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Peritoneal tuberculosis: retrospective analysis of clinical
and radiologic findings in our institution from 2003 to 2013
Poster No.:
C-2332
Congress:
ECR 2015
Type:
Scientific Exhibit
Authors:
A. Viteri, B. Ruiz, O. L. Ferrero Beneitez, M. Schuller, E. Alcalde,
F. Diez Renovales, I. Lecumberri, M. Barcena, D. Grande; Bilbao/
ES
Keywords:
Abdomen, CT, Ultrasound, Diagnostic procedure, Infection
DOI:
10.1594/ecr2015/C-2332
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Page 1 of 24
Aims and objectives
•
To retrospectively review the clinical data and imaging findings of patients
diagnosed with peritoneal tuberculosis at our center between 1-1-2002 and
31-8-2013.
•
To analyze the performance of CT and ultrasound when diagnosing
peritoneal tuberculosis in these patients.
Methods and materials
•
All patients diagnosed of peritoneal tuberculosis in our center between
1-1-2003 and 31-8-2013 were included.
•
Epidemiological, clinical, microbiological and histopathologic data were
collected and analysed.
•
Ultrasound and CT images and reports were reviewed by two blind
observers.
•
Comparisons between groups were assessed using Fisher's exact test.
•
Institutional Review Board approval was obtained.
Results
Twenty-five patients had a confirmed diagnosis of peritoneal tuberculosis between
1-1-2003 and 31-8-2013.
Patients´ characterisitics are shown in the following tables:
Page 2 of 24
Table 1: Patients´ characteristics
References: Radiology Department, Hospital Universitario Basurto - Bilbao/ES
Table 2: Risk factors
Page 3 of 24
Table 3: Time from symptoms to diagnosis
Table 4: Diagnostic criteria
ULTRASOUND FINDINGS:
Ultrasound was performed in 19 patients. Ultrasound findings are shown in table 5.
Page 4 of 24
Table 5: Ultrasound findings in 19 patients
Although most patients had free fluid or enlarged lymph nodes at ultrasound, these
findings were very unspecific and tuberculous peritonitis was only suggested in two
patients.
Page 5 of 24
Fig. 1: Ultrasound findings in two different patients.A: ascites. B: enlarged lymph
nodes in the mesenteric root.
Of note, ultrasound-guided procedures were very helpful: i. e. lymph node biopsies,
peritoneal biopsies, fluid and tissue sampling for culture, ...
COMPUTED TOMOGRAPHY FINDINGS:
Twenty-three patients underwent at least one MDCT before the diagnosis of peritoneal
tuberculosis. CT findings are shown in table 6.
Page 6 of 24
Table 6: CT findings in 23 patients
Our data show that three quarters of the patients had ascites, more than a half had
enlarged mesenteric and/or retroperitoneal lymph nodes and almost half of the patients
had peritoneal and/or omental involvement. However, in 11 cases peritoneal tuberculosis
was not suggested in the report as a probable diagnosis, probably due to the lack of
clinical suspicion.
We present some examples of CT findings.
1.- The most common form of peritoneal tuberculosis is the wet type. It is characterized
by the presence of exudative ascites with lymphocytic predominance and high ADA.
Enhancement of peritoneal leaves and the presence of thick septa are frequently
observed.
Page 7 of 24
Fig. 2: A: 37 y-o woman from Colombia. Abundant high attenuation ascites with
enhancing peritoneum and septa. "Smudged" omental thickening (caseating
granulomas). B: 41 y-o man HIV+, C3. Ascites (exudative, with lymphocytic
predominance and elevated ADA) and prominent omental hyperattenuation and
stranding.
2.- Caseating lymphadenopathies and fibrous adhesions are the typical features of "dry
type" tuberculous peritonitis.
Page 8 of 24
Fig. 3: Thickened peritoneal leaves and omentum in a 32 y-o man from Morocco.
Necrotizing peritoneal granulomas were found at a negative appendectomy.
3.- Omental cake with matted bowel loops and mesentery are the most distinguishing
features of the fibrotic type tuberculous peritonitis. Ascites is typically loculated.
Page 9 of 24
Fig. 4: Matted bowel loops, thickened omentum, loculated ascites and enlarged lymph
nodes in a 28 y-o woman from Equatorial Guinea suffering from chronic abdominal
pain. Omental biopsy showed granulomas with caseous necrosis and Mycobacterium
tuberculosis grew in cultures.
4.- Classical tuberculous lymphadenopathy is described as having low attenuation due
to underlying necrosis. However in our series few patients showed this feature. In most
cases enlarged lymph nodes had homogeneous enhancement that led to suspect a
lymphoproliferative process.
Fig. 5: In these two cases malignant proceseses were suspected. A:
Lymphadenopathy around the mesenteric vessels in a patient with abdominal pain
and general syndrome for five months, suggesting lymphoma. Ultrasound guided
biopsy showed caseous necrotising granulomas. B: Retroperitoneal mass that caused
Page 10 of 24
thrombosis of the inferior vena cava and collateral circulation simulating a neoplasm in
a 41-year-old man from Morocco.
5.- Extraperitonal and extraabdominal findings can be very helpful: in the presence of
typical radiological manifestations of tuberculosis in other locations, one should always
suspect that peritoneal findings are due to the dissemination of tuberculosis.
Some extraperitoneal findings are characteristic of disseminated tuberculosis.
Fig. 6: Some extraperitoneal findings are characteristic of disseminated tuberculosis.
We present examples from three different patients. A: Ileocecal inflammation and
enlarged lymph nodes with necrotic center. B: Splenic microabscesses and pleural
Page 11 of 24
effusion. C: Hepato-splenic microabscesses (caseating granulomas on histologic
examination).
A high index of suspicion is required to diagnose peritoneal tuberculosis. Thus, in cases
of diagnosed or suspected pleuropulmonary tuberculosis, even subtle and nonspecific
abdominal findings can point to peritoneal involvement.
Fig. 7: A: pleural effusion and miliary tuberculosis. B: tuberculous cavities, nodules
and tree-in-bud.
STATISTICAL ANALYSIS
Page 12 of 24
No statistically significant differences were found between the presence of different risk
factors and radiological manifestations, probably due to the low number of patients in
each group. Also, we didn´t find any correlation between radiological manifestations and
microbiological, histological and ascitic fluid findings.
A trend towards shorter time-to-diagnosis without statistical significance was found
for patients with characteristic ascitic fluid (lymphocytic predominance with high ADA)
(p=0,31) and for patients who underwent exploratory laparoscopy (p=0,54).
Images for this section:
Table 1: Patients´ characteristics
Page 13 of 24
Table 2: Risk factors
Table 3: Time from symptoms to diagnosis
Page 14 of 24
Table 4: Diagnostic criteria
Table 5: Ultrasound findings in 19 patients
Page 15 of 24
Fig. 1: Ultrasound findings in two different patients.A: ascites. B: enlarged lymph nodes
in the mesenteric root.
Table 6: CT findings in 23 patients
Page 16 of 24
Table 7: Extraperitoneal findings
Table 8: Extraabdominal findings
Page 17 of 24
Fig. 2: A: 37 y-o woman from Colombia. Abundant high attenuation ascites
with enhancing peritoneum and septa. "Smudged" omental thickening (caseating
granulomas). B: 41 y-o man HIV+, C3. Ascites (exudative, with lymphocytic
predominance and elevated ADA) and prominent omental hyperattenuation and
stranding.
Page 18 of 24
Fig. 3: Thickened peritoneal leaves and omentum in a 32 y-o man from Morocco.
Necrotizing peritoneal granulomas were found at a negative appendectomy.
Fig. 4: Matted bowel loops, thickened omentum, loculated ascites and enlarged lymph
nodes in a 28 y-o woman from Equatorial Guinea suffering from chronic abdominal
pain. Omental biopsy showed granulomas with caseous necrosis and Mycobacterium
tuberculosis grew in cultures.
Page 19 of 24
Fig. 5: In these two cases malignant proceseses were suspected. A: Lymphadenopathy
around the mesenteric vessels in a patient with abdominal pain and general syndrome
for five months, suggesting lymphoma. Ultrasound guided biopsy showed caseous
necrotising granulomas. B: Retroperitoneal mass that caused thrombosis of the inferior
vena cava and collateral circulation simulating a neoplasm in a 41-year-old man from
Morocco.
Page 20 of 24
Fig. 6: Some extraperitoneal findings are characteristic of disseminated tuberculosis. We
present examples from three different patients. A: Ileocecal inflammation and enlarged
lymph nodes with necrotic center. B: Splenic microabscesses and pleural effusion. C:
Hepato-splenic microabscesses (caseating granulomas on histologic examination).
Page 21 of 24
Fig. 7: A: pleural effusion and miliary tuberculosis. B: tuberculous cavities, nodules and
tree-in-bud.
Page 22 of 24
Conclusion
Diagnosing peritoneal tuberculosis is challenging for the radiologist as well as for the
clinician. In our series, the typical imaging manifestations were infrequent and in most
cases we faced non-specific findings.
Therefore, a combination of clinical, laboratory and imaging data along with a high index
of suspicion are required to prevent diagnostic and therapeutic delays.
In our experience, peritoneal tuberculosis should be suspected in patients with risk factors
for disseminated tuberculosis or in patients with typical manifestations of tuberculosis at
any other location, even in the presence of subtle radiographic findings.
Personal information
From the Radiology Department, Hospital Universitario Basurto, Bilbao, Spain:
•
•
•
•
•
•
•
•
Ainhoa Viteri Jusué, MD (*)
Berta Ruiz Morín, MD
Miguel Arturo Schuller Arteaga, MD
Eider Alcalde Odriozola,MD
Fernando Diez Renovales, MD
Iñigo Lecumberri Cortés, MD
Maria Victoria Bárcena Robredo, MD
Domingo Grande Icaran, MD, PhD
From the Infectious Diseases Department, Hospital Universitario Basurto, Bilbao, Spain:
•
Oscar Luis Ferrero Beneitez, MD
(*) Corresponding author.
ainhoa.viterijusue@osakidetza.net
References
Page 23 of 24
1.
2.
3.
4.
5.
6.
Uzunkoy A, Harma M, Harma M. Diagnosis of abdominal tuberculosis:
experience from 11 cases and review of the literature. World J Gastroenterol
2004; 10:3647.
Akhan O, Pringot J. Imaging of abdominal tuberculosis. Eur Radiol 2002;
12:312.
Vázquez Muñoz E, Gómez-Cerezo J, Atienza Saura M, Vázquez Rodriguez
JJ. Computed tomography findings of peritoneal tuberculosis: systematic
review of seven patients diagnosed in 6 years (1996-2001). Clin Imaging
2004; 28:340.
Poyrazoglu OK, Timurkaan M, Yalniz M, et al. Clinical review of 23 patients
with tuberculous peritonitis: presenting features and diagnosis. J Dig Dis
2008; 9:170.
Riquelme A, Calvo M, Salech F, et al. Value of adenosine deaminase (ADA)
in ascitic fluid for the diagnosis of tuberculous peritonitis: a meta-analysis. J
Clin Gastroenterol 2006; 40:705.
Shen YC, Wang T, Chen L, et al. Diagnostic accuracy of adenosine
deaminase for tuberculous peritonitis: a meta-analysis. Arch Med Sci 2013;
9:601.
Page 24 of 24

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