Role of ascites adenosine deaminase in differentiating between tuberculous peritonitis and peritoneal carcinomatosis

Differential diagnosis of ascites: etiologies, ascitic fluid analysis, diagnostic algorithm

Ascites is the pathological accumulation of fluid within the peritoneal cavity. It often occurs as results of liver cirrhosis, malignant neoplasia, tuberculous infection, cardiac insufficiency, renal diseases, etc. Determining the etiology is an essential step in the management of patients with new-onset ascites. Abdominal paracentesis with appropriate ascitic fluid analysis is probably the most cost-effective method of determining the cause of ascites. We performed a literature search of PubMed and identified articles published in the field of ascites, to evaluate diagnostic values of various parameters in defining the etiologies of ascites and then provides diagnostic algorithm for patients with new-onset ascites. In patients with ascites, the constituent ratio of underlying etiology varies between developed and developing countries. It is a challenge to define the etiologies of ascites in developing countries. Routine ascitic fluid analysis should include the serum ascites albumin gradient (SAAG), total protein concentration, cell count and differential. Optional ascitic fluid analysis includes cholesterol, fluid culture, cytology, tumor markers, lactate dehydrogenase, adenosine deaminase (ADA), triglyceride, amylase, glucose, brain natriuretic peptide (BNP), etc. Our review evaluated diagnostic values of the above parameters in defining the etiologies of ascites. Diagnostic algorithm established in this review would provide a practical and convenient diagnostic strategy for clinicians in diagnosing patients with new-onset ascites.

Clinical and Radiological Parameters to Discriminate Tuberculous Peritonitis and Peritoneal Carcinomatosis

It is challenging to differentiate between tuberculous peritonitis and peritoneal carcinomatosis due to their insidious nature and intersecting symptoms. Computed tomography (CT) is the modality of choice in evaluating diffuse peritoneal disease. We conducted an ambispective analysis of patients suspected as having tuberculous peritonitis or peritoneal tuberculosis between Jan 2020 to Dec 2021. The study aimed to identify the clinical and radiological features differentiating the two entities. We included 44 cases of tuberculous peritonitis and 45 cases of peritoneal carcinomatosis, with a median age of 31.5 (23.5-40) and 52 (46-61) years, respectively (p ≤ 0.001). Fever, past history of tuberculosis, and loss of weight were significantly associated with tuberculous peritonitis (p ≤ 0.001, p = 0.038 and p = 0.001). Pain in the abdomen and history of malignancy were significantly associated with peritoneal carcinomatosis (p = 0.038 and p ≤ 0.001). Ascites was the most common radiological finding. Loculated ascites, splenomegaly and conglomeration of lymph nodes predicted tuberculous peritonitis significantly (p ≤ 0.001, p = 0.010, p = 0.038). Focal liver lesion(s) and nodular omental involvement were significantly associated with peritoneal carcinomatosis (p = 0.011, p = 0.029). The use of clinical features in conjunction with radiological findings provide better diagnostic yields because of overlapping imaging findings.

An Updated Systematic Review and Meta-Analysis for the Diagnostic Test Accuracy of Ascitic Fluid Adenosine Deaminase in Tuberculous Peritonitis

BACKGROUND

Tuberculous peritonitis is difficult to diagnose due to its non-specific clinical manifestations and lack of proper diagnostic modalities. Current meta-analysis was performed to find the overall diagnostic accuracy of adenosine deaminase (ADA) in diagnosing tuberculous peritonitis.

MATERIALS AND METHODS

PubMed, Google Scholar, and Cochrane library were searched to retrieve the published studies which assessed the role of ascitic fluid ADA in diagnosing tuberculous peritonitis from Jan 1980 to June 2022. This meta-analysis included 20 studies and 2,291 participants after fulfilling the inclusion criteria.

RESULTS

The pooled sensitivity was 0.90 (95% confidence interval [CI]: 0.85 - 0.94) and pooled specificity was 0.94 (95% CI: 0.92 - 0.95). The positive likelihood ratio was 15.20 (95% CI: 11.70 - 19.80), negative likelihood ratio was 0.10 (95% CI: 0.07 - 0.16) and diagnostic odds ratio was 149 (95% CI: 86 - 255). The area under the summary receiver operating characteristic curve was 0.97. Cut- off value and sample size were found to be the sources of heterogeneity in the mete-regression analysis.

CONCLUSION

Ascitic fluid ADA is a useful test for the diagnosis of tuberculous peritonitis with good sensitivity and specificity however, with very low certainty of evidence evaluated by Grading of Recommendations, Assessment, Development and Evaluation approach. Further well- designed studies are needed to validate the diagnostic accuracy of ascitic fluid ADA for tuberculous peritonitis.

Diagnostic performance of adenosine deaminase for abdominal tuberculosis: A systematic review and meta-analysis

Background and aim

Abdominal tuberculosis (TB) is a common type of extrapulmonary TB with an insidious onset and non-specific symptoms. Adenosine deaminase (ADA) levels increase rapidly in the early stages of abdominal TB. However, it remains unclear whether ADA serves as a diagnostic marker for abdominal TB.

Methods

We performed a systematic literature search for relevant articles published in PubMed, Web of Science, Cochrane Library, and Embase up to April 2022. First, we used the Quality Assessment of Diagnostic Accuracy Studies tool-2 (QUADAS-2), to evaluate the quality of the included articles. Bivariate and hierarchical summary receiver operating characteristic (HSROC) models were then utilized to analyze pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), diagnostic odds ratio (DOR) and area under the receiver operating characteristic curve (AUROC). In addition, we explored a subgroup analysis for potential heterogeneity and publication bias among the included literature.

Results

Twenty-four articles (3,044 participants, 3,044 samples) which met the eligibility criteria were included in this study. The pooled sensitivity and specificity of ADA for abdominal TB detection were 93% [95% confidence interval (CI): 0.89-0.95] and 95% (95% CI: 0.93-0.96), respectively. PLR and NLR were 18.6 (95% CI: 14.0-24.6) and 0.08 (95% CI: 0.05-0.12), respectively. DOR and AUROC were 236 (95% CI: 134-415) and 0.98 (95% CI: 0.96-0.99), respectively. Furthermore, no heterogeneity or publication bias was found.

Conclusions

Our meta-analysis found ADA to be of excellent diagnostic value for abdominal TB and could be used as an auxiliary diagnostic tool.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022297931.

Utility of ascitic tumor markers and adenosine deaminase for differential diagnosis of tuberculous peritonitis and peritoneal carcinomatosis

Background

Differential diagnosis between tuberculous peritonitis and peritoneal carcinomatosis remains challenging in clinical practice; thus, in-patients diagnosed with tuberculous peritonitis or peritoneal carcinomatosis were retrospectively enrolled, and diagnostic values of ascitic tumor markers and adenosine deaminase were determined.

Methods

Consecutive patients diagnosed with tuberculous peritonitis or peritoneal carcinomatosis were retrospectively enrolled. The pertinent data of 169 patients enrolled were collected.

Results

A panel of ascitic tumor makers (CEA, CA15-3, CA19-9) had high specificity (96.83%) and accuracy (94.67%) in the differentiation of peritoneal carcinomatosis from tuberculous peritonitis; and ascitic ADA was a good discriminator between these patients, with an accuracy of 91.72%. Combined use of ascitic tumor makers and ADA (ascitic ADA < 22.5 IU/L or ascitic CEA > 3.65 ng/mL or CA15-3 > 42.70 U/mL or CA19-9 > 25.10 U/mL) performed high sensitivity (99.06%) and accuracy (94.08%) for the diagnosis of peritoneal carcinomatosis. In addition, combined ascitic ADA and tumor marker (positive ascitic tumor makers and ADA < 22.50 IU/L) had 100% of the specificity in diagnosing peritoneal carcinomatosis.

Conclusions

Combined use of ascitic tumor markers and adenosine deaminase showed excellent efficiency in the differential diagnosis between tuberculous peritonitis and peritoneal carcinomatosis, thus these two simple and cost‐effective parameters should be determined when tuberculous peritonitis or peritoneal carcinomatosis was suspected in clinic practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02480-x.

Diagnosis of Peritoneal Tuberculosis from Primary Peritoneal Cancer

Peritoneal tuberculosis (PTB) is an uncommon extrapulmonary infection mimickng primary peritoneal cancer (PPC). We retrospectively included 23 women with PTB and 47 women with PPC treated in a medical center to study the clinical and radiological features that differentiate PTB from PPC. Body temperature above 38 °C was a unique feature of PTB (34.7% versus 0%, p < 0.001). Body Mass Index (BMI) was lower (21.9 ± 3.7 versus 25.2 ± 4.1, p = 0.003), white blood cell (WBC) count was lower (5179.6 ± 1502.2 versus 7716.2 ± 2741.8, p < 0.001), and CA-125 level was lower (508.0 ± 266.1 versus 2130.1 ± 2367.2 U/mL, p < 0.001) in PTB compared with PPC. Imaging detected more pulmonary infiltration and consolidation (52.2% versus 6.4%, p < 0.001), and less omental/mesentery changes (52% versus 83%, p < 0.001) in PTB compared with PPC. The operated patients received earlier treatment compared to patients without operation (7.9 ± 5.3 days versus 17.2 ± 11.0 days, p = 0.010). In conclusion, fever above 38 °C, lower BMI, lower WBC count, less elevated CA-125 level, and imaging of less omental involvement were features of PTB differentiated from PPC.

Diagnosis of malignant versus tuberculous ascites using tumor markers and globulin ratios in serum and ascites: A Fisher discriminant model

BACKGROUND AND STUDY AIMS

This study was conducted to investigate the significance of tumor and biochemical markers in serum and ascitic fluid in the differential diagnosis of tuberculous and malignant ascites.

PATIENTS AND METHODS

Based on findings from natural orifice transluminal endoscopic surgery and postoperative pathology or cytology of 63 patients, they were divided into the malignant group (31 patients) and the tuberculous group (32 patients). Levels of tumor markers, albumin, globulin, and lactate dehydrogenase were measured simultaneously. Data were statistically analyzed, and a Fisher discriminant model was established. The receiver operating characteristic curve was constructed to confirm the discriminant value.

RESULTS

The levels of carcinoembryonic antigen (CEA), cancer antigen 125 (CA125), cancer antigen 19-9 (CA 19-9), and globulin in serum and ascitic fluid were different between the tuberculous and malignant ascites groups (P < .05). The ratios of ascites-to-serum levels of CEA, CA125, and CA 19-9, as well as the ratio of serum-to-ascites of globulin levels, were different between the two groups (P < .05). The Fisher discriminant model was established based on the ascites-to-serum ratios of CEA, CA125, and CA 19-9 levels and the serum-to-ascites ratio of globulin levels. The area under the curve was 0.908, the sensitivity was 0.838 (26/31), and the specificity was 0.875 (28/32).

CONCLUSION

A Fisher discriminant model can be established using serum and ascites tumor markers and globulin ratios, which is valuable in the differential diagnosis of tuberculous versus malignant ascites.

Gastrointestinal and Abdominal Tuberculosis

Gastrointestinal (GI) tuberculosis (TB) remains a significant problem worldwide, and may involve the luminal GI tract from oral cavity to perianal area in addition to associated viscera and peritoneum. Although GI TB more commonly affects immunocompromised hosts, it can also occur in immunocompetent people. Diagnosis is difficult because it usually mimics a malignancy or inflammatory bowel disease. A high index of clinical suspicion and appropriate use of combined investigative methods help in early diagnosis, and reduce morbidity and mortality. Anti-TB therapy is the same as for pulmonary disease, and invasive and specialized interventions are reserved for selected complications.

Development and validation a simple model for identify malignant ascites

The differential diagnosis of benign ascites and malignant ascites is incredibly challenging for clinicians. This research aimed to develop a user-friendly predictive model to discriminate malignant ascites from non-malignant ascites through easy-to-obtain clinical parameters. All patients with new-onset ascites fluid were recruited from January 2014 to December 2018. The medical records of 317 patients with ascites for various reasons in Renmin Hospital of Wuhan University were collected and reviewed retrospectively. Thirty-six parameters were included and selected using univariate logistic regression, multivariate logistic regression, and receiver operating characteristic (ROC) curve analyses to establish a mathematical model for differential diagnosis, and its diagnostic performance was validated in the other groups. Age, cholesterol, hypersensitivity C-reactive protein (hs-CRP) in serum, ascitic fluid adenosine deaminase (AF ADA), ascitic fluid lactate dehydrogenase (AF LDH) involvement in a 5-marker model. With a cut-off level of 0.83, the sensitivity, specificity, accuracy, and area under the ROC of the model for identifying malignant ascites in the development dataset were 84.7%, 88.8%, 87.6%, and 0.874 (95% confidence interval [CI], 0.822-0.926), respectively, and 80.9%, 82.6%, 81.5%, and 0.863 (95% CI,0.817-0.913) in the validation dataset, respectively. The diagnostic model has a similar high diagnostic performance in both the development and validation datasets. The mathematical diagnostic model based on the five markers is a user-friendly method to differentiate malignant ascites from benign ascites with high efficiency.

Guidelines on the management of ascites in cirrhosis

The British Society of Gastroenterology in collaboration with British Association for the Study of the Liver has prepared this document. The aim of this guideline is to review and summarise the evidence that guides clinical diagnosis and management of ascites in patients with cirrhosis. Substantial advances have been made in this area since the publication of the last guideline in 2007. These guidelines are based on a comprehensive literature search and comprise systematic reviews in the key areas, including the diagnostic tests, diuretic use, therapeutic paracentesis, use of albumin, transjugular intrahepatic portosystemic stent shunt, spontaneous bacterial peritonitis and beta-blockers in patients with ascites. Where recent systematic reviews and meta-analysis are available, these have been updated with additional studies. In addition, the results of prospective and retrospective studies, evidence obtained from expert committee reports and, in some instances, reports from case series have been included. Where possible, judgement has been made on the quality of information used to generate the guidelines and the specific recommendations have been made according to the 'Grading of Recommendations Assessment, Development and Evaluation (GRADE)' system. These guidelines are intended to inform practising clinicians, and it is expected that these guidelines will be revised in 3 years' time.

Visual PET/CT scoring of mesenteric fdg uptake to differentiate between tuberculous peritonitis and peritoneal carcinomatosis

PURPOSE

We aimed to differentiate tuberculous peritonitis (TBP) from peritoneal carcinomatosis (PC) using a visual positron-emission tomography/computed tomography (PET/CT) scoring system based on mesenteric fluorodeoxyglucose (FDG) uptake.

METHODS

PET/CT scans from 31 patients with TBP and 92 patients with PC were retrospectively reviewed. A visual PET/CT scoring system for mesenteric FDG uptake was used according to the following characteristics: FDG uptake intensity (low = 0, moderate = 1, high = 2), FDG uptake deposits (uniform = 0, irregular = 1, ascitic = 2), FDG uptake focality (diffuse = 0, segmental = 1, focal = 2), nodularity on the corresponding CT (nonnodular = 0, micronodular = 1, macronodular = 2) and mesenteric lymphadenopathy (absent = 0, lymphadenopathy without FDG uptake = 1, lymphadenopathy with FDG uptake = 2). The FDG uptake intensity, deposits, focality, nodularity and mesenteric lymphadenopathy scores between TBP and PC were compared using chi-square tests. The diagnostic performance of this scoring system for differentiating TBP from PC was analyzed using a receiver operating characteristic (ROC) curve. P < 0.05 was considered statistically significant.

RESULTS

Twenty-four patients with TBP (77.4%) and 56 patients with PC (60.9%) had mesenteric FDG uptake (P = 0.095) and were included for evaluation with the visual PET/CT scoring system. PC lesions scored higher than TBP lesions in FDG uptake deposits (P < 0.001), focality (P < 0.001) and nodularity (P < 0.001). No significant differences were observed between PC and TBP lesions in FDG uptake intensity (P = 0.396) and lymphadenopathy (P = 0.074). The total score that combined deposits, focality and nodularity had significant value for differentiating TBP from PC (area under the curve (AUC) = 0.869, P < 0.001), and a cutoff > 1 had a sensitivity (the accuracy for diagnosis of PC) of 80.4% and a specificity (the accuracy for diagnosis of TBP) of 75.0%.

CONCLUSION

A visual PET/CT scoring system based on mesenteric FDG uptake performed well in differentiating between TBP and PC.

Use of adenosine deaminase (ADA) to diagnose suspected peritoneal tuberculosis in Rwanda: a cross-sectional study

Background

Peritoneal tuberculosis is the most common cause of low albumin gradient ascites in developing countries, but it can be easily confused with other causes of ascites. Peritoneal tuberculosis requires early recognition of symptoms and signs in order to make a quick diagnosis for appropriate treatment. Measurement of adenosine deaminase (ADA) level > 39 in ascites fluid is an established test to diagnose peritoneal tuberculosis. Many low-income countries do not currently test for adenosine deaminase in ascites fluid, including Rwanda.

Method

Cross-sectional, descriptive study conducted through the Internal Medicine Department of three university teaching hospitals in Rwanda. Participants were patients older than 16 years presenting to tertiary referral hospitals with ascites of unknown cause.

Results

Of 103 ascites fluid samples collected, 52 of them (50.5%) had an elevated ADA, consistent with a presumptive diagnosis of peritoneal TB. Among those 52 subjects diagnosed with peritoneal TB, 39 out of 52 (75%) did not receive anti-TB medications. Among the 17 subjects who were treated with anti-TB medications, 4 of 17 (23.6%) did not have peritoneal TB based on ADA level. Samples with low-albumin gradient ascites were more likely to have high ADA ≥39 IU/L (p = 0.039).

Conclusion

Our findings suggest that 3out of 4 patients with PTB in Rwanda are not getting TB treatment and 1 in 4 patients who are taking TB medications do not need it. Even if the true number of Rwandans who are being undertreated and overtreated is less than our study suggests, these results should prompt a larger study of peritoneal tuberculosis. Adding adenosine deaminase (ADA) to the diagnostic tools available to clinicians could help achieve the goal of correctly putting every Rwandan with tuberculosis on treatment, while avoiding unnecessary tuberculosis medications in those who do not have the disease.

Diagnostic performance of CT for differentiating peritoneal tuberculosis from peritoneal carcinomatosis: a systematic review and meta-analysis

AIM

To undertake a systematic review and meta-analysis of the diagnostic performance of CT for differentiating peritoneal tuberculosis (PTB) from peritoneal carcinomatosis (PC).

MATERIAL AND METHODS

PubMed, Embase, the Web of Science, and the Cochrane Library were searched for papers published before 23 July 2019. The methodological quality of the studies was analysed. Overlapping descriptors used in different studies to denote the same image finding were subsumed under a single CT feature. Sensitivity, specificity, and positive and negative likelihood ratios were pooled. A summary receiver operating characteristic curve (sROC) was constructed and the area under the curve (AUC) of the included studies was calculated when possible.

RESULTS

Six studies were included and 17 CT features were analysed. The pooled sensitivity and specificity of smooth peritoneal thickening were 59% (95% CI: 52-66%) and 84% (95% CI: 79-88%), respectively. The AUC of smooth peritoneal thickening was 0.83. Omentum line/rim, lymph node necrosis or calcification, and mesenteric macro nodules had a pooled specificity ranging from 95% to 100% and a pooled sensitivity ranging from 12% to 67%. The other 12 signs had a pooled sensitivity ranging from 21% to 79% and a pooled specificity ranging from 19% to 81%. Omentum involvement (cake-like pattern) showed a threshold-effect, so only the AUC (=0.70) was calculated.

CONCLUSIONS

Smooth peritoneal thickening shows fairly good diagnostic accuracy, while omentum rim/line, lymph nodes necrosis or calcification, mesenteric macro nodules have good specificity but limited sensitivity. The informative features summarised in this study may aid clinical practice and future studies.

A diagnostic approach for differentiating abdominal tuberculosis from ovarian malignancy: a case series and literature review

Background

Abdominal tuberculosis is an uncommon variant of extrapulmonary tuberculosis. It accounts for 3.5% of extrapulmonary tuberculosis. Diagnosis of abdominal tuberculosis is still a challenge due to its non-specific symptoms. Abdominal tuberculosis and ovarian cancer may show similar symptoms, laboratory and imaging features. The goal of our report is to emphasize for the need of a diagnostic approach based on clinical manifestations, laboratory, imaging findings, and additional tests for considering a diagnosis of abdominal tuberculosis rather than ovarian cancer.

Case presentation

We report 3 cases of abdominal tuberculosis in our Onco-gynaecology Division, Department of Obstetrics and Gynaecology, Sardjito Hospital, Yogyakarta, Indonesia in 2018 which were previously diagnosed as ovarian malignancy and managed surgically. All of our patients experienced abdominal pain and enlargement but only two of them had significant weight loss. The general symptoms were typically found in onco-gynaecology patients, especially in those with ovarian malignancy. Ultrasound examination showed multilocular masses, 2 of them with solid parts and ascites. Cancer antigen 125 (CA-125) levels were found increasing in those three patients. All of them were treated surgically and diagnosis of abdominal tuberculosis was established through the histopathological result of tissue biopsy. Based on our cases and literature, we consider the need of a diagnostic approach to differentiate abdominal tuberculosis from ovarian malignancy, an attempt to avoid unnecessary invasive procedures that put burden risk for the patients.

Conclusion

Minimally invasive tests to establish the diagnosis of abdominal tuberculosis should be optimized to reduce the burden risk of laparotomy. Careful diagnostic steps should be followed to avoid wrong diagnosis.

Tuberculous abdominal cocoon mimicking peritoneal carcinomatosis

Background

Tuberculous abdominal cocoon is an uncommon manifestation of abdominal tuberculosis. As a rare clinical entity, it is often encountered unexpectedly in patients with small intestinal obstruction. Here we presented a rare case of tuberculous abdominal cocoon which was suspected to be peritoneal carcinomatosis and was finally diagnosed by laparoscopy.

Case presentation

A 47-year-old man developed small intestinal obstruction and massive ascites that did not resolve with conservative management. Surgical exploration revealed a fibrous sheath covering the small-bowel, and pathologic assessment of biopsies confirmed intra-abdominal tuberculous infection. After antituberculosis therapy, the ascites has greatly diminished and the patient was functioning normally.

Conclusion

Preoperative diagnosis of tuberculous abdominal cocoon is a true challenge. Early diagnostic peritoneal biopsy should be recommended and surgery is usually unnecessary if definitive diagnosis can be made.

Predictive value of omental thickness on ultrasonography for diagnosis of unexplained ascites, an Egyptian centre study

Etiology of ascites of unknown origin varies with geographic area and ethnic origin. Tuberculous peritonitis and peritoneal carcinomatosis constitute a considerable proportion of patients. Differentiation between both is a major challenge. The role of omental thickness (OT) by ultrasonography to predict risk of malignancy in unexplained ascites. This prospective study was done at Kasr Alainy School of Medicine, Cairo University and included 100 adults with unexplained ascites and thickened omentum (>15 mm) on ultrasonography. An expert performed ultrasonography to assess peritoneum and peritoneal cavity and measure OT. Ascites was assessed regarding volume, echogenicity, and loculation. The ascitic fluid was analyzed to measure lactate dehydrogenase, adenosine deaminase, and total leukocytic count. Laparoscopic exploration with biopsy was done for final diagnosis that divided the patients into; TB Group (n = 44) and peritoneal carcinomatosis group (n = 56). Main Outcome Measures were to determine degree of omental thickness as a predictor of malignancy risk in unexplained ascites and other ultrasonographic features to predict malignancy risk including omental echogenicity and results of diagnostic ascitic tapping. We found that OT was greater in the PC group compared to the TB group (24.6 ± 4.6 mm vs. 17.9 ± 3.0 mm, respectively, p < 0.001). Higher frequency of hypoechogenicity, irregular peritoneal surface, omental cakes, and lymph nodes was seen in PC Group. ADA, TLC, and relative lymphocyte count were higher in TB group. Omental thickness ≥19.5 mm has a sensitivity of 89.3%, specificity of 84.1% to diagnose PC. We can conclude that omental thickness >19 mm is a sensitive and specific predictor of malignancy in patients with unexplained ascites.

Transient Segmental Enhancement of Pyogenic Liver Abscess: A Comparison Between Contrast-Enhanced Ultrasound and Computed Tomography

OBJECTIVE

This study aimed to investigate the correlation between the transient segmental enhancement (TSE) of liver abscesses on contrast-enhanced ultrasound (CEUS) imaging and contrast-enhanced computed tomography (CT) scans.

METHODS

In total, 42 abscesses in 38 patients were evaluated with real-time CEUS and contrast-enhanced CT imaging. The CT imaging and CEUS examinations were performed within one to 2 days of each other in all cases. The initial reports of the observations of TSE on CEUS scans were correlated later with the findings of TSE on contrast-enhanced CT images. Contrast-enhanced CT was used as the reference standard to evaluate the presence of TSE. Relationships between the 2 groups were analyzed using the χ test. P < 0.05 was considered to be statistically significant.

RESULTS

In 16 patients, 16 typical TSE signs were shown by CEUS. Meanwhile, enhanced CT imaging showed 18 typical signs of TSE in 17 patients. We identified 38 patients with hepatic abscesses proven by needle aspiration (10 patients) or image-guided biopsy (28 patients). Ten patients had hepatobiliary cholelithiasis, 5 had diabetes mellitus type 2, and 2 had gastric cancer, whereas no evidence of underlying hepatobiliary or gastrointestinal diseases was found in the other 21 patients. Considering that enhanced CT is the reference standard for the diagnosis of hepatic abscesses, the sensitivity of CEUS in showing TSE was 89%, and the specificity was 100%. The χ test indicated that CEUS and enhanced CT were significantly correlated for detection of hepatic perfusion disorders (P < 0.05).

CONCLUSIONS

The appearance of TSE in liver abscess was reliably detected by CEUS, which correlated well with the enhanced CT images (P < 0.05).

PET/CT for differentiating between tuberculous peritonitis and peritoneal carcinomatosis: The parietal peritoneum

OBJECTIVES

Tuberculous peritonitis (TBP) mimics peritoneal carcinomatosis (PC). We aimed to investigate the discriminative use of PET/CT findings in the parietal peritoneum.

MATERIALS AND METHODS

Parietal peritoneal PET/CT findings from 76 patients with TBP (n = 25) and PC (n = 51) were retrospectively reviewed. The lesion locations were noted as right subdiaphragmatic, left subdiaphragmatic, right paracolic gutters, left paracolic gutters, and pelvic regions. The distribution characteristic consisted of a dominant distribution in the pelvic and/or right subdiaphragmatic region (susceptible area for peritoneal implantation, SAPI) (SAPI distribution), a dominant distribution in the remaining regions (less-susceptible area for peritoneal implantation, LSAPI) (LSAPI distribution), or a uniform distribution. PET morphological patterns were classified as F18-fluorodeoxyglucose (F-FDG) uptake in a long beaded line (string-of-beads F-FDG uptake) or in a cluster (clustered F-FDG uptake) or focal F-FDG uptake. CT patterns included smooth uniform thickening, irregular thickening, or nodules.

RESULTS

More common findings in the parietal peritoneum corresponding to TBP as opposed to PC were (a) ≥4 involved regions (80.0% vs 19.6%), (b) uniform distribution (72.0% vs 5.9%), (c) string-of-beads F-FDG uptake (76.0% vs 7.8%), and (d) smooth uniform thickening (60.0% vs 7.8%) (all P < 0.001), whereas more frequent findings in PC compared with TBP were (a) SAPI distribution (78.4% vs 28.0%), (b) clustered F-FDG uptake (56.9% vs 20.0%), (c) focal F-FDG uptake (21.6% vs 4.0%), (d) irregular thickening (51.0% vs 12.0%), and (e) nodules (21.6% vs 4.0%) (P < 0.001, P < 0.05, P > 0.05, P < 0.05, P > 0.05, respectively).

CONCLUSION

Our data show that PET/CT findings in the parietal peritoneum are useful for differentiating between TBP and PC.

Value of measurement of gradient and ratio of ascites-serum tumor markers in differential diagnosis of tuberculous ascites and malignant ascites

AIM

To assess the value of measurement of the gradient and ratio of ascites-serum tumor markers in the differential diagnosis of tuberculous ascites and malignancy-related ascites.

METHODS

Sixty patients with ascites were divided into two groups, namely, 31 cases of malignant ascites and 31 cases of tuberculous ascites. Tumor markers in serum and ascites were simultaneously detected to calculate and compare the gradient and ratio of serum-ascites tumor markers between the two groups.

RESULTS

The positive rates of CEA and CA199 in the malignant group were significantly higher than those of the tuberculosis group (P < 0.01). The positive rates of CA125 and α-fetoprotein (AFP) showed no significant difference between the two groups (P > 0.05). Ratio analysis of tumor markers in ascites and serum revealed that CA125, CA199, and CEA ratios were statistically significant between the two groups, with CA125 ratio having the most significant difference (P < 0.01). Ascites-serum gradient analysis showed that CA125, CEA, and CA199 gradients were significantly different between the two groups (P < 0.01). The ratio and gradient of AFP were not significantly different between the two groups (P > 0.05).

CONCLUSION

At the cutoff values of CA125 ratio > 2.16, CA125 gradient > 264.05 ng/mL, CEA ratio > 4.8, CEA gradient > 23.05 ng/mL, CA199 ratio > 0.96, and CEA gradient > -0.20 ng/mL, the diagnostic value of combining the gradients and ratios of the three tumor markers are more helpful to distinguish tuberculous ascites and non-liver cancer ascites than any of the three markers alone.

Gastric Cancer with Peritoneal Tuberculosis: Challenges in Diagnosis and Treatment

Herein, we report a 39-year-old female patient presenting with gastric cancer and tuberculous peritonitis. The differential diagnosis between advanced gastric cancer with peritoneal carcinomatosis and early gastric cancer with peritoneal tuberculosis (TB), and the treatment of these two diseases, were challenging in this case. Physicians should have a high index of suspicion for peritoneal TB if the patient has a history of this disease, especially in areas with a high incidence of TB, such as South Korea. An early diagnosis is critical for patient management and prognosis. A surgical approach including tissue biopsy or laparoscopic exploration is recommended to confirm the diagnosis.

Age and sex distribution in malignant and tuberculous serous effusions: A study of 127 patients and review of the literature

AIM

Tuberculosis and carcinomatosis are the two most frequent causes of pleural effusion and exudative ascites, and both are characterized by lymphocyte-rich effusion. We attempted to discover if there is any significant difference in the age and sex distribution between patients presenting with these two conditions.

METHODS

A total of 161 serous effusion samples from 127 patients (89 with pleural effusion and 38 with ascites) having follow-up biopsy and histopathological examination were included in the present study. Three groups - malignancy (47 patients), tuberculosis (47) and non-tuberculous benign lesions (26) as per histopathological diagnoses - were compared in respect to age and sex distribution.

RESULTS

A total of 29 (61.7%) patients with malignancy were aged ≥50 years as compared with three (6.4%) tuberculosis patients with serous effusions (P = 0.00000). A similar trend was observed in the ≥60 years age group (18 or 38.3% malignancy vs none with tuberculosis, P = 0.00000). A total of 36 (76.6%) tuberculous effusion patients were aged less than 40 years as opposed to eight (17.0%) patients with malignant effusions (P = 0.00000). There was also s significant difference between tuberculous and non-tuberculous benign lesions in the ≥50 years age group (6.4% vs 69.2%, P = 0.00000), but no significant difference between malignancy and non-tuberculous benign lesions (P = 0.61385). There were 31 female (66.0%) patients with malignancy, which was significantly higher than that of patients with tuberculosis (16, [34%], P = 0.00365) and non-specific inflammation/benign lesions (23.1%, P = 0.00059). However, the difference between tuberculosis and non-tuberculous benign lesions was not significant (P = 0.42756).

CONCLUSION

Whereas malignancy in serous effusions is found in older and middle-aged people, tuberculous effusion is a disease of younger people.

Ascitic Fluid Analysis in the Differential Diagnosis of Ascites: Focus on Cirrhotic Ascites

Ascites is the pathologic accumulation of fluid within the peritoneal cavity. Because many diseases can cause ascites, in particular cirrhosis, samples of ascitic fluid are commonly analyzed in order to develop a differential diagnosis. The concept of transudate versus exudate, as determined by total protein measurements, is outdated and the use of serum-ascites albumin gradient as an indicator of portal hypertension is more accurate. Lactate dehydrogenase (LDH), vascular endothelial growth factor (VEGF), and other tumor markers can be helpful in distinguishing between malignant and benign conditions. Glucose and adenosine deaminase levels may support a diagnosis of tuberculous disease, and amylase level may indicate a diagnosis of pancreatitis. Given the specificity and sensitivity of laboratory results, accurate diagnosis should be based on both laboratory data and clinical judgment.

Diagnostic accuracy of adenosine deaminase for tuberculous peritonitis: a meta-analysis

INTRODUCTION

Tuberculous peritonitis remains a diagnostic challenge for clinicians. Many studies have investigated the usefulness of adenosine deaminase (ADA) in ascites for the diagnosis of tuberculous peritonitis; however, the overall diagnostic accuracy of ADA for tuberculous peritonitis remains unclear. The aim of the present meta-analysis was to determine the overall accuracy of ADA measurements in the diagnosis of tuberculous peritonitis.

MATERIAL AND METHODS

We performed a systematic search in PubMed and Embase to identify published studies that evaluated the diagnostic role of ADA for tuberculous peritonitis. Quality was assessed according to standardized Quality Assessment of Diagnostic Accuracy Studies criteria. Sensitivity, specificity and other measures of accuracy of ADA assay in order to diagnose tuberculous peritonitis were pooled using random effects models. Summary receiver operating characteristic curve (SROC) was used to summarize overall test performance.

RESULTS

Sixteen studies met inclusion criteria for the present meta-analysis. The pooled sensitivity and specificity for diagnosing tuberculous peritonitis were 0.93 (95% CI: 0.89-0.95) and 0.96 (95% CI: 0.94-0.97), respectively. The positive likelihood ratio was 15.80 (95% CI: 10.87-22.95), negative likelihood ratio was 0.09 (95% CI: 0.05-0.16) and diagnostic odds ratio was 249.28 (95% CI: 113.11-549.39). The area under the SROC was 0.98.

CONCLUSIONS

Ascitic ADA determination is a relatively sensitive and specific test for the diagnosis of tuberculous peritonitis. Measurement of ADA in ascites is thus likely to be a useful diagnostic method for tuberculous peritonitis.

Use of natural orifice translumenal endoscopic surgery in the diagnosis of suspected tuberculous peritonitis: a retrospective case series of 7 patients

BACKGROUND AND OBJECTIVE

In cases of ascites of unknown etiology, tuberculosis peritonitis (TBP) is a possible cause but a diagnostic challenge. This retrospective case series assessed the effectiveness and safety of diagnostic natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and the Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) in 7 consecutive patients with suspected TBP.

SUBJECTS AND METHODS

Between September 2011 and August 2012, peritoneal biopsy was performed using transgastric NOTES for subsequent histology in 7 consecutive hospitalized patients who presented with ascites and were diagnosed with suspected TBP. The outcome measures included diagnostic accuracy and procedure-related morbidities.

RESULTS

Diagnostic NOTES was successfully completed in all 7 patients. Peritoneoscopy with NOTES went uneventfully and lasted 5-10 minutes. Typical peritoneal nodules characteristic of TBP were identified in all patients and confirmed pathologically as TBP. No clinically significant adverse events occurred in any patients following NOTES, except for 1 patient who experienced mild and transient pyrexia. Postoperative blood culture detected no microbial growth. Follow-up upper gastrointestinal endoscopy showed that the gastric wall wound healed well with minimal scarring. All patients were prescribed a standard four-drug antituberculosis chemotherapy regimen. The treatment outcomes were determined to be effective or curative, and no relapse was detected within the follow-up period.

CONCLUSIONS

NOTES is an effective and safe diagnostic technique in patients with suspected TBP presenting as ascites of unknown etiology.