Tuberculous Peritonitis: The Closer You Go, the More Confused You Get

Abstract

We read the article entitled ‘‘Comparison between Laparoscopy and Noninvasive Tests for the Diagnosis of Tuberculous Peritonitis’’ by Hong et al. [1] with great interest. The authors presented a retrospective study of 60 patients who underwent diagnostic laparoscopy for either undiagnosed ascites (n = 19) or a condition that needed to be differentiated from peritoneal carcinoma (n = 41). Forty-one patients were diagnosed with tuberculous peritonitis (TBP). The positive and negative results of diagnostic laparoscopy were compared with ascitic deaminase levels [30 U/l and ascitic lactate dehydrogenase levels [90 U/l. The authors concluded that laparoscopy with combined biopsy is the most sensitive and the quickest method for diagnosing tubercular peritonitis. We would like to make the following observations regarding this article. The authors chose to present their results as mean ± SD. This method is always not representative, especially if data is nonuniform. This is apparent by looking at the duration of symptoms in the patients with TBP: 40 ± 57 (range, 3–360). Median ± interquartile range is a preferable method to represent the nonuniform data compared with mean ± SD [2]. The diagnosis of TBP was considered definitive by the authors, on the basis of either caseous granuloma or positive bacteriological results for M. tuberculosis. The diagnosis was considered probable in the presence of suggestive clinical and laparoscopic findings and noncaseous granuloma without positive bacteriologic findings. The authors did not mention how many patients were in the category of probable diagnosis or how many of them actually proved to be definitive case of TBP after favorable clinical response to antituberculosis therapy. The authors reported that biopsy tissues were deemed inadequate for the diagnosis in 12 of 60 cases. However, all of these patients were considered while assessing the presence of granuloma/caseous granuloma under the heading of laparoscopy in Table 4 [1]. This needs further clarification. The diagnosis of abdominal tuberculosis is classically based on microbiological confirmation [3]. Although the yield may be less, positive acid fast staining (AFB) and M. tuberculosis culture results confirm the diagnosis of tuberculosis unequivocally. The authors performed AFB of peritoneal biopsy specimen in 22 and culture for M. tuberculosis in 6 of 60 patients. Selective use of these investigations rules out the opportunity of exploring their full potential in the diagnosis of TBP. The authors mentioned that ascites was present in 92.7% (38/41) of patients of TBP. Table 2 shows that acid fast staining was conducted in 48 patients, and M. tuberculosis culture and PCR was undertaken in 48 and 39 patients respectively. The authors did not indicate why these investigations were selectively performed in a few patients and not in all patients. We believe that AFB staining, which is an inexpensive and freely available investigation, should be performed in the ascitic fluid of all patients suspected to have TBP. The authors stated that an abnormal chest X-ray was seen in 20 of 41 patients of TBP and active concomitant pulmonary disease was present in 8 patients (20%). It becomes imperative to know whether the sputum of these patients was examined for the presence of AFB. It will be interesting to know how many of these sputum AFBpositive patients were ultimately found to have TBP. P. K. Garg (&) B. K. Jain D. Mohanty Department of Surgery, University College of Medical Sciences and Guru Teg Bahadur Hospital, University of Delhi, Delhi 110095, India e-mail: dr.pankajgarg@gmail.com