Tuberculous peritonitis

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We were interested to read the recent report by Panoskaltsis et al on the topic of tuberculous peritonitis as part of the differential diagnosis in ovarian cancer (Panoskaltsis TA, Moore DA, Haidopoulos DA, McIndoe AG. Tuberculous peritonitis: Part of the differential diagnosis in ovarian cancer. Am J Obstet Gynecol 2000;182:740-2). Overlooking this possibility reportedly resulted in an eventual exploratory laparotomy because of the clinical findings and inexperience. We read this with sympathy, but we were greatly concerned about the unnecessary laparotomy. We agree that diagnosis of tuberculous peritonitis is often delayed until after exploratory laparotomy in malignant clinical presentations. However, we disagree with the opinion of Panoskaltsis et al against ultrasonography and laparoscopy in diagnosis but in favor of laparotomy. We have found color Doppler ultrasonography to be a powerful tool in detecting tuberculous peritonitis by means of characteristics such as caseous necrotic changes, small size, and miliary scattered spread.1Wang PH Yuan CC Yu KJ Lee RC Linn JJ Hung JH et al.High resistance index of Doppler ultrasound in tuberculous peritonitis presenting as abdominal carcinomatosis: report of two cases.Chung Hua I Hsueh Tsa Chih (Taipei). 1998; 61: 175-179Google Scholar In our experience ultrasonography showed a nearly normalized size of tuberculous ovarian mass, multiple thin incomplete septa, and mesentery nodularity. The feeding vessels of the abdominal tuberculous implants were absent or present in a high impedance (resistance index >0.8).1Wang PH Yuan CC Yu KJ Lee RC Linn JJ Hung JH et al.High resistance index of Doppler ultrasound in tuberculous peritonitis presenting as abdominal carcinomatosis: report of two cases.Chung Hua I Hsueh Tsa Chih (Taipei). 1998; 61: 175-179Google Scholar Observations of the fine delicate septations might exclude the possibility of peritoneal carcinomatosis (thick bands). Furthermore, just as Panoskaltsis et al noted, laparoscopy could diagnose 97% of tuberculous peritonitis cases among 135 patients. Panoskaltsis et al were concerned about port site metastases, and we sympathize with their anxiety; however, in cases of clinically uncertain ascites the least invasive procedure possible should be used, except in a life-threatening situation.2Wang PH Chao HT Tseng JY Yang TS Chang SP Yuan CC et al.Laparoscopic surgery for heterotopic pregnancies: a case report and a brief review.Eur J Obstet Gynecol Reprod Biol. 1998; 80: 267-271Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar We wonder whether Panoskaltsis et al considered performing paracentesis or laparoscopy at the initial evaluation of the patient. Why did they abandon performing such procedures? Both of these procedures could possibly have yielded an accurate diagnosis. Paracentesis and laparoscopy not only are simple, effective, and minimally invasive diagnostic tools but also can be therapeutic tools whenever uncertain conditions of massive ascites are noted. Certainly, the diagnosis of tuberculous peritonitis was so treacherous in this case that we should emphasize that these dangers seem those created by the acts of omission. 6/8/109362