tuberculous peritonitis
Introduction
Introduction to tuberculous peritonitis Tuberculous peritonitis (Tuberculous peritonitis) is a chronic diffuse peritoneal infection caused by Mycobacterium tuberculosis. It is more common in children and young adults. The woman is slightly more than the male, 1.2~2.0:1. The main clinical manifestations are burnout, fever, abdominal pain and bloating, which can cause complications such as intestinal obstruction, intestinal perforation and fistula formation. basic knowledge The proportion of sickness: 0.6% Susceptible people: more common in children, young adults, more common in patients with tuberculosis Mode of infection: non-infectious Complications: intestinal obstruction
Cause
Cause of tuberculous peritonitis
The majority of tuberculous peritonitis is secondary to tuberculosis in other organs. The path of infection of this disease can be directly spread by intra-abdominal tuberculosis or disseminated by blood. The former is more common, such as intestinal tuberculosis, mesenteric lymphatic tuberculosis, tubal tuberculosis, etc., can be the direct primary lesion of the disease. More women than men may be due to retrograde infection of pelvic tuberculosis.
(1) Causes of the disease
Mycobacterium tuberculosis belongs to actinomycetes, Mycobacterium genus of mycobacteria, and is a pathogenic acid-tolerant bacteria. It is mainly divided into human, cattle, bird, and mouse. People who are pathogenic to humans are mainly human. Bacteria, bovine bacteria rarely infected, tuberculosis morphology is slender and curved, both ends are obtuse, no spores or capsules, no flagella, length of about 1 ~ 5m, width of 0.2 ~ 0.5m, scattered or formed in the specimen Heap or arranged in a chain shape, Mycobacterium tuberculosis is an aerobic bacteria, does not multiply in the absence of oxygen, but can still survive for a long time, under good conditions, about 18 ~ 24h breeding generation, bacterial lipid composition It accounts for 1/4 of its weight. It is acid-resistant when dyed. Tuberculosis is very resistant to dryness and strong acid and strong alkali. It can exist in the external environment for a long time. It can survive for 20~30h in the sputum. Survival for 6-8 months, but the resistance to damp heat is very low, boil for 5min or direct exposure in the sun for 2h to kill, UV disinfection effect is better, human and bovine tuberculosis strains are obligate parasites, Human and bovine are the natural storage hosts, respectively, which have the same intensity for humans, monkeys and guinea pigs. The resistance of tuberculosis to drugs can be formed by the development of congenital drug-resistant bacteria in the flora, or it can be produced quickly by using an anti-tuberculosis drug alone in the human body. Drug-resistant bacteria and drug-resistant bacteria can cause treatment difficulties and affect the curative effect. The long-term exposure of Mycobacterium tuberculosis to streptomycin can also produce dependence, that is, the so-called Lai medicine, but Lai medicine is rare in clinical practice.
There are two sources of peritoneal lesions:
1. Abdominal lesions such as intestinal tuberculosis, mesenteric lymphatic tuberculosis or active lesions of pelvic tuberculosis directly spread to the peritoneum.
2. Blood-stained miliary tuberculosis and tuberculosis can be disseminated to the peritoneum by blood; the blood-borne dissemination caused by the primary pulmonary syndrome can form a potential lesion in the peritoneum, and tuberculous peritonitis can occur when the body's resistance is low.
(two) pathogenesis
According to the main pathological changes of the peritoneum, it is divided into exudative type, adhesion type and cheese type.
1. Exudative abdominal cavity is mostly serous fibrinous exudate, grass yellow, occasionally slightly bloody, thickened visceral layer and wall peritoneum, congestion, edema, attached fibrinous exudate, yellow or grayish white Small tuberculous nodules of varying sizes of miliary granules also merge into larger plaques.
2. Adhesive peritoneum is obviously thickened, there is a small amount of serous fibrinous exudate, a large amount of fibrin deposition and fibrous tissue hyperplasia cause extensive adhesion between mesentery, mesenteric lymph nodes and intestinal tube, forming masses, resulting in compression of intestinal tract caused by chronic intestine Obstruction, thick omentum thickening, hardening into clumps, severe abdominal cavity completely occlusion.
3. The cheese type is mainly peritoneal cheese-like necrotic lesions. The intestine, the omentum, the mesenteric or the abdominal viscera are separated from each other into a small chamber, and a small amount of turbid purulent exudate accumulates. The vaginal or abdominal wall is worn out to form internal hemorrhoids or feces, which is more common in patients with advanced stage. At the same time, mesenteric lymph nodes with necrosis of cheese can form tuberculous abscesses.
According to statistical analysis, the most common type of adhesion is followed by the type of exudation, and the type of cheese is the least. In the process of disease development, there are often two types or three types coexisting, called "hybrid type".
Prevention
Tuberculous peritonitis prevention
1. Controlling the source of infection and managing the source of infection is an important link in the prevention and treatment of tuberculosis. Early detection and early treatment should be done. For this reason, collective lung health check should be carried out regularly, and a registration management system should be implemented.
2. Cut off the route of transmission to manage and treat the patient's sputum. The main methods are: carry out mass health campaigns, widely publicize phlegm prevention knowledge, develop good hygiene habits, and not spit, TB patients should vomit on paper Add and burn, or cough in a cup to add 2% coal phenol soap or 1% formaldehyde solution (about 2h can be sterilized), the contact directly exposed to sunlight (sterilized for several hours).
3. Vaccination with BCG to inoculate BCG can enhance the body's resistance to tuberculosis, and is conducive to the prevention of tuberculosis. At present, China is required to vaccinate BCG after birth, and the negative ones add seeds. For ethnic minorities, border residents enter the inland cities, or recruits. When the tuberculin test is necessary, the negative person is vaccinated with BCG.
Complication
Tuberculous peritonitis complications Complications, intestinal obstruction, intestinal fistula
In severe cases, complications such as intestinal obstruction, intestinal perforation, intestinal fistula and suppurative peritonitis may occur.
Symptom
Tuberculous peritoneal inflammation symptoms Common symptoms Abdominal "flexibility" signs Acute abdominal pain Intestinal adhesions Forced supine diarrhea Bowels Peritonitis Pain edema Ascites
The clinical manifestations of tuberculous peritonitis vary with the primary lesion, the route of infection, the pathological type and the reactivity of the body. The onset of this disease is mixed. Most of the onset is slow, but the number of acute cases is also not uncommon. At the onset of illness, the main symptoms are burnout, fever, bloating and abdominal pain, as well as chills and high fever. Light cases began to be insidious.
First, the whole body performance
Fever and night sweats are the most common, accounting for 67-95%. The hot type is mostly low heat and moderate heat. About three minutes of patients are hyperthermia. Exudative, cheese-type cases or patients with severe extra-abdominal tuberculosis may present. Spare heat, severe night sweats, and later manifestations of malnutrition such as anemia, weight loss, edema, glossitis, angular cheilitis and vitamin A deficiency. Among women of childbearing age, menopausal infertility is more common.
Second, abdominal pain
About three-point patients may have varying degrees of abdominal pain, mostly persistent dull or dull pain, and the pain is mostly in the umbilicus, lower abdomen, and sometimes in the abdomen. When patients have acute abdomen, it should be considered whether acute peritonitis caused by ulceration of mesenteric lymph nodes or other tuberculous necrotic lesions in the abdominal cavity may also be caused by acute intestinal perforation of intestinal tuberculosis.
Third, abdominal distension and ascites
Most patients have a feeling of bloating, which can be caused by tuberculosis symptoms or intestinal dysfunction associated with peritonitis. Ascites can occur in about three-thirds of patients, which is more common in small and medium doses. Mobility dullness can be found when the amount of ascites exceeds 1000 ml. A small amount of ascites needs to be checked by B-ultrasound.
Fourth, the abdominal wall flexibility
The pliability is caused by mild irritation or chronic inflammation of the peritoneum, which can be seen in various types of the disease, but is generally considered to be a clinical feature of adhesion-type tuberculous peritonitis. Most patients have different degrees of tenderness, generally mild, a small number of tenderness and rebound tenderness, the latter more common in cheese type.
Fifth, abdominal mass
Adhesive and cheese-type patients often have a bump in the abdomen, mostly in the lower abdomen. The masses are mostly composed of thickened omentum, enlarged mesenteric lymph nodes, intestinal tracts of adhesions, or caseous necrosis. They vary in size and margins, sometimes in the form of horizontal blocks or Nodules, a little tenderness.
Sixth, other
Some patients may have diarrhea, usually due to stimulation of peritoneal inflammation, or due to fistula formation. Usually -4 times a day. In patients with adhesions, constipation is more common, sometimes diarrhea and constipation alternate. Hepatomegaly is not uncommon and can be caused by fatty liver or liver tuberculosis caused by malnutrition. Such as complicated intestinal obstruction, visible peristaltic waves, bowel sounds reluctant.
Examine
Tuberculous peritonitis examination
Laboratory inspection
1. Blood routine, more than half of patients with erythrocyte sedimentation rate have mild to moderate anemia, severe anemia is rare, white blood cell count can be normal; but in exudative type, cheese-type or disseminated tuberculosis, secondary infection, white blood cell count and neutral grain The cell value can be significantly increased. In most patients, the erythrocyte sedimentation rate increases rapidly, and the degree of increase is usually parallel to the activity of tuberculosis.
2. Tuberculin test The tuberculin test is based on the use of tuberculosis purified protein derivative (PPD) as an antigen for intradermal test, also known as PPD test. The result is strongly positive, suggesting that there is tuberculosis in the body. Infection, in patients with tuberculous peritonitis, the positive rate of PPD test is 30% to 100%.
3. Gene diagnosis technology using polymerase chain reaction (PCR) can detect 1fg ~ 100fg purified Mycobacterium tuberculosis nucleic acid (DNA), about 1 to 20 Mycobacterium tuberculosis, the positive rate is 26.5% ~ 80.0% It is suitable for rapid diagnosis of extrapulmonary tuberculosis, but this technique can produce false positive results due to contamination during the operation process.
4. Ascites examination of ascites often showed exudative changes, more than 85% of patients with ascites protein more than 25g / L, white blood cell count 400 × 106 / L, lymphocytes (70%), serum - ascites albumin ratio > 0.5 , or serum-ascites albumin gradient is small, often <1.1, in addition to tuberculous peritonitis, ascites cholesterol ester, lactate dehydrogenase (LDH), ascites / serum LDH ratio, lysozyme activity increased; ascites decreased, About 1/2 of blood sugar; ascites pH decreases and lactate levels increase.
Long-term peritoneal dialysis patients with tuberculous peritonitis, their ascites can be mainly neutrophils, a small number of tuberculous peritonitis ascites can be bloody or chylorrhea; especially when it is combined with cirrhosis ascites or severe hypoproteinemia, Ascites can be changed by leaking fluid, causing diagnostic difficulties.
Film degree exam
1. X-ray plain film can be seen in the increase of total abdominal density, ascites effusion, tuberculosis calcification, intestinal obstruction and other signs.
2. The barium meal examination shows intestinal flatulence, power loss, intestinal tube compression, traction, fixation and other performance.
3. Ultrasound examination is used to detect intra-abdominal effusion, and can be percutaneous peritoneal biopsy under ultrasound guidance, and encapsulated effusion.
4. CT or MRI in addition to help to find signs of effusion, intestinal adhesions, obstruction, etc., but also contribute to the identification of tuberculosis, blood ascites and cancerous ascites.
5. Laparoscopy is a safe and effective diagnostic method for early exudative cases. For patients with adhesion or cheese type, the peritoneal biopsy can be performed under the microscope.
Diagnosis
Diagnosis and diagnosis of tuberculous peritonitis
diagnosis
1. Most of the patients are young and middle-aged, especially women.
2. Have a history of tuberculosis or have extra-abdominal tuberculosis.
3. With fever, fatigue, weight loss, abdominal pain, bloating and diarrhea and other symptoms.
4. The abdominal wall is flexible, with or without signs of ascites or abdominal mass.
Differential diagnosis
1. Taking fever as the main manifestation such as high fever with acute abdominal pain, abdominal muscle tension, elevated white blood cell count should be differentiated from acute appendicitis, suppurative peritonitis; relaxation heat with hepatosplenomegaly, increased white blood cell count Should be differentiated from liver abscess, sepsis, puerperal fever; the need for missed fever with low white blood cell count and typhoid fever; fever with progressive weight loss and anemia or abdominal mass with abdominal lymphoma, malignant Tissue cell disease phase identification.
2. Ascites as the main manifestation of ascites or liver dysfunction should be differentiated from cirrhosis ascites; blood ascites with abdominal or pelvic mass as a prominent manifestation should be differentiated from the tumor; ascites stubborn and should be associated with constrictive pericarditis , hepatic vein occlusion syndrome, chronic pancreatic ascites, cancer, abdominal cavity metastasis and other identification.
3. Abdominal mass as the main manifestation of tuberculous peritonitis can occur in different parts of the abdominal mass, and has different traits, it should be differentiated from liver cancer, gastric cancer, colon cancer, ovarian cancer.
