Níveis ascíticos e soros de biomarcadores tumorais (CA 72-4, CA 19-9, CEA e CA 125) em discriminação de causa de ascites: um estudo prospectivo / Ascitic and serum levels of tumor biomarkers (ca 72-4, ca 19-9, cea and ca 125) in discrimination of cause of ascites: a prospective study

ABSTRACT Background: The role of ascitic and serum levels of various tumour biomarkers in the discrimination of cause of ascites is not well established. Objective: To evaluate the role of serum and ascitic levels of tumor biomarkers (CA 72-4, CA 19-9, CEA and CA 125) in discrimination of cause of ascites. Methods: A prospective study was conducted in consecutive patients presenting with ascites. Serum and ascitic levels of CA 19-9, CA 125, CA 72-4 and carcinoembryonic antigen (CEA) were determined at the presentation. The patients with cirrhotic ascites, tuberculous peritonitis (TBP) and peritoneal carcinomatosis (PC) were eventually included in analysis. Results: Of the 93 patients (58 males, mean age 47 years) included, the underlying cause was cirrhosis in 31, PC in 42 and peritoneal tuberculosis in 20. The best cutoff for discriminating benign and malignant ascites for serum CEA, CA 19-9 and CA 72-4 were 6.7 ng/mL, 108 IU/mL and 8.9 IU/mL, respectively. The best cutoff for discriminating benign and malignant ascites for ascitic CA 125, CEA, CA 19-9 and CA 72-4 were 623 IU/mL, 8.7 ng/mL, 33.2 IU/mL and 7 IU/mL, respectively. Conclusion: The performance of single biomarker for the prediction of underlying PC is low but a combination of serum CA 19-9 and CA 72-4 best predicted the presence of peritoneal carcinomatosis.

RESUMO Contexto: O papel dos níveis ascíticos e séricos de vários biomarcadores de tumores na discriminação da causa das ascites não está bem estabelecido. Objetivo: Avaliar o papel dos níveis séricos e ascíticos de biomarcadores tumorais (CA 72-4, CA 19-9, CEA e CA 125) na discriminação da causa das ascites. Métodos: Estudo prospectivo foi realizado em pacientes consecutivos que apresentaram ascite. Foram determinados níveis do soro e ascítico de CA 19-9, CA 125, CA 72-4 e antígeno carcinoembrínico (CEA). Os pacientes com ascites cirróticas, peritonite tuberculosa e carcinomatose peritoneal (CP) foram eventualmente incluídos na análise. Resultados: Dos 93 pacientes (58 homens, média de idade 47 anos) incluídos, a causa básica foi cirrose em 31, CP em 42 e tuberculose peritoneal em 20. O melhor corte para discriminação de ascites benignas e malignas para soro CEA, CA 19-9 e CA 72-4 foram 6,7 ng/mL, 108 UI/mL e 8,9 UI/mL, respectivamente. O melhor corte para discriminação de ascites benignas e malignas para CA 125 ascitico, CEA, CA 19-9 e CA 72-4 foram 623 UI/mL, 8,7 ng/mL, 33,2 UI/mL e 7 UI/mL, respectivamente. Conclusão: O desempenho do biomarcador único para a previsão do CP subjacente é baixo, mas uma combinação de soro CA 19-9 e CA 72-4 melhor previu a presença de carcinomatose peritoneal.

Clinical Status and Research Progress of Tuberculous Peritonitis / 中国医学科学院学报

Tuberculous peritonitis(TBP)is currently one of the common manifestations of extrapulmonary tuberculosis.Due to the atypical clinical features,diverse types of diseases to be distinguished,and limited detection methods,TBP is difficult to be diagnosed and the fatality caused by delayed diagnosis increases significantly.We studied the current research status of TBP and found that T cells spot test,abdominal CT,and laparoscopic biopsy were of high diagnostic value for TBP.However,the application of ascites Xpert-MTB/RIF-ultra assay,ascites ADA,and whole-body positron emission tomography/computed tomography remained to be studied.Serum CA125 helps to judge the efficacy of anti-tuberculosis treatment.

Peritonitis tuberculosa en un niño / Pediatric tuberculous peritonitis: case report

Resumen La peritonitis tuberculosa es una entidad infrecuente en la población pediátrica. Es una forma poco común de tuberculosis extrapulmonar y representa un muy bajo porcentaje de todos los casos de tuberculosis. Sus síntomas son inespecíficos, manifestándose usualmente con ascitis, dolor abdominal, fiebre y baja de peso. El retraso en su diagnóstico y tratamiento, dada su forma de presentación, puede incrementar su morbimortalidad. Se comunica el caso de una adolescente de 14 años, previamente sana, quien se presentó con fiebre y ascitis. La laparoscopia demostró múltiples nódulos en la cavidad abdominal compatibles con una tuberculosis peritoneal, la cual fue posteriormente confirmada por cultivo y biología molecular. La paciente completó su tratamiento antituberculoso recuperándose en forma satisfactoria.

Tuberculous peritonitis is an uncommon entity in the infant population. It is an uncommon form of extrapulmonary tuberculosis and represents a very low percentage of all cases of tuberculosis. Its symptoms are nonspecific and usually manifesting with ascites, abdominal pain, fever and low weight. The delay in its diagnosis and treatment, originated by its form of presentation, can cause an increase in its morbidity and mortality. We report the case of a 14-year-old patient without concomitant disease or pulmonary tuberculosis, who presented with ascites and fever. Laparoscopy showed multiple nodules in the abdominal cavity compatible with peritoneal tuberculosis, which was subsequently confirmed by culture and molecular test. The patient completed her antituberculosis treatment recovering satisfactorily.

A Case of Tuberculous Peritonitis Presenting as Small Bowel Obstruction / 대한소화기학회지

The peritoneum is one of the common extrapulmonary sites of tuberculosis infection. Patients with underlying end-stage renal or liver disease are frequently complicated by tuberculous peritonitis; however, the diagnosis of the tuberculous peritonitis is difficult due to its insidious nature, well as its variability in presentation and limitation of available diagnostic tests. Once diagnosed, the preferred treatment is usually antituberculous therapy in uncomplicated cases. However, surgical treatment may also be required for complicated cases, such as small bowel obstruction or perforation. An 85-year-old woman was referred our hospital for abdominal pain with ileus. Despite medical therapy, prolonged ileus and progression to sepsis were shown, she underwent surgery to confirm the diagnosis and relief of mechanical ileus. Intraoperative peritoneal biopsy and macroscopic findings confirmed tuberculous peritonitis. Therefore, physicians should consider the possibility of tuberculous peritonitis in patients with unexplained small bowel obstruction.

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.

Tuberculosis peritoneal simulando cáncer de ovario / Peritoneal tuberculosis simulating ovarian cancer

La tuberculosis (TB) peritoneal es una forma de TB abdominal y/o pélvica. Esta entidad en ocasiones puede simular clínicamente un carcinoma ovárico, lo cual sumado a un aumento sérico del CA 125, puede hacer del diagnóstico diferencial entre estas dos enfermedades, un reto difícil para el clínico. Se presenta el caso de una mujer de 49 años de edad con síntomas, signos, hallazgos imagenológicos y de laboratorio sugestivos de carcinoma ovárico, en quien además se documentan factores de riesgo para el desarrollo de TB. Finalmente, gracias a la realización de estudios complementarios y a un adecuado análisis de los datos se llega al diagnóstico de TB peritoneal. El presente caso busca concientizar a la comunidad médica sobre la importancia de considerar la TB peritoneal como diagnóstico diferencial en pacientes con sospecha de carcinoma ovárico, permitiendo así realizar un acertado y oportuno diagnóstico evitando la exposición a procedimientos quirúrgicos riesgosos e innecesarios.

Peritoneal tuberculosis (TB) is a form of peritoneal and / or pelvic TB. This entity can sometimes clinically simulate an ovarian carcinoma, which added to an incresed serum CA 125 can make the differential diagnosis between these two diseases, a difficult challenge for the clinician. The case of a 49 years old woman with symptoms, signs, and imaging and laboratory findings suggestive of ovarian carcinoma in whom also risk factors for the development of TB are documented, is presented. Finally, thanks to the complementary studies and adequate analysis of the data, the diagnosis of peritoneal TB is made. This case aims to raise awareness of the medical community about the importance of considering the peritoneal TB as a differential diagnosis in patients with suspected ovarian carcinoma, allowing to perform an accurate and timely diagnosis avoiding exposure to risky and unnecessary surgical procedures.

Tuberculous Peritonitis Mimicking Primary Peritoneal Carcinoma

Tuberculous peritonitis is one of the most common extrapulmonary tuberculosis. The presenting signs and symptoms, together with the carbohydrate antigen (CA) 125 status and imaging findings may resemble the primary peritoneal carcinoma or ovarian carcinoma. We herein report a case on a 71-year-old woman who is presented with abdominal distension, abdominal pain, nausea, anorexia. Abdomino-pelvic computed tomography scans reveal large amounts of ascites and mottled omentum with diffuse nodular masses, and the serum CA 125 level is elevated. The initial clinical diagnosis is the primary peritoneal carcinoma, but the final histological diagnosis confirms the tuberculous peritonitis. Thus, we discuss the differential diagnosis of tuberculous peritonitis from primary peritoneal carcinoma and also the problems especially found in old aged patients. In conclusion, although the elderly patients are suspected with malignancy, we should keep in mind the possibility of curable diseases and perform laparoscopic biopsy during the early stage aggressively.

Clinical Significance of Serum CA-125 in Korean Females with Ascites

PURPOSE: Mycobacterium tuberculosis is endemic in Korea. Because tuberculous peritonitis is characterized by ascites, abdominal pain, abdominal mass and elevation of serum CA-125, it can be confused with ovarian malignancies. The aim of this study was to evaluate the significance of serum CA-125 level in the differential diagnosis of tuberculous peritonitis and ovarian malignancy in a Mycobacterium tuberculosis-endemic area. MATERIALS AND METHODS: The medical records of patients diagnosed with tuberculous peritonitis (n=48) or epithelial ovarian malignancy (n=370) at Samsung Medical Center from January 2000 to October 2009 were retrospectively reviewed. RESULTS: Median serum CA-125 level in the epithelial ovarian cancer group was significantly higher than that in the tuberculous peritonitis group (p< or =0.01). Only one patient (2.1%) in the tuberculous peritonitis group had a serum CA-125 level over 2000 U/mL. However, 109 patients (29.5%) in the epithelial ovarian cancer group had a serum CA-125 level over 2000 U/mL. At the CA-125 ranges of 400 to 599 and 600 to 799, the proportions of those with tuberculous peritonitis were 24% and 21.9%, respectively. At a serum CA-125 level over 1000 U/mL, however, the proportion of tuberculous peritonitis was much lower (2.1%). CONCLUSION: Tuberculous peritonitis should be considered in the evaluation of female patients with ascites and high serum CA-125.

A Case of Tuberculous Liver Abscess Developed during Chemotherapy for Tuberculous Peritonitis as Paradoxical Response / 대한소화기학회지

Tuberculous liver abscesses are rare. Paradoxical response in tuberculosis is common and occurred between 2 weeks and 12 weeks after anti-tuberculous medication. We report here a case of tuberculous liver abscess that developed in a paradoxical response during chemotherapy for tuberculous peritonitis in a 23-year-old male. He was hospitalized, complaining of ascites, epigastric pain. He was diagnosed tuberculous peritonitis by expiratory laparoscopic biopsy and took medication for tuberculosis. After 2 months, a hepatic lesion was detected with CT scan incidentally. Chronic granulomatous inflammation was seen in ultrasound-guided liver biopsy, and tuberculous liver abscess was diasnosed. It was considered as paradoxical response, rather than treatment failure or other else because clinical symptoms of peritoneal tuberculosis and CT scan improved. After continuing initial anti-tuberculous medication, he was successfully treated. Herein, we report a case of tuberculous liver abscess as paradoxical response while treating peritoneal tuberculosis without changing anti-tuberculous treatment regimen.

Serum - ascites albumin and cholesterol gradients in differential diagnosis of ascites.

Background: Differential diagnosis of ascites is a common clinical problem. Less expensive biochemical techniques are required to differentiate ascites with unknown etiology. Aim: To evaluate the diagnostic efficiency of ascitic fluid cholesterol, serum ascites albumin gradient (SAAG) and serum ascites cholesterol gradients (SACG) in differentiating cirrhotic, tuberculous and malignant ascites. Methods: 50 patients (25 with hepatic cirrhosis, 15 with tuberculosis and10 with malignancy) were evaluated for ascitic fluid total protein, albumin, cholesterol, SAAG and SACG. Results: The mean ascitic fluid cholesterol was significantly higher in malignant ascites when compared with cirrhosis and tuberculous ascites (p= 0.0001 each). The difference between tuberculous and cirrhotic ascites was also significant (p= 0.001). The mean value of SAAG was significantly higher in cirrhosis when compared with tuberculous and malignant ascites (p= 0.0001; p= 0.001 respectively) but the difference between tuberculous and malignant ascites was not significant The mean SACG was significantly lower in malignant compared to tuberculous and cirrhotic ascites (p= 0.0001; p= 0.001 respectively). The difference between tuberculous and cirrhotic ascites was not significant. Conclusion: SAAG is a better marker to differentiate cirrhotic ascites from tuberculous and malignant ascites. Ascitic fluid cholesterol and SACG are better markers to differentiate malignant ascites from cirrhotic and tuberculous ascites.

A Case of Tuberculous Peritonitis Developed during Chemotherapy for Tuberculous Pleurisy as Paradoxical Response / 대한소화기학회지

After the start of anti-tuberculous treatment, paradoxical worsening of tuberculous lesions has been described. However, abdominal tuberculosis as paradoxical response is relatively rare. This report describes the 26-year-old female who suffered from peritoneal tuberculosis while treating tuberculous pleurisy with anti-tuberculous medications. It was considered as paradoxical response, rather than treatment failure or else. She was successfully managed with continuing initial anti-tuberculous medications. When a patient on anti-tuberculous medications is presented with abdominal symptoms, the possibility of paradoxical response should be considered to avoid unnecessary tests and treatments, which may result in more suffering of the patient. Herein, we report a case of peritoneal tuberculosis as paradoxical response while treating tuberculous pleurisy.

Tuberculous Peritonitis in a Patient with Rheumatoid Arthritis Treated with Infliximab

One of the severe adverse reactions to anti-tumor necrosis factor (TNF)-alpha therapy is the reactivation of tuberculosis. We present a case of tuberculous peritonitis in a 57-year-old woman with rheumatoid arthritis (RA) that appeared during treatment with infliximab. Confirming a diagnosis of tuberculous peritonitis is difficult and can be delayed because of the nonspecific symptoms, the rarity of the disease and the low detection rate of mycobacteria in ascites fluid. This case illustrates that prompt anti-tuberculous therapy is needed for suspected cases of tuberculous peritonitis in RA patients treated with infliximab.

A Case of Tuberculous Peritonitis Confirmed by Laparoscopic Biopsy in a Patient Receiving Maintenance Hemodialysis Patient after Renal Transplantation / 대한이식학회지

Tuberculosis is an opportunistic infection that causes significant morbidity and mortality in recipients of renal transplants. Although tuberculous peritonitis is easily diagnosed by paracentesis, it is difficult to diagnosis in the absence of ascites. Laparotomy and laparoscopic biopsies are needed for the diagnosis of tuberculous peritonitis. According to recent reports, the latter has a better outcome because of fewer associated complications. A case of tuberculous peritonitis in a renal transplant patient is reported that was diagnosed by laparoscopic peritoneal biopsy

Sonograms of Tuberculous Peritonitis / 中国医科大学学报

Objective To study the sonograms of tuberculous peritonitis and improve the diagnostic accuracy of this disease.Methods We retrispectively analyzed 138 cases of tuberculous peritonitis diagnosed by ultrasonically guided biopsy,postoperative pathology,and clinical manifestation.The characteristics of the sonograms were analyzed,including the amount and character of ascites,the changes in greater omentum,peritoneum,and mesenterium.the enlarged celiac lymph nodes,and the organ involvement.Results The sonograms of tuberculous peritonitis were characterized by thickening of greater omentum with different degrees of ascites,which usually presented cerebral fissure sign under high-frequency ultrasound,together with aggregation of intestines,thickening of peritoneum,enlarged celiac lymph nodes,hepatomegaly,splenomegaly,and pleural effusion.Conclusion Ultrasonography is of great clinical significance in the diagnosis of tuberculous peritonitis and the guidance of greater omentum biopsy.

The significance of multifunctional peritoneal biopsy needle in the diagnosis of tuberculous peritonitis / 中国实用内科杂志

Objective To identify applied value of multifunctional peritoneal biopsy needle(MPBN)in the diagnosis of tuberculous peritonitis(TP).Methods Peritoneal biopsy was performed with MPBN in 19 cases of 27 patients with TP between January 2001 and September 2005,which was compared with the clinical presentation,laboratory analysis and laparoscopy.Results Five patients were diagnosed as TP according the clinical presentation and laboratory analysis.In 19 patients with TP,73.68% was accurately diagnosed as with MPBN.All of the 3 patients were accurately diagnosed as TP with laparoscopy.Conclusion Peritoneal biopsy with MPBN is useful in diagnosis of tuberculous peritonitis,especially when there is no laparoscope.

Clinical Study of Tuberculous Peritonitis / 대한산부인과학회잡지

OBJECTIVE: The aim of this study is to evaluate the clinicopathologic characteristics of tuberculous peritontitis from calcinomatosis peritonei. METHODS: From July 1994 to May 2002, fifteen women who were diagnosed tuberculous peritonitis in Kangnam St. Mary's Hospital were analyzed. We reviewed their medical records. RESULTS: A total of 15 patients eventually diagnosed by pathological or bacteriological method were reveiwed. Five patients were taken explorative lapartomy and biopsy. Eight patiets were taken laparoscopy and biopsy. One patient shows M. tubcerculous only cutured in ascites. One patient with cervical lyhphadenopathy shows chronic granuloma on cervical lymph node. CONCLUSION: Tuberculous peritonitis needs differential diagnosis with ovarian cancer because of its vague symptoms as ascites, abdominal pain and fever. Since there is no specific and sensitive method, at present, an explorative laparotomy or pelviscopic surgery can be alternatives for differetial diagnosis between tuberculous peritonitis and ovarian cancer.

A Case of Primary Tuberculous Peritonitis in Pregnancy / 대한주산의학회잡지

Although the diagnosis of primary tuberculous peritonitis in pregnancy is seems challenging because of protean manifestations and difficult surgical intervention, prompt diagnosis and treatment can minimize both maternal and fetal/neonatal mortality. We have experienced one case of this disease in 23-year-old primigravida in 24 weeks of gestation.

Tuberculous Peritonitis Diagnosed by Laparoscopy / 대한소화기내시경학회지

BACKGROUND/AIMS: Tuberculous peritonitis is still a very important cause of exudative ascites in Korea. We analized the clinical features and laparoscopic findings in patients with tuberculous peritonitis diagnosed by laparoscopy. METHODS: We studied 51 patients who had tuberculous peritonitis confirmed by laparoscopic biopsy from 1980 to 2000, in retrospective method. RESULTS: The ratio of male to female was 1:2. The peak incidence was between 21 and 40 years of age. The mean duration of symptoms is 60 days. The most frequent chief complaints and physical findings was abdominal fullness (88.2%) and shifting dullness (94.1 %). Involvement of other organs included pulmonary tuberculosis (27.4%), cervical tuberculous lymphadenitis (3.9%). The mean ascitic fluid protein concentration was 4.9 gm/dL, mean WBC count 1,240/mm3 and lymphocyte dominant exudate 88.2%. AFB smear was positive only one patient (2.0%). Tuberculous nodules on laparoscopy were noted in all of the patients. Histolologic findings were caseating granuloma (72.6%), non-caseating granuloma (19.6%) and nonspecific inflammation (7.8%). Tissue AFB stain was positive 10 patients (19.6%). CONCLUSIONS: Tuberculous peritonitis shows nonspecific clinical features. Therefore, laparoscopic examination with biopsy is the most useful method to make differential diagnosis of patients who are suspected tuberculous peritonitis.

A Case of Tuberculous Peritonitis Mimicking Surgical Abdomen / 대한소아소화기영양학회지

Childhood tuberculous peritonitis is difficult to diagnose especially in cases without pulmonary involvement. It may present as mechanical ileus, perforation, simulating acute appendicitis, enterocolitis or intusussception. Early diagnosis in children may be difficult, largely because of variable vague symptoms and nonspecific signs. Surgery has often been required for pathologic confirmation. We have experienced a case of tuberculous peritonitis presenting with abdominal pain, abdominal distension and persistent high fever in a 10-year-old boy who was diagnosed by explo- laparotomy and pathologic confirmation from biopsy specimen from omentum. The patient was treated with antituberculous drugs and recovered uneventfully.

A Case of Superimposed Tuberculous Peritonitis on Chemical Peritonitis Arising in Ruptured Both Ovarian Cystic Teratoma / 대한산부인과학회잡지

Rupture of teratoma is rare. Ovary cystic teratoma was occurred 95% in benign ovary tumor, but chemical peritonitis arising from ruptured cystic teratoma is a scarce case. Peritoneal tuberculosis is also rare disease nowadays. It causes easily fatigue, abdominal distension, intermittent abdominal pain and ascities insidiously. We have recently experienced a case of chemical peritonits from ruptured both ovary cystic teratoma of ovary with superimposed peritoneal tuberculosis in 44 year-old woman and report our scarce case with a brief review of the literature.