[Tuberculous peritonitis. 'Forgotten' disease]. / Tuberkuleznyi peritonit. 'Zabytaia' bolezn'.

AIM: To analyze diagnosis and treatment of patients with tuberculous peritonitis, to develop the algorithms for instrumental examination and differential diagnosis. MATERIAL AND METHODS: There were 48 patients with tuberculous peritonitis. The examination included radiography, abdominal and thoracic computed tomography, ultrasound, and laparoscopy. All patients underwent histological, cytological, microbiological and molecular-genetic analysis of abdominal exudate and peritoneal biopsy. Exclusion criterion was signs of secondary peritonitis. RESULTS: Clinical picture of tuberculous peritonitis was accompanied by nonspecific symptoms. Previously identified pulmonary tuberculosis and HIV-infection were present in 93.8 and 70.8% of patients. Diagnostic laparoscopy of abdominal cavity as the main method of instrumental diagnosis together with cytological, molecular-genetic and microbiological research of peritoneal exudate and tissue specimens were useful to determine diagnosis in 87.2-95.8% of cases. CONCLUSION: Tuberculous peritonitis may be assumed in patients with previous tuberculosis of lungs or other localizations, HIV-infection. Computed tomography is the most informative method to diagnose tuberculous peritonitis. Diagnostic laparoscopy is indicated for suspected tuberculous peritonitis. This procedure is supplemented by peritoneal biopsy, cytological, molecular-genetic and microbiological examination of peritoneal exudate and tissue specimens.

[The clinical picture and diagnosis of complicated forms of abdominal tuberculosis].

The paper presents the diagnostic features of 95 cases with complicated forms of abdominal tuberculosis (AT). The latter has been found to be concurrent with disseminated progressive pulmonary tuberculosis in 97.3% of cases. HIV infection is present in 25.2% of the patients. In 42.1%, a complication of AT is its first onset. The late diagnosis of AT in the phase of development of complications is due to its asymptomatic course at the early stage, the similarity of clinical manifestations with various nonspecific abdominal diseases, the low informative value of radiodiagnostic techniques, and scanty bacterial excretion. In this connection, AT is detectable in 92.6% with the development of acute surgical abdominal pathology requiring emergency diagnostic laparoscopy and surgery. Among all acute surgical abdominal diseases, complicated abdominal tuberculosis ranks third, which in the presence of any abdominal symptoms, particularly those concurrent with pulmonary tuberculosis needs examination for abdominal tuberculosis. Various surgical interventions (more commonly right-sided hemicolectomy, enterectomy, and abdominal abscess lancing) were made in 92 patients with complicated abdominal tuberculosis. There were intraoperative complications, such as perforated tuberculous intestinal ulcers (54.7%), ileus (30.5), abdominal and retroperitoneal abscesses (11.6%), as well as other rare complications, such as intestinal hemorrhage, perforated tuberculous gastric ulcer, and splenic abscess (3.2%). In 42.1% of cases, surgery was ineffective and it was followed by the development of recurrent complications that required surgery. In HIV-infected patients, AT ran more severely. Overall mortality in patients with AT was 47.4%, that in patients with and without HIV infection was 58.3 and 43.7%, respectively.

[The prevalence of abdominal tuberculosis and the specific features of its detection].

A hundred and thirteen case histories of patients with isolated and generalized forms of abdominal tuberculosis were analyzed. The patients' age was 15 to 79 years; there were 86 (76.1%) males and 27 (23.9%) females. The patients were admitted more frequently from other tuberculosis facilities (66.7%) and less frequently from general hospitals (33.3%). In 62 (54.9%) cases, abdominal tuberculosis showed a complicated course. The residents of Moscow and its region, predominantly the unemployed (85.8%), prevailed in the structure of detected patients with abdominal tuberculosis. In the period of 2001 to 2004, there was a rise in the incidence of new-onset abdominal tuberculosis, its rate increased from 4.4 (2001) to 8.3% (2004) of the total number of patients admitted to Moscow clinical hospital No. 7 for extrapulmonary tuberculosis admitted. This gives no way of considering this site of tuberculosis to be rare. In the structure of abdominal tuberculosis, its generalized forms were prevalent (86.7%), which was associated with the late detection of abdominal tuberculosis and the significant increase in the number of HIV-infected patients from 14.3 (2000) to 33.3% (2004). Abdominal organ lesions were more frequently observed in severe generalized pulmonary processes, such as disseminated (45.1%), infiltrative (18.6%) or fibrocavernous (15.9%) tuberculosis. An algorithm of diagnosis of abdominal tuberculosis and the rates of its detection by various studies are presented in the paper. Abdominal tuberculosis was diagnosed in 8.9% of cases by noninvasive comprehensive examination methods, in 18.6% by laparoscopy, and in most cases (57.5%) intraoperatively. In socially dysadapted persons, postmortem abdominal tuberculosis was detected in 15% of cases.

[Diagnosis and treatment of acute intestinal obstruction due to gall-stone].

Results of treatment of 43 patients with acute intestinal obstruction due to gall-stones are analyzed. Forty patients were operated, 3 patients were not because of extremely severe state. Enterolythotomy was performed in 27 cases, incision of intestinal wall was carried out directly above the stones (14 cases, group 1), above or below it (13 cases, group 2). Insufficiency of enteral suture was seen in 4 patients of group 1 that required repeated surgery. Lethality in group 1 was 21.4%, in group 2-7.1%. Intestinal resection was performed in 12 patients of group 3, there were no cases of suture insufficiency, and lethality was 8.3%. It is concluded that enterotomy should be performed above or below strangulated stone. Intestinal resection should be performed when concrement is immovable or in cases of intestinal necrosis.

[Surgical treatment of complicated forms of abdominal tuberculosis].

The results of surgical treatment were analyzed in 31 patients with complicated abdominal tuberculosis in 2001 to 2003. Before 2003, a surgical intervention was mainly palliative and reduced to the suturing of perforative tuberculous ulcers limited to the resections of the small intestine and to the separation of adhesions (Group 1, n=17). Then radical surgical interventions were undertaken in the volume of extended right-sided hemicolectomies, by removing caseously changed mesenteric lymph nodes (Group 2, n=14). Postoperative peritoneal lavage was performed, by using antituberculous agents. Twelve and 5 patients died in Groups 1 and 2, respectively. The authors suggest that radical surgical interventions for complicated abdominal tuberculosis can improve the outcomes of treatment of this disease.

[Surgical treatment in complicated forms of abdominal tuberculosis]. / Operativnye vmeshatel'stva pri oslozhnennykh formakh tuberkuleza organov briushnoi polosti.

Results of surgical treatment of 31 patients with complicated forms of abdominal tuberculosis treated in 2001-2003 were analyzed. Before 2003 surgery was mainly palliative and managed by suturing of perforated ulcers or economic resection of the small intestine (group 1--17 patients) was made. Since 2003 radical right-sided hemi-colectomies with removal of caseous mesenterial lymph nodes is used (group 2--14 patients). Peritoneal lavage with antituberculosis drugs was performed after surgery. From 17 patients of group 1--12 died, from 14 patients of group 2--5. It is concluded that radical surgery in complicated forms of abdominal tuberculosis permits to improve results of surgical treatment of this disease.