Tuberculous peritonitis - reports of 26 cases, detailing diagnostic and therapeutic problems

Objective To evaluate the clinical presentation, biochemical (ascites and s erum) and laparoscopic findings, and to assess the efficacy of triple antit uberculous therapy without rifampicin for 6 months in patients with tubercu lous peritonitis. Methods Twenty-six tuberculous peritonitis patients (11 male, 15 female) wi th a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features. Results The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in a ll patients. An abnormal chest radiography suggestive of previous tuberculo sis was present in five patients (19.2%), and two patients (7.7%) had extra -peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 o f the 25 patients who underwent laparoscopy with directed biopsy, whitish n odules suggested tuberculous peritonitis; 76% of the biopsy specimens revea led caseating, 20% non-caseating granulomatous inflammation, and 4% non-spe cific findings. The ascitic fluid of one patient (3.8%) was positive for ac id-resistant bacilli, and culture was positive in two patients (7.7%). Twen ty-four of the patients were treated for 6 months with isoniazid, streptomy cin (total dose 40 g) and pyrazinamide (for the first 2 months and then sub stituted with ethambutol). Eighteen patients also received methyl prednisol one, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain ab ated earlier in patients on steroid therapy. AII but two of the 24 patients responded to treatment. Conclusion Non-invasive tests such as acid-fast stain and culture of the as citic fluid are usually insufficient, hence invasive laparoscopy and perito neal biopsy are necessary for the diagnosis of tuberculous peritonitis if n on-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis. for J Gastroenterol Hepatol 1 3: 581-585 (C) 2001 Lippincott Williams & Wilkins.