This document discusses peritoneal tuberculosis and tuberculous mesenteric lymphadenitis. It provides details on the clinical presentation, pathology, types, investigations and treatment for each condition. Peritoneal tuberculosis typically presents with abdominal distension, obstruction, pain and weight loss. Chronic cases can lead to ascites or adhesions. Tuberculous lymphadenitis most commonly involves the right mesenteric lymph nodes and may cause obstruction, presenting like appendicitis. Investigations include imaging, fluid analysis and Mantoux testing. Both conditions are generally treated with anti-tubercular drugs, and sometimes surgery is needed for complications like obstruction.

1. PERITONEAL
TUBERCULOSIS &
TUBERCULOUS
MESENTERIC
LYMPHADENITIS
PRAVEEN RK
NO: 75

2. PERITONEAL
TUBERCULOSIS

3. CLINICAL PRESENTATION
■ Distension of abdomen
■ Recurrent subacute intestinal obstruction
■ Pain abdomen
■ Recurrent fever
■ Loss of weight and appetite

4. Basic Pathology
■ Enormous thickening of parietal peritoneum with Multiple tiny
yellowish tubercles
■ Dense adhesions in peritoneum and omentum with small intestines
looking like abdominal cocoon. It may precipitate obstruction
■ Thickening of bowel wall with adhesions

5. ■ Can be: wet type
dry type
■ Wet type
-Common(95%)
-Formation of different types of ascites
■ Dry type
-shows typical fibrosis and adhesions

6. Routes of spread of infection
■ Blood spread
■ From diseased mesenteric lymph nodes
■ Intestine
■ Fallopian tubes

7. Types
■ Acute
■ Chronic
 Ascitic type
 Encysted/loculated type
 Plastic type
 Purulent form

8. Acute type
■ Rare
■ Exploratory laprotomy reveals
-straw coloured fluid
-multiple tubercles in peritoneum, greater omentum, bowel wall
■ Occurs due to perforation or rupture of mesenteric lymph nodes

9. Chronic tuberculous peritonitis
■ Abdominal pain
■ Fever
■ Ascites
■ Loss of appetite and weight
■ Abdominal mass
■ Doughy abdomen
■ Peritoneum thickened with multiple tubercles. Omentum is thick ,
fibrosed and rolled up.

10. Ascitic form
■ Common in young children and adults
■ Enormous distension of abdomen with dilated vein
■ Shifting dullness present
■ Fluid thrill
■ Rolled up omentum

11. ■ Ascitic tap shows
-Straw colored exudate from which AFB can be isolated
-Fluid is pale yellow, clear
-Rich in lymphocytes>40%
-High specific gravity>1.016
■ Chest X-ray
■ Mantoux test
■ Treatment:
ATD for one year
Repeated tapping may be required

12. Encysted / Loculated ascites
■ Ascites gets loculated due to fibrinous depositions
■ Present as Intra abdominal mass
■ Dullness- not shifting
■ Mimics -Ovarian cyst
-Retro peritoneal cyst
-Mesenteric cyst
■ Treatment
U/S guided aspiration with antituberculous drugs

13. Plastic type
■ Widespread adhesions of bowel loops
■ Blind loop formation, intestinal
obstruction, thickened parietal
peritoneum
■ Presents as
-Recurrent colicky abdominal pain
-Diarrhea
-Loss of weight, wasting
-Mass abdomen, doughy abdomen

14. ■ D/D:
Peritoneal carcinomatosis
■ Open /laparoscopic peritoneal biopsy
■ Surgery is indicated if obstruction occurs

15. Purulent form
■ As a complication of genitourinary tuberculosis(tuberculous salpingitis)
■ Presents as acute peritonitis
■ Peritoneal cavity is studded with tubercles, cold abscess and pus

16. Investigation
■ Blood investigations
■ Chest Xray
■ USG abdomen
■ CT abdomen
■ Ascitic fluid analysis

17. Treatment
 Antitubercular drug therapy
 Indications for surgery:
■ Complete intestinal obstruction
■ Recurrent intestinal obstruction
■ Perforation
■ Multiple stictures
• Stricturoplasty , localised resections

18. TUBERCULOUS
MESENTERIC
LYMPHADENITIS

19. ■ Infection is usually through the Peyer‘s patches of the intestine(i.e.
through oral cavity).
■ Usually several lymph nodes are involved often causing massive lymph
node enlargement.
■ Commonly right-sided lymph nodes are involved,
■ Presents with general symptoms (fever, malaise, weight loss).
■ It may present with features of acute appendicitis.
■ Often coils of intestine get adherent to the caseated mesenteric lymph
nodes leading to intestinal obstruction.
■ Most often caseating material may collect between the layers of the
mesentery.
■ It forms a cold abscess, mimicking a mesenteric cyst (Pseudomesenteric
cyst).

20. ■ Massive enlargement of mesenteric lymph nodes due to tuberculosis is
called as tabes mesenterica.
■ Mesenteric tuberculous adenitis is more common in children.
Present with anaemia, fever, loss of appetite and reduced weight,
failure to thrive, palpable mass in right iliac fossa which is firm
and nodular.

22. Differential diagnosis
• Carcinoma caecum.
• Lymphoma.
• Retroperitoneal tumour.
• Nonspecific lymphadenitis.
• (Acute nonspecific mesenteric lymphadenitis is called as nurses’
syndrome).

23. INVESTIGATIONS
• X-ray abdomen shows calcification.
• USG abdomen may confirm the diagnosis.
• Mantoux test may be positive.
• Diagnostic laparoscopy—is very useful inTB lymphadenitis.
• TREATMENT
• Mesenteric cold abscess can be drained safely
through laparoscopy.
• Anti tubercular drugs.
• Do Laparoscopy and proceed. prognosis is good.

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