Peritoneal tuberculosis: retrospective analysis of clinical and radiologic findings in our institution from 2003 to 2013

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1 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: /ecr2015/C-2332 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 24

2 Aims and objectives To retrospectively review the clinical data and imaging findings of patients diagnosed with peritoneal tuberculosis at our center between and 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 and 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 and Patients characterisitics are shown in the following tables: Page 2 of 24

3 Table 1: Patients characteristics Table 2: Risk factors Page 3 of 24

4 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

5 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

6 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

7 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

8 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

9 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

10 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

11 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

12 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

13 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

14 Table 2: Risk factors Table 3: Time from symptoms to diagnosis Page 14 of 24

15 Table 4: Diagnostic criteria Table 5: Ultrasound findings in 19 patients Page 15 of 24

16 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

17 Table 7: Extraperitoneal findings Table 8: Extraabdominal findings Page 17 of 24

18 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

19 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

20 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

21 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

22 Fig. 7: A: pleural effusion and miliary tuberculosis. B: tuberculous cavities, nodules and tree-in-bud. Page 22 of 24

23 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

24 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 ( ). 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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