and acute pain in 1 case. Only 1 patient presented weight loss, anorexia, fever, and night sweats. On clinical examination, there was a distended abdomen in all cases. A dullness of the entire abdomen on percussion was noted in 3 cases. General edema was noted in 1 case. A biological inflammatory syndrome was reported in 2 patients. All patients were explored by ultrasound. It revealed abundant ascites in all cases. This ascites was multicompartmental in 1 patient. Hepatomegaly was reported on ultrasound in 1 patient. Computed tomography (CT) was performed in 2 patients. It showed abundant ascites with micronodular thickening of the peritoneal layers with multiple mesenteric and retroperitoneal lymphadenopathies (Fig. 1). Magnetic resonance imaging (MRI) was performed in 1 patient, which showed abundant ascites with nodular thickening of the peritoneal layers (Fig. 2).

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FIG. 1.

Computed tomography: (A) Abundant ascites associated with micronodular thickening of the peritoneal layers. (B) Multiple mesenteric and retroperitoneal lymphadenoma. Color images are available online.

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FIG. 2.

Magnetic resonance imaging: Abundant ascites with nodular thickening of the peritoneal layers.

Laparoscopy was performed on all patients. It was indicated in emergency for 1 patient for the suspicion of peritonitis. The exploration by laparoscopic revealed for all patients, an abundance ascites with multiple visceroparietal adhesions and presence of whitish micronodules taking the aspect of granulation of 3–5 mm, scattered over the entire abdominal cavity (Figs. 3 and 4). An agglutination of the intestinal loops was noted in 2 cases (Fig. 5). This exploration was completed by a peritoneal biopsy for all patients (Fig. 6). Histological examination confirmed the diagnosis of PT for all patients. Antituberculosis treatment was introduced for 9 months in all patients. The clinical evolution was good with a follow-up of 30 months with extremes between 6 months and 4.5 years.

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FIG. 3.

Laparoscopic exploration: an abundant ascites, visceroparietal adhesions. Color images are available online.

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FIG. 4.

Laparoscopic aspect: whitish micronodules. Color images are available online.

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FIG. 5.

Laparoscopic exploration: inflammatory peritoneal cavity with agglutination of the intestinal loops. Color images are available online.

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FIG. 6.

Laparoscopic exploration: peritoneal biopsies. Color images are available online.

Discussion

Tuberculosis remains a significant cause of morbidity and mortality in endemic countries. The peritoneal tuberculosis (PT) is a rare form of extrapulmonary tuberculosis.^1,2 Its incidence varies from 0.1% to 0.7% among all forms of tuberculosis worldwide. ³ PT in children remains a rare entity and delay in treatment initiation can lead to high mortality.^2,4

PT is a subacute disease and its symptoms often progress over several months. It presents with nonspecific symptoms and signs, including abdominal masses, ascites, and weight loss. The ascites remains the most frequent symptom, as observed in the literature as well as in our study.^1,5–7

For PT, there is no specific biological marker or radiological examination, reported in literature, which contributes to the diagnosis. Classically a moderate inflammatory syndrome was founded. ⁸ Radiological examinations (ultrasound, CT, and MRI) are very limited in the diagnosis of PT because no pathognomonic radiological signs are associated. The most common radiological PT signs are ascites, lymphadenopathy, peritoneal thickening, and thickening of the intestinal loops. However, these radiological findings were not sufficient because these features are also detected in other diseases, such as primary malignant tumors, lymphoma, and peritonitis.^9,10

Laparoscopic exploration reminds actually the gold standard in case of no radiological contribution. In this case, three macroscopic aspects were described. The most common aspect is the thickened hyperemic parietal peritoneum with ascites and whitish granular nodules (5 mm) scattered over the peritoneum. The second aspect combines adhesions to signs of peritoneal inflammation. The third so-called fibroadhesive aspect is the rarest: it has nodules yellowish and marked peritoneal thickening with multiple thick adhesions partitioning the peritoneal cavity and the agglutination of the intestinal loops.^11,12 Besides these pathognomonic appearances, this laparoscopy allows us to take a peritoneal biopsy, which allows histological and bacteriological diagnosis.^5,11,12

Macroscopic examination of the peritoneum at laparoscopy coupled with the biopsy establish the diagnosis in 80%–95% of cases.^11–13

Most studies suggest that gross laparoscopic findings suggestive of PT had histopathological findings compatible with PT with a percentage varying according to the studies from 85% to 95%.^7,14

In addition, laparoscopy can result in a more rapid diagnosis of PT by a visual diagnosis during laparoscopy followed by histopathological verification, which takes a few days. Rather than relying on conventional microbiological assays, which may take up to 4–6 weeks and have low sensitivity.^7,14,15 In addition, there is evidence that delaying treatment, even by as little as 30 days can have considerable detrimental effects.^14,16

Most published studies have shown that the laparoscopy had an excellent accuracy for diagnosis of PT. As direct observation of the entire peritoneal space is feasible, targeted biopsy of suspicious nodules can be effortlessly carried out by laparoscopy.^14,15,17

If there are pathognomonic features on laparoscopy, it is imperative to start empirical anti-tuberculosis treatment even before the definitive histology.^14,15,18

Several studies conclude that in patients suspected to have PT without evidence of extra-abdominal disease, early laparoscopy is very useful to establish a diagnosis and early treatment can be instituted, to reduce the morbidity rate.^15,17,18

Histopathological results from peritoneum biopsy was extremely specific and accurate (100% positive) for PT,^15,17,18 as were the case in our cases as well when the diagnosis of PT was confirmed by laparoscopy with biopsy.

Conclusion

PT is an uncommon presentation of tuberculosis in children. Its diagnosis is more difficult because of nonspecific symptoms. Laparoscopy is a standard examination for the diagnosis of PT. It is the most reliable, fast, and safe method for definite diagnosis. It not only allows exploration of the peritoneum but also offers the possibility to obtain directed biopsies for histological and bacteriological examination.