A bacterial contamination from spillage an intraabdominal viscus it could be life threatening event
TUBERCULOUS PERITONITIS
Infection occurs most commonly mass reactivation of latent tuberculous foci in the peritoneum that were established from hematogenous spread from a primary lung focus , It can also become via hematogenous spread from active pulmonary or miliary TB. Much less frequently, the organisms enter the peritoneal cavity transmurally from an infected diminutive intestine or contiguously from tuberculous salpingitis .
Peritoneal T.B. is an uncommon site of extrapulmonary infection caused by Mycobacterium T.B. (TB). The venture is accumulated in patients with cirrhosis, retrovirus infection, diabetes mellitus, underlying malignancy, mass treatment with anti-tumor necrosis factor (TNF) agents, and in patients undergoing continuous ambulatory peritoneal dialysis.
As the disease progresses, the visceral and parietal peritoneum become progressively studded with tubercles. Ascites develops alternative to "exudation" of proteinaceous fluid from the tubercles, similar to the mechanism leading to ascites in patients with peritoneal carcinomatosis. More than 90 percent of patients with TB rubor have ascites at the time of presentation, while the remainder present with a more advanced "dry" phase, representing a fibroadhesive modify of the disease.
Pathologically Gastrointestinal tuberculosisis characterized by rousing and fibrosis of the bowel surround and the regional lymph nodes. Mucosal lesion results from necrosis of Peyer patches, lymph follicles, and vascular thrombosis. At this stage of the disease, the changes are rechargeable and healing without scarring is possible. As the disease progresses, the lesion becomes confluent, and extensive fibrosis leads to bowel surround thickening, fibrosis, and pseudotumoral accumulation lesions. Strictures and fistulae formation may occur.
ORIGIN OF INFECTION from tberculous mesentric lymph nodes .from tuberculosis of ileocecal region ,from tuberculous pyosalpinx ,Blood-borne infection from pulmonary tuberculosis ,usually milliary.
CLINICAL TYPES
ASCITIC FORM peritoneum is studded with tubercles and peritoneal cavity becomes filled with pale ,straw colored fluid .its onset is insidious .with loss of energy , facial pallor and some loss of weight ,enlargement of abdomen ,pain often completely absent ,but there may br abdominal discomfort ,usually associated wih constipation or diarrhea . Even pyrexia and night sweats.
Dilated veins can be seen coursing beneath the skin of abdominal wall. shifting dullness and fluid thrill present , congenital hydrocele sometimes appear in male child .Umblical hernia may develop .A transverse solid mass can often be palpated per abdominally ,( this is rolled up greater omentum infiltrated with tubercles )
ENCYCTED ( LOBULATED ) FORM pathologically it is similar to ascitic form , but one part of abdominal cavity alone is involved .clinical features also resemble to ascitic form ,but there is a localized intraabdominally lump . .localized intraabdominally swelling .fluid thrill and shifting dullness may or may not be present ,depending upon the site of collection .
FIBROUS ( PLASTIC FORM ) there is widespread intraperitoneal adhesions .which causes coils of intestine especially the ileum , to become matted together and distended.These distended coils act as a blind loop. There are symptoms of steatorrhea , loss of weight , attacks of abdominal pain ,Evening pyrexia and night sweats ,and some symptoms of acute and subacute intestinal obstruction , with signs of wasting ,a palpable swelling or swellings per abdominally ( this is adherent intestine with omentum attached ,together with thickened mesentry ).
PURULENT FORM pathlogically there is mass of adherent intestine and omentum ,is surrounded by tuberculous pus to form a cold abscess .This may point to the surface ,commonly near umblicus ,or burst into bowel . In clinically it shows loss of weight ,abdominal pain .discharge from an opening on abdominal skin .evening pyrexia and night sweats ,with signs of discharge from a sinus or fistula ,the opening of which is often wide ,with thin blue and undermined margin. A swelling may be palpated per abdominally ( consisted of adherent intestine and omentum )
ACUTE FORM pathologically resemble with ascitic form and clinically resembles acute bacterial peritonitis .
Some investigations can reveal this lesion such as
PERITONEAL ASPIRATION fluid is pale yellow .usually clear , rich in lymphocytes and have a high specific gravity.1.020 or more .Mycobacterium tuberculosis can be demonstrated by culture and microscopy with Ziehl-Neelsen staining.
MANTOUX TEST a positive test is strongly suggestive ,in non immunized patients .
CHEST X-RAY may reveal pulmonary tuberculosis
LAPROSCOPY can demonstrate the clinical type
PERITONEAL BIOPSY reveal characteristic tuberculous granuloma.
TREATMENT
CHEMOTHERAPY initial phase ethambutol .plus isoniazid plus rifampin plus pyrazinamide for two months .and in continuation phase ethambutol plus isoniazid plus rifampin for four to seven months .
SURGICAL TREATMENT
IN CASES OF FLUID COLLECTION laparotomy is performed ,fluid is evacuated and abdomen is closed without drainage .
IN FIBROUS FORM
On laparotomy ,bands of adhesion are divided. if adhesions are accompanied by fibrous strictures of ileum ,then excise the affected bowel, if adhesions only are present , a plication may be performed.
IN PURULENT FORM
On laparotomy ,cold abscess are evacuated ,fecal fistula is closed , combined with some form of anastomosis between segment of intestine above the fistula and an unobstructed area below.
TUBERCULOUS PERITONITIS
Infection occurs most commonly mass reactivation of latent tuberculous foci in the peritoneum that were established from hematogenous spread from a primary lung focus , It can also become via hematogenous spread from active pulmonary or miliary TB. Much less frequently, the organisms enter the peritoneal cavity transmurally from an infected diminutive intestine or contiguously from tuberculous salpingitis .
Peritoneal T.B. is an uncommon site of extrapulmonary infection caused by Mycobacterium T.B. (TB). The venture is accumulated in patients with cirrhosis, retrovirus infection, diabetes mellitus, underlying malignancy, mass treatment with anti-tumor necrosis factor (TNF) agents, and in patients undergoing continuous ambulatory peritoneal dialysis.
As the disease progresses, the visceral and parietal peritoneum become progressively studded with tubercles. Ascites develops alternative to "exudation" of proteinaceous fluid from the tubercles, similar to the mechanism leading to ascites in patients with peritoneal carcinomatosis. More than 90 percent of patients with TB rubor have ascites at the time of presentation, while the remainder present with a more advanced "dry" phase, representing a fibroadhesive modify of the disease.
Pathologically Gastrointestinal tuberculosisis characterized by rousing and fibrosis of the bowel surround and the regional lymph nodes. Mucosal lesion results from necrosis of Peyer patches, lymph follicles, and vascular thrombosis. At this stage of the disease, the changes are rechargeable and healing without scarring is possible. As the disease progresses, the lesion becomes confluent, and extensive fibrosis leads to bowel surround thickening, fibrosis, and pseudotumoral accumulation lesions. Strictures and fistulae formation may occur.
ORIGIN OF INFECTION from tberculous mesentric lymph nodes .from tuberculosis of ileocecal region ,from tuberculous pyosalpinx ,Blood-borne infection from pulmonary tuberculosis ,usually milliary.
CLINICAL TYPES
ASCITIC FORM peritoneum is studded with tubercles and peritoneal cavity becomes filled with pale ,straw colored fluid .its onset is insidious .with loss of energy , facial pallor and some loss of weight ,enlargement of abdomen ,pain often completely absent ,but there may br abdominal discomfort ,usually associated wih constipation or diarrhea . Even pyrexia and night sweats.
Dilated veins can be seen coursing beneath the skin of abdominal wall. shifting dullness and fluid thrill present , congenital hydrocele sometimes appear in male child .Umblical hernia may develop .A transverse solid mass can often be palpated per abdominally ,( this is rolled up greater omentum infiltrated with tubercles )
ENCYCTED ( LOBULATED ) FORM pathologically it is similar to ascitic form , but one part of abdominal cavity alone is involved .clinical features also resemble to ascitic form ,but there is a localized intraabdominally lump . .localized intraabdominally swelling .fluid thrill and shifting dullness may or may not be present ,depending upon the site of collection .
FIBROUS ( PLASTIC FORM ) there is widespread intraperitoneal adhesions .which causes coils of intestine especially the ileum , to become matted together and distended.These distended coils act as a blind loop. There are symptoms of steatorrhea , loss of weight , attacks of abdominal pain ,Evening pyrexia and night sweats ,and some symptoms of acute and subacute intestinal obstruction , with signs of wasting ,a palpable swelling or swellings per abdominally ( this is adherent intestine with omentum attached ,together with thickened mesentry ).
PURULENT FORM pathlogically there is mass of adherent intestine and omentum ,is surrounded by tuberculous pus to form a cold abscess .This may point to the surface ,commonly near umblicus ,or burst into bowel . In clinically it shows loss of weight ,abdominal pain .discharge from an opening on abdominal skin .evening pyrexia and night sweats ,with signs of discharge from a sinus or fistula ,the opening of which is often wide ,with thin blue and undermined margin. A swelling may be palpated per abdominally ( consisted of adherent intestine and omentum )
ACUTE FORM pathologically resemble with ascitic form and clinically resembles acute bacterial peritonitis .
Some investigations can reveal this lesion such as
PERITONEAL ASPIRATION fluid is pale yellow .usually clear , rich in lymphocytes and have a high specific gravity.1.020 or more .Mycobacterium tuberculosis can be demonstrated by culture and microscopy with Ziehl-Neelsen staining.
MANTOUX TEST a positive test is strongly suggestive ,in non immunized patients .
CHEST X-RAY may reveal pulmonary tuberculosis
LAPROSCOPY can demonstrate the clinical type
PERITONEAL BIOPSY reveal characteristic tuberculous granuloma.
TREATMENT
CHEMOTHERAPY initial phase ethambutol .plus isoniazid plus rifampin plus pyrazinamide for two months .and in continuation phase ethambutol plus isoniazid plus rifampin for four to seven months .
SURGICAL TREATMENT
IN CASES OF FLUID COLLECTION laparotomy is performed ,fluid is evacuated and abdomen is closed without drainage .
IN FIBROUS FORM
On laparotomy ,bands of adhesion are divided. if adhesions are accompanied by fibrous strictures of ileum ,then excise the affected bowel, if adhesions only are present , a plication may be performed.
IN PURULENT FORM
On laparotomy ,cold abscess are evacuated ,fecal fistula is closed , combined with some form of anastomosis between segment of intestine above the fistula and an unobstructed area below.
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