Peritoneal carcinomatosis: the importance of laparoscopy

Description

A 64-year-old woman presented with diffuse abdominal pain, postprandial bloating and 5 kg of unintentional weight loss in the last 3 months. She had a previous medical history of nephrectomy due to recurrent pyelonephritis and hypothyroidism. Physical examination revealed only mild tenderness in the umbilical area. Relevant laboratory values included a normocytic normochromic anaemia (11.7 g/dL) and positive CA-125 (100.9 U/mL). CT presented areas of irregular soft tissue thickening of the peritoneum, multiple peritoneal nodules and mild ascites; uterus and adnexa had no abnormalities. Transvaginal ultrasound confirmed a homogeneous and normal-sized uterus and morphologic large ovaries, without expansive lesions. Positron emission tomography confirmed diffuse heterogeneous peritoneal ¹⁸F-FDG uptake, consistent with carcinomatosis, and enlarged lymph nodes with ¹⁸F-FDG uptake in the supraclavicular, hilar, oesophageal, paratracheal, preaortic and external iliac lymph nodes. Peritoneal fluid revealed 56% of lymphocytes and high activity of ascitic fluid adenosine deaminase (ADA) (63 UI/L). Interferon gamma release assay (IGRA) to detect Mycobacterium tuberculosis infection was positive (>10 UI/mL). The remaining examinations performed—upper gastrointestinal endoscopy, colonoscopy, breast ultrasound, mammography—were normal.

Exploratory laparoscopy unmasked a peritoneum with a strawberry appearance (figure 1), with multiple white nodules/granulomas. The histopathological examination of parietal peritoneum biopsies and round ligament samples revealed a necrotising granulomatous inflammation involving the peritoneum (granulomatous peritonitis), suggestive of Mycobacterium, with no evidence of neoplasia. Ziehl-Neelsen test for acid-fast bacilli was negative; cultures were not performed.

Figure 1.

Laparoscopy image of peritoneal tuberculosis, revealing a peritoneum with a strawberry appearance, with multiple white nodules/granulomas on its surface.

After exclusion of malignancy, the diagnosis of peritoneal tuberculosis was made and antituberculosis agents were initiated (ethambutol, rifampicin, isoniazid and pyrazinamide) and maintained for 9 months, with complete resolution of the radiological alterations. There were no signs of relapse after 2 years of follow-up.

Peritoneal tuberculosis involves the parietal and visceral peritoneum and intestinal mesentery; it can be provoked by a reactivation of a latent tuberculous infection of the peritoneum, rupture of caseous abdominal lymph nodes or haematogenous spread of the infection.^{1 2} This disease is often difficult to distinguish from peritoneal carcinomatosis due to its non-specific symptoms and similar radiological presentation.³ Peritoneal tuberculosis should be considered in any patient presenting with ascites, peritoneal thickening and increased levels of CA-125.⁴ Laparoscopy is reported as the ideal method for early diagnosis because it allows a magnified observation of the peritoneal surfaces; any surgeon should be aware of the typical laparoscopic findings enabling an early diagnosis.^{5 6} The histological confirmation of the granulomatous involvement and high activity of ADA are also extremely useful for the diagnosis since a negative culture cannot exclude tuberculosis.^{5 7}

Learning points.

• Abdominal tuberculosis should be considered in patients who present non-specific abdominal reports, peritoneal thickening of unknown origin in the abdominal CT and increased CA-125 levels.

• Laparoscopy is reported as the ideal method for early diagnosis because of the magnified observation of the peritoneal surfaces.

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