Tuberculous Peritonitis:what About Imaging: Poster No.: Congress: Type: Authors

Tuberculous Peritonitis:what about imaging
Poster No.:
C-1548
Congress:
ECR 2013
Type:
Scientific Exhibit
Authors:
M. Abdelkafi , E. Daoud , H. Fourati , M. W. Turki , Y. Hentati , M.
1 1
Koubaa , M. Ben jemaa , Z. Mnif ; Sfax/TN, TN

Keywords:
Infection, Surgery, MR, CT, Conventional radiography, Abdomen
DOI:
10.1594/ecr2013/C-1548
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Purpose
The peritoneum is one of the most common locations outside pulmonary tuberculosis.
Peritoneal tuberculosis (PT) is due to the development of Koch's Bacillus(KB) in the
peritoneum. It is a disease that poses a public health problem in endemic regions of the
world. The phenomenon of migration, the increased use of immunosuppressive therapy
and the epidemic of AIDS have contributed to a resurgence of this disease in regions
where it was previously controlled.
The diagnosis of this disease is difficult and still remains a challenge because of its
insidious nature, the variability of presentation and limitations of available diagnostic
tests.
Early and accurate diagnosis leads to an effective therapy and good survival rates.
Delayed initiation of treatment can lead to high mortality rates. It is therefore necessary
to recognise the disease early and initiate treatment for this curable disease.
The purpose of this study was to illustrate radiographic findings in 28 cases of tuberculous
peritonitis with a literature review.
Methods and Materials

We report 28 observations of patients (10 male and 18 female) whose age ranges
between 14 and 61 years. Fever was seen in 19 patients. loss of weight, weakness and
anorexia were noted in 24 cases. 16 patients had abdominal pain and 11 presented
abdominal distension.2 patients had vomiting; 5 had night sweats and 4 had abdominal
mass. The duration of symptoms varied from one week to two months prior to attending
the hospital. Preoperative imaging was performed. It consisted in a plain abdominal film
in supine for 2 patients, abdominal ultrasonography for 23 patients and abdominal CT
for 15 patients. Laparotomy was performed for 27 patients and confirmed the peritoneal
tuberculosis histopathologically.
Results
The plain abdominal film didn't show any trouble. Abdominal ultrasonography showed
free or loculated ascites in 21 cases,loculated fluid collection in 4 cases.4 patients had a
tethering of the small bowel. Mesenteric thickening and nodular lesions of the mesentery
was noted in 6 patients and lymph nodes in 5 patients. Abdominal CT, when practised,
permitted a better characterisation of the disease by showing the most specific features
Page 2 of 9
of peritoneal tuberculosis mainly cocoon in 6 cases.Histopathological examination found

sclerosing encapsulating peritonitis also called abdominal cocoon in 6 cases.
Conclusion
PT remains a common public health problem in endemic regions of the world. It
is considered to be a result of rupture of the mesenteric lymph nodes seeded by
haematogenous dissemination from a distant primary focus (usually the lung) or
lymphatic spread from the primary lesion sites. Direct spread is rarely from the
genitourinary infection. The diagnosis of PT is difficult to establish because of its variable
clinical manifestations and nonspecific laboratory investigations. Accurate diagnosis of
tuberculous peritonitis is very important because there is a good prognosis following an
early and appropriate treatment. Imaging serves as an important non invasive diagnostic
tool for assessing the extent of the disease. Tuberculous peritonitis has been divided
into four types; "wet" type with free or loculated ascites (fig 1,2); "dry" or "plastic" type
with caseous nodules, fibrous peritoneal reaction and dense adhesions; "fibrotic fixed"
type with mass formation of omentum and matted loops of bowel and mesentery and
occasionally loculated ascites; and sclerosing encapsulating peritonitis (SEP) also known
as abdominal cocoon characterized by encasement of the small bowel by a thick, fibrous
membrane.
On the basis of this study and on previous reports, although no sonographic features
alone or in combination are pathognomonic for tuberculosis, septated ascites (fig 3), a
thickened peritoneum, and a thickened or nodular omentum are highly suggestive of PT .
PT is mainly manifested on CT by varying degrees of mesenteric and/or omental
infiltration with (wet type) or without (dry type) associated ascites. It has been suggested
that high density (25-45UH) may be characteristic of tuberculosis , which be explained
by the high protein and cellular contents in a tuberculous exudate.
However, tuberculous ascites may also be of near water density, perhaps reflecting an
earlier transudative stage of immune reaction.
Therefore, we did not record the density of the ascitic fluid in our patients. We found
ascites in 21 cases,loculated in 10 cases.
Peritoneal enhancement is usually associated with smooth uniform thickening of the
peritoneum (fig 4).Nodular implants with irregular thickening (fig 5) are extremely
uncommon and should suggest a diagnosis of peritoneal carcinomatosis.In our study,
peritoneal involvement was present in 15 patients. In most of our patients, the peritoneum
showed a unique type of enhanced and smooth uniform thickening.
Involvement of the omentum is classified as nodular, smudged (infiltration with ill-defined
lesions)(fig 6) ,and caked
(soft tissue replacement)appearances(fig 7).CT reveals omental
Page 3 of 9
changes in most cases in up to 80% of cases.

The smudged type is the most common type demonstrated by CT, while the caked
type is uncommon. We found omental involvement in 10 cases and the smudged type
was the most common. The caked pattern was found in 2 cases. In these cases, we
could not distinguish tuberculous peritonitis from peritoneal carcinomatosis. The omental
caking is more commonly seen in peritoneal carcinomatosis. The nodular type of omental
involvement has not been reported in any case with tuberculous peritonitis, but it was
reported in3 of our patients .
Mesenteric infiltration varies from mild involvement in the form of linear soft tissue
strands ,thickened(fig 4) and crowded vascular bundles (fig 6),a"stellate"appearance,
and/or subtle increase in mesenteric fat density, to more extensive involvement resulting
in diffuse infiltration with soft tissue density masses involving the leaves of the mesentery
surrounding the adjacent small bowel loops.
SEP secondary to tuberculosis is extremely rare. To date,tuberculous abdominal cocoon
has been reported in 11 cases only, the largest series comprising six cases.
Preoperative diagnosis of abdominal cocoon is difficult because of non-specific clinical
features and reduced awareness. Imaging (barium meal follow through"BMFT"and CT)
studies play an important role in the definitive preoperative diagnosis of abdominal
cocoon.
Radiographs are not specific and may show evidence of small bowel obstruction. The
BMFT shows reduced transit time and serpentine or concertina-like configuration of
dilated small bowel loops in a fixed U-shaped cluster (fig 8).The CT bestshows the fibrous
membrane encasing the bowel loops (fig9);thus, helps in reaching a definite diagnosis.
In conclusion,manifestations of tuberculous peritonitis are variable. CT reliably
demonstrates the entire range of findings. Although no single CT feature is diagnostic of
the disease, CT findings interpreted in the light of clinical and laboratory data, can be a
valuable tool in the diagnosis of abdominal tuberculosis. The common features in
the patients with tuberculous peritonitis include the combination of free ascites, thickened
strands with crowded vascular bundles within the mesentery, smudged pattern of the
omental involvement, and smooth uniform thickening of the peritoneum.
Images for this section:
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Fig. 1
Fig. 4
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Fig. 5
Fig. 9
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Fig. 6
Fig. 8
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Fig. 7
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References
1-AnkurGadodia,RajuSharma and Nadarajah Jeyaseelanr.Images in Clinical Tropical
Medicine Tuberculous Abdominal Cocoon.Am. J. Trop. Med.Hyg., 84(1), 2011, pp. 1-2
2-JoshuaBurrillet and al.Tuberculosis: A Radiologic Review.RadioGraphics 2007;
27:1255-1273
3-Na Chiang MaiW ,Pojchamarnwiputh S,LertprasertsukeN,Chitapanarux T.CT findings
of tuberculous peritonitis.Singapore Med J 2008; 49(6) : 488
4-TheeraTongsonget and al.Sonographic Features of Female Pelvic Tuberculous
Peritonitis. JUltrasoundMed 2007; 26:77-82
5-UzunkoyA,HarmaM,HarmaM.Diagnosis of abdominal tuberculosis: experience from 11
cases and review of the literature. World JGastroenterol2004; 10:3647-3649.
6-MalikA,SaxenaNC.Ultrasoundin
28:574-579.
abdominal
tuberculosis.
AbdomImaging
2003;
7-SuriS, Gupta S,SuriR. Computed tomography in abdominal tuberculosis. Br J Radiol

1999; 72:92-8.
8-A.Guirat and al.Peritoneal tuberculosis.Clinics and Research in Hepathology and
Gastroenterology (2011) 35, 60-69
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Tuberculous Peritonitis:what about imaging

M. Abdelkafi , E. Daoud , H. Fourati , M. W. Turki , Y. Hentati , M.

Koubaa , M. Ben jemaa , Z. Mnif ; Sfax/TN, TN

Infection, Surgery, MR, CT, Conventional radiography, Abdomen

Methods and Materials

of peritoneal tuberculosis mainly cocoon in 6 cases.Histopathological examination found

changes in most cases in up to 80% of cases.

7-SuriS, Gupta S,SuriR. Computed tomography in abdominal tuberculosis. Br J Radiol

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