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Tuesday, 28 February 2012

Diagnosis and Management Tuberculosis Peritonitis with Intestinal Obstruction

Tuberculosis is still an endemic disease that is quite worrying in Indonesia. From the existing data that Indonesia occupied the position-3 in the world after China and India. However, for the discovery of new cases in recent years Indonesia occupied the fifth position after China, India, Philippines and Thailand. This does not necessarily indicate that tuberculosis has been declining in Indonesia, probably many factors that cause yain. Because of Indonesia's total population is pretty much (pulmonary tuberculosis), then the extra-pulmonary tuberculosis were also many in Indonesia, especially nutritional status in Indonesia is still not good.

A. Definition
Peritoneal tuberculosis is an inflammation of the parietal or visceral peritoneum caused by the bacteria Mycobacterium tuberculosis, and the disease is also frequently seen on the entire peritoneum, gastrointestinal system tools, mesentery and internal organs genetalia

B. Incidence
Peritoneal tuberculosis is more common in women than men with a ratio of 1.5:1, and more often decades to 3 and 4. Peritoneal tuberculosis found 2% of all pulmonary tuberculosis and 59.8% of abdominal tuberculosis. In the United States this disease is the sixth largest among extra pulmonary disease, while other researchers found that only 5-20% of patients with peritoneal tuberculosis who have active pulmonary TB. At this time it was reported that cases of peritoneal tuberculosis in developed countries is increasing and this increase is in accordance with the increasing incidence of AIDS in developed countries. 1
She Asia and Africa where tuberculosis is still prevalent, peritoneal tuberculosis is still an important issue. Manohar et al reported on King Edward III Hospital Durban South Africa found 145 cases of peritoneal tuberculosis over a period of 5 years (1984-1988) while peritonoskopi way. Daldiono find as many as 15 cases at Cipto Mangunkusumo Hospital in Jakarta during the period 1968-1972 and Solomon in the same hospital period 1975-1979 found a total of 30 cases of peritoneal tuberculosis was also Sibuea et al reported there were 11 cases of peritoneal tuberculosis in hospital for a period Tjikini Jakarta 1975 to 1977. Whereas in Medan Zain LH reported there were 8 cases during the period 1993-1995.

C. Pathogenesis
Peritoneal tuberculosis can be subjected by a number of ways:
A. Through haematogenous spread mainly from lung
2. Through the intestinal wall of infected
3. From mesenteric lymph nodes
4. Through the fallopian tubes are infected
In most cases of peritoneal tuberculosis occurs not as a result of the spread perkontinuitatum but often due to reactivation of latent processes that occur in the peritoneum obtained through previous haematogenous spread of the primary process (latent infection "Dorman infection"). As is known to have tuberculosis lesion suppression and healing. Still in the latent phase of infection where it can persist throughout life, but latent infection can develop into tuberculosis had at any time. If the organ was started bermutiplikasi intrasseluler quickly.

D. Pathology
There are three forms of tuberculous peritonitis,

A. Exudative form
This form is also known as the wet form or many forms of ascites, prominent symptoms of the stomach is enlarged and filled with fluid (ascites). In this form adhesions are not often found. Tubercles often found small white miliary yellowish, appear scattered on the peritoneum or organs in the peritoneal cavity.
Besides the small particles that were found larger tubercles up for peanuts. Tissue reaction around the tubercles there is a congestion of blood vessels peritoneum. Exudate can form quite a lot, and the peritoneum covering the tubercles and changes the tense abdominal wall, ascites fluid are sometimes mixed with blood and redness that looks suspicious possibility of malignancy. Omentum can be affected resulting in thickening and felt like a lump of tumor.

B. Form of adhesive
Also referred to as a form of dry or liquid plastic which is not much formed. In this type occurs more frequently adhesions. Extensive adhesions between the intestines and peritoneum often give you an idea such as tumors, are sometimes formed fistula. This is because the presence of adhesions, adhesions.
Sometimes a fistula is formed, this was due to adhesions to the bowel wall and parietal peritoneum thereon necrosis process. This form often leads to a state of ileus obstruction. Tubercles, tubercles are usually larger.

C. Form of a mixture
This form is sometimes referred to as cysts, cystic swelling occurs through a process of exudation, together with adhesion to form pockets of fluid in these adhesions.
Some authors consider that this division is more to see the level of disease, which occurs initially and then form the shape exudatif adhesive. Giving hispatologi peritoneum biopsy tissue will show tuberculous granulation tissue composed of epithelial cells and cell datia, Langerhans, and pengkejutan commonly found.

E. Clinical symptoms
Clinical symptoms vary, in general, complaints and symptoms occur slowly for months, often patients are not aware of this situation. On physical examination are common symptoms are ascites, fever, abdominal swelling, abdominal pain, pallor and fatigue, depending on the duration of the complaint.
Patient's general condition is still good enough to be thin and kahexia circumstances, often found in women with peritoneal tuberculosis by tuberculosis process in the ovaries or fallopian, so that the genitals can be found signs of inflammation are often difficult to distinguish from ovarian cysts.

F. Examination Support
Peripheral blood examination of common chronic disease anemia, mild leukocytosis or leukopenia, thrombocytosis, impaired liver physiology and common erythrocyte sedimentation rate (ESR) is increased, while in the examination of tuberculin test results are often negative,
On examination of ascitic fluid analysis generally showed exudates with protein> 3 g / dl above the number of cells 100-3000sel/ml. Typically more than 90% is usually meningkat. lymphocyte LDH,
Perulen ascites fluid can be found as well as bloody ascites fluid (serosanguinous). Examination of acid-fast bacilli (AFB) found the results were less than 5% of the positive and the culture fluid was found less than 20% positive results.
There are some researchers who have almost 66% of culture positive BTAnya and will increase again to 83% when using a culture of ascites fluid that had disentrifugejengan number more than 1 liter of fluid. And ascitic fluid culture results can be obtained within 4-8 weaks
Comparison of serum ascites albumin (Saag) in peritoneal tuberculosis was found the ratio is <1.1 g / dl, but it can also be found on the state of malignancy, nephrotic syndrome, pancreatic disease, gallbladder or connective tissue, while if found> 1.1 g / dl This is due to portal ascites fluid.
Comparison of blood glucose in ascites fluid with peritoneal tuberculosis <0.96, while the other causes of ascites with a ratio> 0.96. Decrease in ascitic fluid pH and elevated levels of lactate can be found in peritoneal tuberculosis and found significantly different from ascites fluid on a sterile liver cirrhosis, but examination of pH and lactate content of ascites fluid is less specific and not yet a certainty because it is also found in cases of ascites due to malignancy or spontaneous bacterial peritonitis.
Examination of ascitic fluid is another very helpful, quick and non invasive is the examination of ADA (adenosine deminase actifity), interferon gamma (IFNΥ) and PCR. With ADA levels> 33 u / l had a sensitivity of 100%. Specificity 95%, and the cutt off> 33 u / l to reduce false positive of liver cirrhosis or malignancy.
In the liver cirrhosis was significantly lower concentrations of NO from peritoneal tuberculosis. Hafta A et al in a study comparing the concentration of NO to the patient's peritoneal tuberculosis, peritoneal tuberculosis concurrent with liver cirrhosis and passien-only liver cirrhosis patients. They concluded that the protein concentration with a low asietas ADA value may be a false negative. For this examination Gama interferon (INFΥ) is even better value together with an examination dalah ADA, whereas the PCR results are lower than the second examination. Fathy ME reported a sensitivity rate for peritoneal tuberculosis examination of Gama interferon was 90.9%, NO: 18.8% and 36.3% PCR with each of the specificity of 100%. Other researchers who examined the levels of ADA Bargava. Bargava et al conducted a study of ADA levels in ascitic fluid and serum of patients peritoneal tuberculosis. ADA levels> 36 u / l in ascites fluid and> 54 u / l in serum supporting a diagnosis of peritoneal tuberculosis. Comparison of ascites fluid and serum (asscitic / serum ADA ratio) is more tingggi on peritoneal tuberculosis than in other cases such as cirrhosis, liver cirrhosis with spontaneous bacterial peritonitis, and Budd chiary Ratio> 0.984 sustain a tuberculosis.
Another inspection is a check-125.CA CA-125 (Canker antigen 125), including tumor-associated glycoprotein and found on the cell surface. CA-125 is an ovarian carcinoma associated antigen, the antigen is not found in normal adult ovary, but the CA-125 is reported, is also elevated in benign and malignant state, where approximately 80% increase in women with ovarian malignancy, 26% in the first trimester of pregnancy, menstruation, endometriosis, myoma uteri daan salpingitis, also other gynecological primary cancers sepeerti endometrium, fallopian tube, endocervix, pancreas, kidney, colon also in non-malignant conditions such as chronic renal failure, autoimmune disease, pancreatitis, cirrhosis liver, inflammation of the peritoneum such as tuberculosis, pericardium and pleura, but several reports that found elevated levels of CA-125 in patients with peritoneal tuberkulossis as reported by Sinsek H (Turkey 1996). Zain LH (Field 1996).
Zain LH in Medan in 1996 found eight cases of tuberculosis found peritoneal levels of CA-125 levels rose by an average of 370.7 u / ml (66.2 to 907 u / ml) and concludes when found elevated serum CA-125 with with the exudate ascites fluid, cell count> 350/m3, the dominant lymphocyte peritoneal tuberculosis can be considered as a diagnosis. Bebrapa researchers using CA-125 to see the response to treatment as did Mas MR et al (Turkey, 2000) found the same high CA-125 with ovarian cancer after administration of anti-tuberculosis and serum CA-125 levels to normal levels when a previous average CA-125, 475.80 5.8 u / ml (normal <35 u / ml) after 4 months of anti-tuberculosis treatment. Lately, Teruya J et al in 2000 in Japan found elevated levels of CA 19-9 in serum and ascitic fluid and peritoneal tuberculosis patients were treated for 6 weeks after reduction in CA19-9 is found to be normal.

On ultrasonography (USG) can be seen in the peritoneal cavity of fluid that is free or fixed (in the form of bags) according to Rama & Walter B, sonographic picture of tuberculosis is often found among others that are free or localized fluid in the abdominal cavity, the cavity of the abscess abdomen, the area ileosaecal and retroperitoneal lymph node enlargement, thickening of the mesentery, adhesions to the bowel lumen and thickening of the omentum, may be seen and should be checked carefully Mizzunoe et al successfully used ultrasound as a tool in a closed biopsy in diagnosing tuberculous peritonitis.

Peritonoskopi (Laparoscopic)
Peritonoskopi / laparoscopy is a relatively safe, easy and best way to diagnose tuberculosis, especially when there is peritoneal ascites fluid and very useful to get a diagnosis of young patients with symptoms of abdominal pain of obscure cause (27.28) and in this way can diagnose tuberculosis peritoneal 85% to 95% and with a directed biopsy can dilakukukan histologic examination and could find a picture of granuloma by 85% to 90% of all cases and when it's done AFB culture can be found almost 75%. Histology results are even more important is obtained when a more specific granuloma that is, if found to be granulomas with shocking.18 picture can be seen in peritoneal tuberculosis:
A. Large or small tubercles varying sizes are found widespread in the peritoneum and intestinal wall and can also be found the surface of the liver or other devices can join and tubercles is as nodules.
. Adhesions which may vary from the simple to the severe (wide) between the means within the peritoneal cavity. These circumstances often change the location of the normal anatomy. Surface of the heart can cling to the walls of the peritoneum and difficult to recognize. Adhesions between the bowel mesentery and peritoneum can be very extensive.
3. Peritoneum often experience changes with a very rough surface that is sometimes changed the picture resembles a nodule.
4. Ascites fluid often dujumpai clear yellow, sometimes clear liquid becomes turbid again but, hemoragis fluid can also be found. A biopsy can be directed to the tubercles, tubercle directionally or other suspect tissue disorders with a special biopsy menggunakanalat fluid can be removed at once.
Even though the general picture of tuberculosis peritonitis peritonoskopi can be easily identified, but the picture of the picture can resemble other diseases such as peritonitis carcinomatosis, therefore biopsy should always be sought and treatment should be given if the results of anatomic pathology support a tuberculous peritonitis. Peritonoskopi not always easy to do and of the 30 cases, 4 cases do not technically considered peritonoskopi because the danger and hard work.
The existence of an extensive network of adhesions will be obstacles and difficulties in entering trokar and further narrow room in the abdominal cavity examination also makes it difficult and often means peritonoskopi trapped in a cavity filled with adhesions, making it difficult to know the anatomy picture of the tools and in normal circumstances it should be done laparotomy diagnostic.

First exploratory laparotomy is often performed actions yangs diagnosis, but now many authors consider surgery only if a more simple way gave the assurance of no diagnosis or if found urgent indication such as intestinal obstruction, perforation, presence of ascites fluid.

X-ray examination:
Ray through the digestive system may be helpful if acquired abnormalities of the small intestine or colon,
Photo illustration by contrast barium rongent shows gastric tuberculose 

Plain abdominal radiology showing diffuse calsification mesentric lymphadenopathy
CT Scan:
CT Scan for peritoneal tuberculosis have not seen a picture of a typical, but the general picture of the peritoneum was found that the sand and for the proof to be found in conjunction with the clinical symptoms of peritoneal tuberculosis. Rodriguez E et al who conducted a study comparing peritoneal tuberculosis and peritoneal dengankarsinoma peritoneal carcinoma with a view
CT scan image of the parietal peritoneum.
The existence of a smooth peritoneum with minimal thickening and enlargement clearly shows a peritoneal tuberculosis while embedded nodules and thickening of the peritoneum which regularly shows a perintoneal karsinoma.

Abdominal CT scans in patients with AIDS show
Edematous jejunal loops and extensive limfodenopati
Which proves the existence of infection intercellulare mycobakterium
CT Scan in HIV positive patients with intra-abdominal tuberculose
shows an overview acites, omental thickening and stranding mesentery

G. Treatment
The treatment basically the same as the treatment of pulmonary tuberculosis, drugs such as streptomycin, INH, Ethambutol, pyrazinamide Ripamficin and gives good results, and improvements will be seen after 2 months of treatment and duration of treatment is usually up to nine months to 18 months or more. minimal :  RHZE for two month  andthan HR for 6-9 month.   Some authors suggest that corticosteroids can reduce inflammation and adhesions to reduce the occurrence of ascites. And also shown that corticosteroids can reduce morbidity and mortality, but corticosteroids should be avoided in endemic areas where there is resistance to Mikobakterium tuberculosis.1, 2
Alrajhi et al who conducted a retrospective study of 35 patients with peritoneal tuberculosis found that administration of corticosteroids as additional drugs are proven to reduce the incidence of blockage in the stomach.
In cases that do peritonoskopi after treatment shows that the particles disappear, but in some places still see the adhesion.

In the event of tuberculous peritonitis with intestinal obstruction, laparotomy is performed release sought not mereseksi bowel obstruction. Then, given the drainage and biopsy for the diagnosis must be made

H. Prognosis
Tuberculous peritonitis if it can be enforced and will generally be treated with medicine to heal the adequate.1

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