4 WORLD GASTROENTEROLOGY NEWS OCTOBER 2017 Editorial | Expert Point of View | WCOG at ACG 2017 | WDHD News | WGO & WGOF News | WGO Global Guidelines | Calendar of Events HIV pandemic and malnutrition 2, 3. Abdominal TB is defined by the involvement of gastrointestinal tract and/or peritoneum and/or the mesen-teric lymph nodes and it is the sixth most common extrapulmonary site in the United States 4. HIV infection is a major risk factor for the develop-ment of TB 1. Furthermore, patients with underly-ing end-stage renal disease and con-tinuous ambulatory peritoneal dialysis (CAPD) are at risk to develop PT 5. In Western countries alcoholic liver disease (ALD) seems to be is a significant risk factor of developing PT, whereas in developing countries underlying liver disease is not linked to increased incidence of PT 6, 7. Peritoneal tuberculosis appears to be a consequence of hematogenous spread of Mycobacterium tuberculosis from a primary pulmonary site. My-cobacteria may rarely spread from ad-jacent organs such as the intestine or the fallopian tubes; ingesting contami-nated food such as milk or swallowing the sputum of pulmonary TB can lead to intestinal tuberculosis 8. Clinical features Peritoneal tuberculosis is a real medi-cal challenge because of its insidious and non-specific symptoms and the variability and paucity of its signs. Unless there is a high index of suspicion, PT diagnosis can easily be delayed or even missed. PT mortality rate is high, ranging from 15 to 30% 9. Delay in diagnosis is a major factor for the high mortality from TP 10. There are many presentations that will make the diagnosis of this life threatening infectious disease difficult. PT frequently occurs in patients with comorbid conditions such as renal failure or cirrhosis; this fact fur-ther adds to the diagnostic difficulty. Three different forms of peritoneal tuberculosis are described: the wet-as-citic, fibrotic-fixed and the dry-plastic ones 11. The wet-ascitic type is char-acterized by free or loculated ascites. The fibrotic-fixed type is characterized by abdominal masses composed of mesenteric and omental thickening. The dry-plastic type is characterized by dense adhesions, caseous nodules, and fibrous peritoneal reaction. Ascites is a common finding except in dry-plastic form. Fever accompa-nied by night sweats usually occurs in PT whereas absence of fever should not exclude the diagnosis. Weight loss, anorexia and malaise can be also noted in peritoneal tuberculosis. Vague abdominal pain is a frequent symptom that can be accompanied by abdominal distension or intermit-tent subacute intestinal obstruction. Diarrhea or constipation are uncom-mon 12. Tenderness on palpation, less often palpable masses, enlarged liver or sple-nomegaly can be detected by abdomi-nal examination Ascites is the usual finding. Yet, a small percentage of patients have only very mild ascites, which can only be detected by ultrasonography or during laparoscopy. The diagnostic approaches Changes of hematological indices in-cluding white cell count, erythrocyte sedimentation rate are non-specific. Usually in PT, the ascitic fluid is straw colored with protein >30g/L, and total cell count of 500-1500/ìl, the cells are predominantly lymphocytes (>70%). However, ascitic fluid total protein levels <25 g/L can be seen when PT complicates cirrhosis 6. A low serum-ascites albumin gradient (<11 g/L) is seen in 100% of patients with PT but its specificity remains low. Due to its low accuracy, ascitic LDH measurement is not used rou-tinely 13. The detection of MT in the ascites fluid is extremely insensitive and Mycobacterium detection is positive on smear in fewer than 3% of cases. A culture is positive in less than 20% of cases and takes 6 to 8 weeks. 14, 15. The polymerase chain reaction (PCR) test is another technique that has been in-troduced for detecting specific regions of bacterial genome; PCR detection of MTB from ascites fluid samples showed poor sensitivity 16. An abnormal chest X-ray can be seen in about 38% of cases, however, coexistent active pulmonary disease is uncommon 14. Ultrasonography can be very useful for PT diagnosis. Intra-abdominal fluid, which may be free or encysted, clear or with septae can be seen. In certain cases, only interloop ascites is noticed. Additionally, discrete or matted lymphadenopathy may be concomitant. Abdominal CT scan can be more accurate in dem-onstrating peritoneal, mesenteric or omental involvement. Commonly, the peritoneum is thickened and nodular; thickened mesentery associated with mesenteric lymph nodes may be seen in early cases 17. All radiologic findings are nonspecific and cannot confirm the diagnosis. Laparoscopy, an inva- Continued from first page. Peritoneal tuberculosis (PT) is the most common form of abdominal tuberculosis and leading cause of ascites in developing countries. Nowadays, ascitic adenosine deaminase can be a good, non-invasive test for PT diagnosis. PT mortality rate is high, ranging from 15 to 30%. Delay in diagnosis is a major factor for the high mortality from TP.
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