Widespread nodules and adhesions in abdomen.

A 36-year-old prisoner was brought to our emergency department with complaint of lower gastrointestinal bleeding. He had hematochezia since 1 month and also experienced generalized abdominal pain in last few months. Colonoscopy was performed and multiple polyps in colon noted without any signs of active bleeding. Upper gastrointestinal (GI) endoscopy was normal. A Technetium-99 red blood cell scan also yielded no obvious locus of bleeding. A day after the RBC scan, the patient experienced an episode of massive bleeding. The patient was resuscitated and was taken to operating room for GI tract exploration with a view towards total colectomy. Laporotomy was performed and serous fluid was found in the abdomen with severe adhesions found in the entire abdomen area, widespread white nodules were seen on peritoneum, omentum, bowels and liver [Figure 1]. A Biopsy was taken from the nodules.

Figure 1

Multiple white nodules in peritoneal surface

QUESTION

What is the diagnosis?

ANSWER

Histopathologic examination reported granulomatous inflammation with caseous necrosis compatible with tuberculosis. Prompt exploration of abdomen was not feasible due to massive adhesions, therefore conservative management was continued.

Abdominal tuberculosis results from hematogenous spread of bacilli from lung or via lymphatics of involved lymph nodes. In GI tract, it may present as ulcers with bleeding or a mass that may cause obstruction.[1] Tuberculosis peritonitis presents as chronic abdominal symptoms and ascites. Tubercle deposits in peritoneum and adhesion bands develop within abdominal cavity.[2] Gross appearance during surgery may be sufficient to diagnose tuberculosis accurately. Tubercle deposits are white yellowish, diffuse, and cover parietal and visceral peritoneum, omentum, liver, and spleen. Adhesions found in tuberculous peritonitis are usually loose and easy to dissect but thick and fibrous adhesions have been reported that may increase risk of bowel injury upon surgery. Carcinomatosis is the most important differential diagnosis of tuberculous peritonitis and since Cancer Antigen-125 can be increased in tuberculosis, this entity can be misdiagnosed as ovarian carcinoma.[3] Laparoscopic peritoneal biopsy is diagnostic procedure of choice.