Peritoneal tuberculosis--an uncommon disease that may deceive the gynecologist

Tuberculous peritonitis mimicking carcinomatosis peritonei: CT findings and histopathologic correlation

The distinction between tuberculous peritonitis and peritoneal carcinomatosis is extremely difficult in patients with omental cake appearance on computed tomography and elevated CA-125 level. A 21-year-old female presented with abdominal distention, diarrhea, nausea, fever, weight loss, and night sweats. Serum CA-125 level was 563 U/L (normal range: <35 U/L) and other tumor markers were within normal range. Radiologic studies showed massive ascites, smooth minimal thickening and increased contrast enhancement of peritoneum, omental nodularities, hepatomegaly, and right pleural effusion. No underlying malignancy that could cause this condition was detected clinically and radiologically. Ultrasound-guided omental tru-cut biopsy was performed to exclude carcinomatosis peritonei. Histopathologic examination showed small-medium-sized granulomas with caseous necrosis. Molecular microbiology tests of biopsy specimens confirmed diagnosis of tuberculosis. In conclusion, tuberculous peritonitis should be in differential diagnosis of a patient with ascites, omental nodularities and elevated serum CA-125 levels.

Tuberculosis endometritis presenting as a leiomyoma

Genitourinary tuberculosis is a common extrapulmonary manifestation of tuberculosis. Taking into consideration that genitourinary tuberculosis may be associated with a diversity of presentations, its diagnoses may be difficult. A young woman with an initial presumptive diagnosis of a uterine leiomyoma presented with abdominal pain and a pelvic mass that after further investigations, she was diagnosed with genital tuberculosis.

Stress urinary incontinence: long-term results of laparoscopic Burch colposuspension

BACKGROUND

The open Burch colposuspension, first described in 1961 had been widely employed for the surgical treatment of women with stress urinary incontinence (SUI) caused by urethral hypermobility. We evaluated the long-term efficacy of laparoscopic Burch colposuspension (LBC) for SUI in women.

METHODS

A randomized prospective trial was conducted from September 2010 to January 2013. The extraperitoneal laparoscopic Burch colposuspension was performed by an operator on 96 women, mean age was 54,3 ± 3,7 years all of whom suffered from SUI or mixed urinary incontinence. Patients completed a self-administered the Short Form-36 (SF-36), the Physical Component Summary (PCS) and Mental Component Summary (MCS), the Short Urinary Distress Inventory (SUDI) and Short Incontinence Impact Questionnaire (SIIQ). at both baseline and follow up(6 weeks, 6 months, 18 months postoperatively). The Genito-Urinary Treatment Satisfaction Scale (GUTSS) was used to assess satisfaction with surgery.

RESULTS

After follow up was recorded an improvement of questionnaries scores. The general health score is improved after surgery (2,60 ± 1.02 versus 2,76 ± 1.06) with p = 0.09. The PCS baseline score is 46.29 ± 10.95 versus 49.54 ± 10.41 after treatment with p = 0.01, so there was a significant baseline to follow up improvement. The MCS improved also, infact baseline score is 42.19 ± 12.57 versus 42.70 ± 13.03 with p = 0.87. The SUDI baseline score is 50.22 ± 20.73 versus 23.92 ± 17.90, while SIIQ score is 49.98 ± 23.90 versus 31.40 ± 23.83 with p < 0.01. In both questionnaires there is an improvement. Satisfaction with treatment outcomes from the GUTSS at 6-month follow up is 29.5 ± 6.3 with p = 0.46.

CONCLUSION

The LBC has significant advantages, without any apparent compromise in short-term and long term outcomes.

Tuberculous salpingitis: a case report

Tuberculosis (TB) of the genital tract commonly occurs secondary to a primary lesion. The mode of spread is via the lymphatics, the haematogenous route or less commonly by a peritoneal spread. The fallopian tubes are the first targets, followed by the pelvic organs. Isolated cases of TB which occur in a unilateral fallopian tube are rare, particularly with it as a primary site. The aim of this study was to report a rare case of TB of the left fallopian tube in a post menopausal lady with no positive history, clinical or laboratory finding to suggest it to be a secondary focus. As the pre-operative diagnosis was that of a right ovarian neoplasm, the patient underwent staging laparotomy. TB of the left fallopian tube was diagnosed, as there were numerous typical granulomata throughout the fallopian tube.

Peritoneal tuberculosis: a retrospective review of 20 cases and comparison with primary peritoneal carcinoma

INTRODUCTION

To evaluate the clinical features of peritoneal tuberculosis (TB) and to compare them with those of primary peritoneal carcinoma (PPC).

METHODS

We conducted a retrospective review of women with peritoneal TB who were managed at Samsung Medical Center from January 1996 to October 2006. As a control sample, patients with a diagnosis of PPC during the same period were also selected for comparison.

RESULTS

During the study period, we identified 20 female patients with peritoneal TB. The median age was 39 years (range, 23-69 years), and the median cancer antigen 125 (CA-125) level was 448 U/mL (range, 32-1725 U/mL). Seventeen patients with PPC whom we examined were older, with a median age of 63 years (range, 50-73 years); their median CA-125 level was higher at 1848 U/mL (range, 42-14,380 U/mL). Compared with those of PPC, the radiologic findings of peritoneal TB indicated less severe involvement of the omentum and the mesentery (P = 0.03). Among the 20 patients who underwent operations, 6 (30%) underwent exploratory laparotomy; 12 (60%), diagnostic laparoscopy; and 2 (10%), laparoscopy converted to laparotomy because of severe adhesion. Frozen tissue sections revealed chronic granulomatous tissue reaction in 15 (83.3%) of 18 women with peritoneal TB.

CONCLUSIONS

Maintaining a high index of suspicion is very important for the successful treatment of peritoneal TB, especially in developing countries. Age, CA-125 level, and omental involvement as identified by computed tomography may be helpful for the differential diagnosis of peritoneal TB and PPC.

Extraovarian conditions mimicking ovarian cancer: a single center experience of 15 years

OBJECTIVE

This study aims to review cases of extra-ovarian conditions that resembled ovarian malignancy and thus, to evaluate the distribution of primary pathology mimicking ovarian malignancy.

METHODS

A retrospective review of women, with final pathology of extra-ovarian diseases mimicking ovarian malignancy, which were managed at Zekai Tahir Burak Women's Health Education and Research Hospital, from January 1995 to April 2010 was undertaken.

RESULTS

Among the 2,210 women treated during the study period, extra-ovarian diseases accounted for 5.11% (113/2,210) of all the cases. Of the 113 extra-ovarian diseases, 42 (37.17%) were peritoneal tuberculosis, 25 (22.13%) were gastrointestinal malignancies, 20 (17.70%) were pelvic abscess, 8 (7.08%) were pelvic echinococcosis, 8 (7.08) were schwannoma and other retroperitoneal tumors, 4 (3.53%) were malignant lymphoma, 2 (1.77%) were chronic ectopic pregnancy, gossypiboma, and mesenteric cyst, respectively.

CONCLUSION

Medical awareness of infectious diseases such as peritoneal tuberculosis, pelvic abscess, and pelvic echinococcosis in the differential diagnosis of ovarian malignancy is still lacking, especially in developing countries. In addition, in case of a pelvic mass, gastrointestinal and retroperitoneal tumors and malignant lymphoma should always be considered to avoid pitfalls in diagnosis and therapy.

Diagnostic dilemma of abdominopelvic tuberculosis:a series of 20 cases

OBJECTIVE

To establish more effective diagnostic procedures to identify the characteristic features of abdominopelvic tuberculosis (APTB) mimicking advanced ovarian cancer.

METHODS

A retrospective review of 20 cases of APTB mimicking advanced ovarian cancer was undertaken.

RESULTS

The mean age of the patients was 28.9 ± 10.8 years. The main clinical manifestations were abdominal pain (45%) and distention (45%). CA125 level was elevated in 18 cases (90.0%). Pelvic mass in 18 patients (90.0%) and ascites in 12 patients (60.0%) were detected by using abdominal US. The bacteriologic cultures and cytological studies were all negative (10 cases, 100%). Laparotomy (17 cases) and laparoscopic evaluation (1 case) was performed with the presumptive diagnosis of advanced ovarian cancer except for 2 patients treated with diagnostic anti-TB chemotherapy. The common intra-operative findings were miliary nodules (14 cases, 77.8%) and widespread adhesion (10 cases, 55.6%). Intra-operative frozen section was obtained in 10 cases, and the typical tuberculosis tubercles were detected in all cases.

CONCLUSION

APTB should be considered in all cases with pelvic mass, ascites and high levels of CA125, although clinical features and laboratory results specifically indicate neither ovarian malignancy nor APTB. Diagnostic laparotomy is a direct and safe method. To avoid extended surgery, the cases with APTB can be diagnosed through intra-operative frozen section in conjunction with clinical features.

Peritoneal tuberculosis in pregnancy mimicking advanced ovarian cancer: a plea to avoid hasty, radical and irreversible surgical decisions

Tuberculous peritonitis is rare in most Western counties, and can cause significant diagnostic and therapeutic problems. A 28-year-old pregnant female presented with nausea and vomiting, right lower quadrant abdominal pain, fever and intra-abdominal fluid. During surgery for presumed complicated acute appendicitis, many small masses (considered to be 'implants') were found within the peritoneal cavity, with a larger mass in the pelvis, mainly on the right. The clinical intra-operative diagnosis was advanced ovarian cancer and multiple biopsies were taken. The histological diagnosis was peritoneal tuberculosis. The patient was successfully treated conservatively. Hasty decisions to undertake radical and irreversible surgery should be avoided; this type of surgery should be performed only after histological confirmation.

Peritoneal tuberculosis mimicking advanced ovarian cancer: a retrospective review of 22 cases

OBJECTIVE

To evaluate the clinical, laboratory and diagnostic features in women with peritoneal tuberculosis that resembled advanced ovarian malignancy.

METHODS

A retrospective review of women with peritoneal tuberculosis who were managed at TCSB Ankara Etlik Maternity and Women's Health Teaching and Research Hospital from July 1992 to November 2004 was undertaken.

RESULTS

Among the 1,826 women treated during the study period, 22 women with peritoneal tuberculosis (1.2%) were identified. The mean age was 36.9 years (range 21-68 years); the mean Ca125 level was 564.95 U/ml (3-2021 U/ml). All patients with peritoneal tuberculosis had ascites, 20 patients (90.91%) had elevated CA125 levels and 17 patients (77.27%) had detectable pelvic masses in the preoperative period. During preoperative diagnostic work-up, pulmonary tuberculosis was diagnosed and antituberculosis therapy had begun in two of 22 patients (9.09%). Among 20 patients, 11 (55%), 8 (40%) and 1 (5%) underwent exploratory laparotomy, diagnostic laparoscopy and laparoscopy converted to laparotomy due to dense pelvic adhesions, respectively. Since frozen section was not available during the surgery in 5 of 20, 3 patients (10%) underwent extended surgery. Frozen section was performed in 15 patients and revealed chronic granulomatous changes and final pathological examination confirmed the diagnosis.

CONCLUSION

Our data indicate that the majority of the cases with peritoneal tuberculosis can be diagnosed intraoperatively through the use of frozen section in conjunction with clinical features. Ascites and high levels of Ca125 do not necessarily indicate that the clinical picture is malignant in reproductive women. Laparoscopic tissue biopsy may be a fundamental tool in the management of such cases to avoid extended surgery.

Ascites and highly elevated CA-125 levels in a case of peritoneal tuberculosis

Peritoneal tuberculosis (PT) is uncommon in industrialized countries. We report the case of a 35-y-old female with a 1-y history of abdominal discomfort, ascites, systemic symptoms, and highly elevated CA-125 suggesting malignancy, in whom the diagnosis of PT was considered. Both clinical symptoms and CA-125 levels regressed under tuberculostatic treatment.

Peritoneal tuberculosis simulating advanced ovarian carcinoma: is clinical impression sufficient to administer neoadjuvant chemotherapy for advanced ovarian cancer?

Peritoneal tuberculosis mimics advanced ovarian cancer because of the similarities in clinical signs and symptoms such as ascites, pelvic and abdominal pain and mass, and elevation of serum CA125 level. We have presented four cases of peritoneal tuberculosis that underwent exploratory laparotomy for suspected advanced ovarian cancer during a 3-year period. Definitive diagnosis of tuberculosis was performed at laparotomy in all the cases. The frozen-section analysis seems to be the gold standard in the differential diagnosis. In view of these data, clinical diagnosis of advanced ovarian cancer is not sufficient for administering neoadjuvant chemotherapy. Cytologic or pathologic findings must be consistent with ovarian cancer for candidates who are being considered for neoadjuvant chemotherapy.

Diagnosis of abdominal tuberculosis: Experience from 11 cases and review of the literature

AIM: To analyze the experience within our hospital and to review the literature so as to establish the best means of diagnosis of abdominal tuberculosis.

METHODS: The records of 11 patients (4 males, 7 females, mean age 39 years, range 18-65 years) diagnosed with abdominal tuberculosis in Harran University Hospital between January 1996 and October 2003 were analyzed retrospectively and the literature was reviewed.

RESULTS: Ascites was present in all cases. Other common findings were weight loss (81%), weakness (81%), abdominal mass (72%), abdominal pain (72%), abdominal distension (63%), anorexia (45%) and night sweat (36%). The average hemoglobin was 8.2 g/dL and the average ESR was 50 mm/h (range 30-125). Elevated levels of cancer antigen CA-125 were determined in four patients. Abdominal ultrasound showed abnormalities in all cases: ascites in all, tuboovarian mass in five, omental thickening in 3, and enlarged lymph nodes (mesenteric, para-aortic) in 2. CT scans showed ascites in all, pelvic mass in 5, retroperitoneal lymphadenopathy in 4, mesenteric stranding in 4, omental stranding in 3, bowel wall thickening in 2 and mesenteric lymphadenopathy in 2. Only one patient had a chest radiograph suggestive of a new TB lesion. Two had a positive family history of pulmonary TB. None had acid-fast bacilli (AFB) in the sputum and the tuberculin test was positive in only two. Laparotomy was performed in 6 cases, laparoscopy in 4 and ultrasound-guided fine needle aspiration in 2. In those patients subjected to operation, the findings were multiple diffuse involvement of the visceral and parietal peritoneum, white ‘miliary nodules’ or plaques, enlarged lymph nodes, ascites, ‘violin string’ fibrinous strands, and omental thickening. Biopsy specimens showed granulomas, while ascitic fluid showed numerous lymphocytes. Both were negative for acid-fast bacilli by staining. PCR of ascitic fluid was positive for Mycobacterium tuberculosis (M. tuberculosis) in all cases.

CONCLUSION: Abdominal TB should be considered in all cases with ascites. Our experience suggests that PCR of ascitic fluid obtained by ultrasound-guided fine needle aspiration is a reliable method for its diagnosis and should at least be attempted before surgical intervention.