Abdominal Tuberculosis with Peritoneal Involvement
A 24-year-old female, HIV negative, presented three days post spontaneous vaginal delivery( a healthy male infant, birth weight 2.56kg, Apgar Score 9,9,10) with a one-month history of progressive abdominal pain and swelling, vomiting, inability to pass stool, cough, fever, night sweat and weight loss during pregnancy. The abdominal pain was predominantly on the right side, vague in nature on and off. The abdominal pain was associated with gradual abdominal swelling. Vomiting
reported as non-bloody, postprandial, and bilious, with about two episodes in a day for eight months and had been treated for hyperemesis gravidarum. She had no family history of chronic illnesses – hypertension, diabetes,
abdominal malignancy, and no history of smoking or alcohol intake. She had no record of any medications or any previous surgeries. On examination, she was sick looking, severely wasted, and dehydrated. She had normal blood pressure but had tachycardia. The abdomen was more protuberant than normal, with the uterus at 16 weeks with a completely involuted uterus, tenderness on palpation, hyper-resonant to percussion with absent bowel sounds.
The preliminary diagnosis was small bowel obstruction with a high index for suspicion for intraabdominal malignancy. Routine blood workups taken at admission were essentially normal.
Radiologically, CT Scan is more sensitive as a diagnostic tool.
Peritoneal involvement often takes two forms, either diffuse or nodular distribution. Imaging done included a CT abdomen, which suggested dilated stomach and small bowel loops with air-fluid levels, possibly due to ileus or adhesions with no free peritoneal air and moderate ascites. A high-resolution chest CT scan showedlobulated patchy density in the apical segment of the left upper lobe with thick-walled cavities.
Conservative management for possible small bowel obstruction was instituted. Gastric decompression, intravenous antibiotics, rehydration, soapy enema and catheterization were done. After 24 hours, symptoms continued to worsen. A decision was made to go in for an exploratory laparotomy. During the exploratory laparotomy, serous ascitic fluid was noted. There were distended loops of small bowel with a caked omentum and multiple nodular and mucinous deposits with a miliary distribution on the small and large bowel, omentum and peritoneum. A peritoneal biopsy was taken, and ascitic fluid collected.
Excessive small bowel adhesions were noted, possibly causing volvulus with a pivot point at the distal ileum. Adhesiolysis was done to relieve the obstruction.
Histopathological report of the peritoneal biopsies demonstrated a caseous granulomatous inflammation with caseification necrosis. The intraabdominal ascitic fluid collected revealed the presence of Mycobacterium tuberculosis. Medical management with a rifampicin-isoniazid-pyrazinamide-ethambutol combination was initiated and continued for six months. The patient showed significant improvement in subsequent clinics.
