GI7
SALHI.K1; AYAT.A1 ;HELLARA.A 1;JERBI.S2 ;MAHJOUB.B1;BOUSSOFFARA.R1;
HAMZA.AH2; SOUA.H; MT.SFAR1.
1 Service de Pediatrie CHU Taher Sfar Mahdia
2 Service de Radiologie CHU Taher Sfar Mahdia
INTRODUCTION:
 The peritoneum is one of the locations outside the
most common pulmonary tuberculosis.
 Peritoneal tuberculosis poses a public health problem
in endemic regions of the world .
 The diagnosis is difficult and still remains a challenge
: insidious nature , variability of presentation and
limitations of available diagnostic tests.
 We report a case of an adolescent girl who was
diagnostic with this disease.
Patients and Methods:
 A 14 years old girl admitted with a chronic diarrhea since 4
months ,weakness ,decreased appetie and weight loss.
 Physical examination showed :
 A pale girl .
 Fever (38.7°).
 Painful abdomen.
 No organomegaly or lymphomegaly .
We completed with a biologic and radiologic
investigation.
Results:
Laboratory investigation revealed:
 elevated erythrocyte sedimentation rate(110/130)
 anemia (Hb=8.7g/dl) ,
 high CRP (97mg/l) .
All other routine biochemical tests, celiac serology
,anti Dnatif , antinuclear anticorps were within
the normal range in the serum.
 The BK search was negative.
Results:
 The chest X ray was normal .
 Abdominal ultrasonographie showed a little ascite.
 TDM showed:
 ascite .
 small bowel thichening.
 Multiples necrotic lymphadenopathy.
 liver nodule (22 mm in the segment IV)
Results:
laparotomymultiple smalls nodules and fibrotic
adhesive bands covering peritoneal surfaces
compatible with peritoneal tuberculosis later
confirmed histologically (caseating granulomas)
The girl was treated with quadritherapie :
Rifampicine, Izoniasid, Pyrazinamide
and Ethambutol during 4 months.
There were no clinical amelioration, and a
cutaneous fistulas appeared.
Results:
 Myelogramme was normal.
 A second abdominal TDM: showed the persistence of the
same pathologie and appearing of cutaneous fistulas.
 we suspected a multidrug resistant tuberculosis so we
added ofloxacine , Amikacine and corticotherapie.
 After 1 month the patient became more better.
Results:
Small bowel thikhening
Ascite
Abdominal TDM of our patient
DISCUSSION :
Peritoneal tuberculosis is predominantly a disease
of young adults between 21-40 years old with an
equal sex incidence.
 Tuberculosis bacteria reachs the gastrointestinal
tract via:

Haematogenous spread

Ingestion of infected sputum

Direct spread from infected contiguous
lymph nodes or fallopian tubes
DISCUSSION :
 Peritoneal tuberculosis occurs in three forms :
 Wet type with ascitis+++
 Dry type with adhesions.
 Fibrotic type with omental thickening and
loculated ascites .
 It is commonly manifested by : abdominal pain ,
diarrhea, fever , weight loss , and anemia.
 Laboratory Findings are:
 Anemia , elevated sedimentation rate , high CRP.
Elevated CA-125
DISCUSSION :
 Chest X ray  search a pulmonary tuberculosis.
 Ultrasonographie  ascites , lymphadenopathy,
omental thickening and caking.
 TDM  Three main types :
 Wet Type Peritonitis :
 Is the most common type of peritonitis (90% ).
 Free or loculated ascites,
 Usually slightly hyperattenuating (20–45 HU) relative
to water due to its (high protein and cellular content) .
DISCUSSION :
Wet type tuberculous peritonitis.
Contrast-enhanced CT scan shows ascites (arrows) that is hyperattenuating relative to urine within the bladder (arrowheads)
DISCUSSION :
Fibrotic Type Peritonitis:
 It accounts for 60% of cases of peritonitis .
 It manifests as mottled low-attenuation masses with




nodular soft-tissue thickening .
Dry Type Peritonitis :
Is seen in 10% of cases.
Characterized by mesenteric thickening, fibrous
adhesions, and caseous nodules.
Its imaging manifestations are highly suggestive of,
but not specific for, tuberculosis.
DISCUSSION :
Fibrotic type tuberculous peritonitis.
CT scan obtained with oral and intravenous contrast material shows omental caking (arrowheads)
with thickening of the underlying small bowel (*).
DISCUSSION :
 Peritoneal Biopsy :

85-95% Sensitive
 Performed by:
- laparoscopic guidance or minilaparotomy
- exploratory laparotomy.
 • Caseating Granulomas
• Langerhans Type Giant Cells.
 Microbiology Ziehl-Neelsen Stain
Treatment
 Same treatment as pulmonary TB
 Four drug regimen:
– Isoniazid
– Rifampicin
– Ethambutol
– Pyrazinamide
 Quadritherapie during 2mounths than bitheraphie
during 4moutns(Isoniazide+Rifampicin)
Conclusion :
The diagnostic of peritoneal tuberculosis is
difficult.
It presents with nonspecific symptoms. laboratory
investigations may not be helpful.
 Radiologic investigation and laparotomy help to
get the diagnostic and to treat early affected
patients.