Tuberculous peritonitis

Disease Description (Causes and Symptoms)

• Cause: Peritoneal infection caused by Mycobacterium tuberculosis (the tuberculosis bacterium). It is mainly spread hematogenously to the peritoneum from a primary lesion in the lungs, and rarely spreads directly from organs within the abdominal cavity.
• Pathophysiology: Granulomatous inflammation caused by Mycobacterium tuberculosis develops throughout the peritoneum. Ascites formation and peritoneal thickening, adhesions, and fibrosis may progress along with involvement of the mesentery and mesenteric lymph nodes. The clinical course is chronic, and diagnosis is often delayed because symptoms are frequently nonspecific.
• Main symptoms: Abdominal distension (ascites), abdominal pain (tenderness), fever (including night sweats), weight loss, malaise, nausea, vomiting, and decreased appetite, tachypnea, tachycardia, and localized tenderness. In women, elevated CA-125 levels and findings suggestive of an abdominal tumor, which may raise suspicion of ovarian cancer, can occur.

Treatment Methods

• Drug treatment (basic standard):
  • Initial intensive treatment for 2 months: isoniazid (INH) + rifampin (rifampicin) + pyrazinamide + ethambutol (HRZE)
  • Continuation treatment for 4 months: isoniazid + rifampin (usually 6 months in total)
  • In some patients (those with extensive disease, complications, poor treatment response, or immunosuppression), extension of the treatment period (e.g., 9 months or longer) may be considered
  • Drugs are adjusted according to drug susceptibility test results (treatment differs from standard treatment in cases of drug-resistant or multidrug-resistant tuberculosis (MDR))
• Adjunctive treatment and management:
  • Vitamin B6 (pyridoxine) supplementation when taking isoniazid (to prevent peripheral neuropathy)
  • Monitoring for hepatotoxicity: medication adjustment is necessary in cases of underlying liver disease or elevated liver enzyme levels
  • Caution regarding rifampin drug interactions (including with oral contraceptives and some anticoagulants)
  • Therapeutic paracentesis (for symptom relief) may be performed for symptomatic ascites
  • Diagnostic and therapeutic laparoscopy (peritoneal biopsy) may be necessary for definitive diagnosis and evaluation of surgical indications, such as long-term complications and mechanical intestinal obstruction
  • Indications for surgical treatment: mechanical intestinal obstruction, intestinal perforation, complications caused by severe adhesions, and others
• Monitoring during treatment:
  • Liver function tests, blood tests, vision tests (related to ethambutol), and assessment of drug-induced symptoms
  • Mycobacterial culture/genetic testing (Xpert) and ascitic fluid ADA (adenosine deaminase) testing can help with diagnosis and follow-up
• Precautions (treatment-related):
  • Stopping medication or taking it irregularly greatly increases the risk of developing drug resistance → regular medication adherence (following the doctor's instructions) is essential
  • Pregnancy, breastfeeding, liver disease, and HIV coinfection may affect the treatment plan

Pre-Outpatient Visit Checklist (Including Example Questions)

• Items to prepare:
  • A list of currently used medications (including over-the-counter medicines, herbal medicines, and vitamins)
  • Previous tuberculosis treatment history (if applicable, including the drugs taken, treatment duration, and when treatment ended)
  • Medical history (liver disease, diabetes, HIV infection status, and possibility of pregnancy)
  • Recent weight changes, fever records, changes in urination or bowel movements, and any respiratory symptoms
  • Results of tests already performed (abdominal ultrasound/CT, ascitic fluid analysis, CA-125, chest X-ray, etc.)
  • Allergy history (including drug allergies)
• Information to tell the doctor in advance during the outpatient visit (examples):
  • Any recent exposure to tuberculosis or family history of tuberculosis
  • Whether you have ever stopped taking tuberculosis medication in the past
  • Possibility of pregnancy or contraceptive method
  • Alcohol consumption (related to the risk of hepatotoxicity)

Examples of General Questions to Ask the Doctor

• "How many months is the standard treatment period expected to be in my case?"
• "What are the main side effects of the antituberculosis drugs I will be prescribed, and what tests will be used for monitoring?"
• "What should I be careful about in daily life during treatment, such as exercise, returning to work, and alcohol consumption?"
• "What contact testing or preventive measures should be taken for family members and people living with me?"
• "Are there any other medications (or contraceptives) that I need to stop because of drug interactions?"

Examples of Disease-Specific Questions

• "My ascites keeps recurring. When is paracentesis (drainage) or surgical intervention necessary?"
• "In women, is there a risk of infertility due to involvement of the reproductive organs (fallopian tubes and ovaries)? I am planning a future pregnancy—what should I consider?"