Tuberculous peritonitis

　　Tuberculous peritonitis is a chronic disseminated peritoneal infection caused by Mycobacterium tuberculosis, which is a type of abdominal tuberculosis. It can affect omentum, intestinal tract, liver, spleen, female reproductive tract, as well as visceral and parietal peritoneum. It often occurs with other tuberculosis foci in other parts. The tuberculosis bacteria generally enter the abdominal cavity through three routes:

　　1. Originating from intestinal tuberculosis.

　　2. Originating from salpingitis tuberculosis.

　　3. Originating from hematogenous dissemination of active pulmonary tuberculosis.

　　Since the advent of anti-tuberculosis chemotherapy, the incidence of tuberculous peritonitis, like tuberculosis in other parts of the body, has shown a significant downward trend. However, in some developing countries, tuberculous peritonitis is still a common form of tuberculosis. Although it can be found in children and the elderly, most patients are aged between 20 to 40 years. Women are more affected than men, with a ratio of 1:2. The incidence is higher in people living in poverty, alcoholics, and those with liver cirrhosis. Clinically, tuberculous peritonitis can be acute or gradually worsen without any noticeable symptoms.

　　The main complications of tuberculous peritonitis include intestinal obstruction, intestinal perforation, intestinal fistula, and peritoneal abscess.

　　Intestinal obstruction: The most common clinical symptoms are abdominal pain, vomiting, abdominal distension, and cessation of排气排便. There may also be disturbances in water, electrolyte, and acid-base balance. In cases of strangulated obstruction or intestinal necrosis, shock, peritonitis, and gastrointestinal bleeding may occur.

　　Intestinal perforation: Mainly manifested as abdominal pain, which often occurs suddenly and presents as persistent cutting pain, worsening with deep breathing and coughing. The extent of pain is related to the degree of peritonitis spread. There are also systemic symptoms of infection and intoxication, such as fever, chills, rapid heart rate, and decreased blood pressure, which are manifestations of toxic shock. Physical signs include weakened or absent abdominal breathing, marked tenderness and rebound pain in the entire abdomen, muscular rigidity, liver dullness, and possible shifting dullness. The bowel sounds may be weakened or absent.

　　Intestinal fistula: There is one or more fistulas on the abdominal wall, with the excretion of intestinal fluid, bile, gas, or food, which is the main clinical manifestation of intestinal extrusion; after the occurrence of intestinal extrusion, due to the loss of a large amount of digestive fluid, patients may experience significant water and electrolyte imbalance and acid-base metabolism imbalance.

　　Peritoneal abscess: ① Subdiaphragmatic abscess: Fever is a common symptom of subdiaphragmatic abscess, manifested as persistent high fever, rapid pulse, and thick and greasy tongue coating. Then, systemic weakness, exhaustion, night sweats, anorexia, and weight loss may occur. Blood tests may show a significant increase in the number of white blood cells, with an increased proportion of neutrophils. The site of the abscess may have continuous dull pain, which may worsen with deep breathing. ② Pelvic abscess: While systemic symptoms are relatively mild, local symptoms are more pronounced. During the treatment of acute peritonitis, appendicitis perforation, or patients after colonic or rectal surgery, if the body temperature returns to normal and then rises again, accompanied by typical rectal or bladder irritation symptoms such as tenesmus (a feeling of incomplete defecation), frequent and small stools, stools mixed with mucus, frequent urination, urgency, dysuria, and difficulty in urination, then the possibility of pelvic abscess should be considered. ③ Intercystic abscess: Mainly manifested as low fever; localized abdominal pain, mostly hidden pain, with abdominal distension and other discomforts. Physical examination may show abdominal tenderness and palpable abdominal masses.

　　The clinical manifestations of tuberculous peritonitis vary due to different pathological types and the body's reactivity. Generally, the onset is slow, with mild symptoms in the early stage; a few cases may have an abrupt onset, mainly manifested as acute abdominal pain or sudden onset of high fever. Sometimes, the onset is insidious with no obvious symptoms, and it may be unexpectedly discovered only when unrelated abdominal diseases are surgically entered into the peritoneal cavity.

　　(1) General symptoms

　　Tuberculous toxicosis is common, mainly fever and night sweats. The fever type is mostly low fever and moderate fever, about 1/3 of the patients have remission

　　Fever, a few can be persistent fever. In patients with high fever accompanied by obvious toxicosis, it is mainly seen in exudative, caseous type, or seen in patients with severe tuberculosis such as miliary pulmonary tuberculosis and caseous pneumonia. In the later stage, there is malnutrition, manifested as emaciation, edema, anemia, glossitis, cheilitis, and so on.

　　(2) Abdominal pain

　　Abdominal pain is not obvious in the early stage, and later can appear persistent dull pain or ache, or there may be no abdominal pain at all. The pain is often located around the umbilicus

　　The lower abdomen, sometimes the whole abdomen. When accompanied by incomplete intestinal obstruction, there is colicky pain. Occasionally, it may manifest as acute abdomen, which is caused by the ulceration of caseous necrosis focus of mesenteric lymph node tuberculosis or other tuberculosis in the abdominal cavity, or it can also be caused by acute perforation of intestinal tuberculosis.

　　(3) Abdominal palpation

　　The softness of the abdominal wall is a manifestation of mild stimulation of the peritoneum or chronic inflammation, which is a common sign of tuberculous peritonitis. Abdominal tenderness is generally mild; in a small number of cases, tenderness is severe, and there is rebound pain, which is common in caseous type tuberculous peritonitis.

　　(4) Ascites

　　Ascites is more common from a small to moderate amount, and small ascites is not easy to be detected in clinical examination, so it must be checked carefully. Patients often have a feeling of abdominal distension, which may be caused by tuberculosis toxicosis or peritonitis accompanied by intestinal dysfunction, and it is not necessarily accompanied by ascites.

　　(5) Abdominal mass   

　　It is more common in adhesive or caseous type, often located around the umbilicus, and can also be seen in other parts. The mass is often formed by thickened omentum, enlarged mesenteric lymph nodes, tangled intestinal loops, or caseous necrotic purulent substances, with varying sizes, irregular edges, uneven surfaces, and sometimes nodular sensation, with small mobility.

　　(6) Other

　　Diarrhea is common, usually not more than 3-4 times a day, and feces are often pasty. Diarrhea is mainly caused by intestinal dysfunction due to peritonitis, occasionally caused by intestinal fistula in the intestines caused by concomitant ulcerative intestinal tuberculosis or caseous necrosis lesions, etc. Sometimes diarrhea and constipation alternate. In patients with concurrent primary tuberculosis focus, there are symptoms, signs, and related examination findings of the primary tuberculosis focus.

　　To prevent the deterioration of tuberculous peritonitis in patients, the following points should be noted:

　　(1) Rest: Fever patients should rest in bed and follow the routine care for fever. Patients with abundant ascites can adopt a semi-recumbent position, as rest can reduce metabolism, slow down blood circulation, reduce the absorption of toxins, and alleviate toxic symptoms.

　　(2) Diet care: Provide high-temperature, high-protein, high-vitamin, and easy-to-digest diet.

　　(3) Observation of illness: (1) Observe abdominal pain and distension; severe abdominal pain may indicate intestinal perforation, which requires emergency treatment. Distension is prominent, and rectal tube exhaust should be performed. If intestinal obstruction occurs, fasting should be prohibited, and gastroenteric decompression should be performed. (2) Observe the side effects of antituberculosis drugs and adrenocortical hormones.

　　(Four) Ascites care: For patients with large amounts of ascites, peritoneal puncture can be performed to appropriately drain ascites, and the nature of ascites should be observed. For patients with frequent peritoneal punctures, good abdominal skin care should be done to prevent infection.

　　(Five) Psychological care: Nursing staff should use kind language, understanding attitude, and skilled techniques to make patients feel trust and security, achieving the effect of adjusting psychology.

　　(Six) Fever care: (1) Bed rest: Rest can reduce metabolism and blood circulation, thereby reducing the absorption of toxins by the body, which can alleviate toxic symptoms. (2)降温: For body temperature above 39℃, methods such as placing an ice bag on the head or alcohol sponge bath can be used for physical cooling. At the same time, an appropriate amount of fluid should be supplemented.

　　(Seven) Skin care: Night sweats are one of the toxic symptoms of tuberculosis. Patients often suffer from body odor due to night sweats, which makes them feel bad, so they need to take a bath or shower once a day; due to poor nutrition, body thinness, and severe patients should turn over on time to keep the bed dry and flat, preventing bedsores.

　　1. Blood count, erythrocyte sedimentation rate, and tuberculin skin test: Some patients have mild to moderate anemia, with moderate anemia more common in patients with a long course and active lesions, especially in caseous type or with complications. The white blood cell count is usually normal or slightly elevated, with a few cases slightly low. In patients with acute diffusion of abdominal tuberculosis foci or caseous type, the white blood cell count may increase. Erythrocyte sedimentation rate can be used as a simple indicator of lesion activity, which generally accelerates during the active phase of the disease and gradually returns to normal as the lesions tend to stabilize. A strong positive tuberculin skin test is helpful for the diagnosis of this disease, but it may be negative in miliary tuberculosis or severe patients.

　　2. Ascites examination: Ascites is a greenish-yellow exudative fluid, which naturally coagulates after standing. A few cases present as hemorrhagic. Occasionally, chylous ascites may be seen, with a specific gravity generally exceeding 1.016, protein content greater than 30g/L, and white blood cell count exceeding 5×10⁸/L, mainly composed of lymphocytes. However, sometimes due to hypoalbuminemia, the nature of ascites can be close to transudative fluid, and it must be analyzed comprehensively. In recent years, it is advocated that the judgment of infectious ascites should increase experimental diagnostic indicators, such as ascites glucose

　　The general bacterial culture of ascites in this disease is negative, and the positive rate of finding Mycobacterium tuberculosis is very low. The positive rate of tuberculosis culture is also low, but the positive rate of animal inoculation of ascites can reach more than 50%.

　　3. Barium meal examination: If intestinal adhesions, intestinal tuberculosis, intestinal fistula, extraintestinal masses, and other phenomena are found, they have auxiliary value for the diagnosis of this disease. Abdominal X-ray films sometimes show calcification shadows, which are mostly calcification of mesenteric lymph nodes.

　　4. Laparoscopic examination is contraindicated in patients with extensive peritoneal adhesions. It is generally applicable to patients with free peritoneal effusion, where scattered or aggregated grayish-white nodules can be seen on the surface of the peritoneum, omentum, and visceral organs. The serous membrane loses its normal luster, becomes turbid and rough, and histological examination has diagnostic value.

　　The dietary taboos for tuberculosis peritonitis include:

　　1. Eat more cooling and diuretic foods such as green vegetables, amaranth, winter melon, winter melon seeds, large cucumber, luffa, kelp, Job's tears, mung bean, Houttuynia, light bamboo leaves, clover sprouts... in tuberculous peritonitis.

　　2. Drink more cooling and diuretic fruits and vegetables such as pear juice, apple juice, watermelon juice, orange juice, tangerine juice, Houttuynia tea, etc. in tuberculous peritonitis.

　　3. Patients with tuberculous peritonitis should drink more than 2500ml of water per day.

　　4. Avoid spicy and irritating foods such as chili, spicy sauce, onions, pepper, curry powder... in tuberculous peritonitis, which can exacerbate inflammation.

　　5. Avoid cold and raw foods such as frozen food, drinks, ice cream... in tuberculous peritonitis.

　　6. Avoid eating fried, fried, roasted, smoked... foods in tuberculous peritonitis.

　　7. Avoid eating hot and dry fruits such as cherries, longan, lychee, durian, black dates, peaches, etc. in tuberculous peritonitis.

　　The key to the treatment of this disease is to give reasonable and sufficient courses of antituberculosis chemical drug treatment as early as possible, in order to achieve early recovery, avoid recurrence, and prevent complications. Paying attention to rest and nutrition, in order to adjust the overall situation and enhance the body's ability to resist diseases is an important auxiliary treatment measure.

　　(1) Antituberculosis chemical drug treatment

　　The selection, usage, and course of antituberculosis chemical drugs are detailed in the treatment of pulmonary tuberculosis. In the application of tuberculous peritonitis, attention should be paid to: for general exudative cases, as the ascites and symptoms often disappear without too much time, patients may stop taking medication themselves, leading to recurrence, so it is necessary to emphasize full-course regular treatment; for adhesion type or caseous type cases, due to a large amount of fibrous hyperplasia, drugs are not easy to enter the focus to reach the required concentration, and the lesion is not easy to control. It is necessary to consider strengthening the combined application of antituberculosis chemotherapy and appropriately extending the course of antituberculosis treatment when necessary.

　　(2) If there is a large amount of ascites, appropriate ascites can be released to alleviate symptoms.

　　(3) Surgical treatment

　　Indications for surgery include: ① Patients with concurrent complete intestinal obstruction or incomplete intestinal obstruction that has not improved after medical treatment; ② Acute intestinal perforation, or peritoneal abscess that has not improved after antibiotic treatment; ③ Intestinal fistula that has not closed after antituberculosis chemotherapy and enhanced nutrition; ④ When the diagnosis of the disease is difficult and cannot be distinguished from acute abdomen, laparotomy can be considered.