Successful Conservative Management of Tuberculous Peritonitis in a 65 Y.O. Male with Multiple Comorbidities
PACE Hospitals
PACE Hospitals’ expert Gastroenterology team successfully managed a 65-year-old male patient diagnosed with tuberculous peritonitis presenting with abdominal distension and pedal edema, in the setting of chronic portal vein thrombosis, portal hypertension, diabetes mellitus, and peripheral arterial disease. Management focused on controlling the underlying tuberculous infection, managing ascites and portal hypertension, correcting nutritional and hematological abnormalities, optimizing diabetes control, and providing multidisciplinary supportive care.
Chief complaints
A 65-year-old male patient with a
body mass index (BMI) of 16 presented to the Gastroenterology Department at
PACE Hospitals, Hitech City, Hyderabad, with complaints of abdominal distension and pedal edema persisting for 2 months. The patient also reported a weight loss of approximately 3–4 kg during the same period, associated with persistent loss of appetite.
Past Medical History
The patient had a history of long-standing type 2 diabetes mellitus for more than 25 years and peripheral arterial disease (PAD), for which he had undergone iliac arterial stenting twice.
Portal vein thrombosis (PVT) was incidentally detected on imaging, following which the patient underwent multiple esophageal variceal ligation (EVL) procedures for complications associated with portal hypertension.
The patient also underwent
transurethral resection of the prostate (TURP) for urinary obstruction associated with
benign prostatic hyperplasia (BPH). A previous Mantoux test was positive, indicating tuberculosis exposure; however, anti-tuberculosis treatment had not been initiated before the current admission.
On Examination
On examination, the patient appeared cachectic, with marked muscle wasting and a thin body habitus suggestive of chronic illness and poor nutritional status. Pallor was present, along with a petechial rash over the left lateral malleolus. The oral and nasal mucosa appeared dry.
The patient also had clinically evident pedal edema and abdominal distension. Overall, the examination findings were suggestive of chronic systemic illness, nutritional compromise, and fluid accumulation in the setting of his underlying medical conditions.
Diagnosis
Upon admission to PACE Hospitals, following a detailed clinical assessment and review of the patient's medical history and diagnostic findings, the Gastroenterology team evaluated him for abdominal distension, pedal edema, weight loss, and loss of appetite in the setting of chronic portal vein thrombosis and portal hypertension.
Upper gastrointestinal endoscopy demonstrated post-esophageal variceal ligation scarring with successfully obliterated esophageal varices, along with erosive antral gastritis and mild portal hypertensive gastropathy (PHG). Diagnostic laparoscopy and peritoneal biopsy revealed granulomatous inflammation consistent with Koch’s etiology, supporting the diagnosis of tuberculous peritonitis.
Based on the clinical evaluation and diagnostic findings, the patient was diagnosed with tuberculous peritonitis with ascites in the setting of chronic portal vein thrombosis and portal hypertension, along with associated diabetes mellitus, anaemia, hypoalbuminemia, and peripheral arterial disease.
Following confirmation of the diagnosis, the patient was advised to undergo
Tuberculous Peritonitis Treatment in Hyderabad, India, with management of associated ascites and portal hypertension, under the expert care of the Gastroenterology team with multidisciplinary support.
Medical Decision-Making (MDM)
After a detailed consultation by Dr. Govind Verma, (Interventional Gastroenterologist, Transplant Hepatologist, Pancreatologist, and Endosonologist), along with cross-consultants Dr. Pradeep Kiran Panchadi (Consultant Interventional Pulmonologist) and Dr. Abhik Debnath (Consultant Laparoscopic Urologist), the patient was diagnosed with tuberculous peritonitis with granulomatous inflammation on peritoneal biopsy, associated with abdominal distension, ascites, pedal edema, weight loss, and loss of appetite. Since the patient had underlying portal vein thrombosis with portal hypertension, diabetes mellitus, peripheral arterial disease, anaemia, and hypoalbuminemia, comprehensive medical management was identified as the most appropriate treatment.
It was determined that Anti-Tuberculosis Therapy (ATT), management of ascites and portal hypertension, albumin supplementation, anaemia correction, proton pump inhibitor therapy for erosive gastritis and portal hypertensive gastropathy, blood glucose management, along with multidisciplinary monitoring, was the most appropriate plan to control the underlying infection, manage associated complications, and optimize overall outcomes.
The patient and his family members were counselled in detail regarding the nature of tuberculous peritonitis, importance of Anti-Tuberculosis Therapy adherence, nutritional support, diabetes management, home care measures, warning symptoms, and the need for regular follow-up in the Gastroenterology outpatient department to assess treatment response and monitor complications.
Treatment
Following the decision, the patient underwent treatment for Tuberculous Peritonitis in Hyderabad at PACE Hospitals, with ascites, chronic portal vein thrombosis with portal hypertension, diabetes mellitus, anemia, and hypoalbuminemia under the expert supervision of the Gastroenterology team and multidisciplinary specialists.
During his hospital stay, the patient received treatment for tuberculous peritonitis. Treatment for suspected secondary bacterial infection was administered. Treatment was also provided for erosive antral gastritis and portal hypertensive gastropathy.
Treatment was administered to address hypoalbuminemia and support plasma oncotic pressure, while treatment was given for anemia correction. Therapeutic paracentesis was performed to relieve symptomatic ascites. Medications for management of his liver-related condition and portal hypertension were continued as clinically indicated.
The patient's blood glucose levels were also monitored and managed with treatment for diabetes. A multidisciplinary approach was followed, with consultations from General Medicine for diabetes management and weight loss evaluation, Pulmonology for assessment of respiratory status and
COPD, and
Dermatology for evaluation of the petechial rash and skin dryness.
Discharge Medications
At discharge, the patient was prescribed medications for tuberculosis treatment, management of portal hypertension and its complications, control of gastric irritation, correction of anemia, management of hypoalbuminemia, and maintenance of optimal blood glucose levels. The prescribed treatment also included medications for fluid and ascites management, prevention of secondary infections, and supportive care based on his clinical condition.
Advice on Discharge
The patient was advised to strictly follow the prescribed Anti-Tuberculosis Therapy and other medications, maintain a balanced, protein-rich diet, and monitor blood glucose regularly. Adequate nutrition and appropriate dietary measures for ascites and portal hypertension were recommended, along with avoiding alcohol and self-medication.
Emergency Care
The patient was informed to contact the
emergency ward at PACE Hospitals in case of any emergency or development of symptoms such as severe abdominal pain, increasing abdominal distension, fever, vomiting, gastrointestinal bleeding, altered sensorium, breathing difficulty, or any alarming symptoms.
Review and Follow-Up Notes
The patient was advised to return for a follow-up with the Gastroenterologist in Hyderabad at PACE Hospitals after 1 week.
Conclusion
This case highlights tuberculous peritonitis presenting with abdominal distension, pedal edema, weight loss, and ascites in a patient with chronic portal vein thrombosis, portal hypertension, and diabetes mellitus. The patient was managed with Anti-Tuberculosis Therapy, supportive treatment, and multidisciplinary care, with symptomatic improvement and stable discharge.
Tuberculous Peritonitis in a Complex Clinical Setting
Tuberculous peritonitis is a form of extrapulmonary tuberculosis that can present with nonspecific symptoms such as abdominal distension, ascites, abdominal discomfort, weight loss, fever, and reduced appetite. It can resemble other causes of ascites, including malignancy and chronic liver disease, making diagnosis challenging. Evaluation may involve imaging, ascitic fluid analysis, microbiological testing, and, when required, diagnostic laparoscopy with peritoneal biopsy.
Diabetes mellitus can increase susceptibility to tuberculosis and may complicate infection management. Early diagnosis and appropriate anti-tuberculosis treatment are important to prevent disease progression. A
gastroenterologist/gastroenterology doctor can help evaluate gastrointestinal and abdominal manifestations and coordinate appropriate management. Patients with associated
liver disease, portal hypertension, nutritional deficiencies, or other comorbidities may require individualized treatment and close multidisciplinary monitoring.
Frequently Asked Questions (FAQs)
Can tuberculous peritonitis be mistaken for other causes of ascites?
Yes. Tuberculous peritonitis can look similar to ascites caused by chronic liver disease, cancer, or other abdominal conditions. When fluid keeps building up without a clear reason, doctors may recommend additional tests to identify the exact cause.
Why is a peritoneal biopsy sometimes needed to diagnose tuberculosis?
Tests on ascitic fluid may not always give a clear answer. In such situations, diagnostic laparoscopy allows the doctor to examine the abdominal lining and take a small tissue sample. The biopsy can then be examined for changes associated with tuberculosis.
Does a positive Mantoux test confirm tuberculous peritonitis?
No. A positive Mantoux test suggests previous exposure or infection with tuberculosis, but it does not show where the infection is located. Other clinical findings and investigations are needed to confirm tuberculous peritonitis.
How is ascites managed when tuberculous peritonitis is present?
The main treatment is directed at the tuberculosis causing the peritoneal inflammation. If the abdomen becomes very swollen or uncomfortable because of excess fluid, therapeutic paracentesis may be performed to remove the fluid and provide relief.
Can diabetes make tuberculosis treatment more difficult?
Diabetes can affect the body's ability to fight infections and is associated with a higher risk of tuberculosis. Keeping blood sugar under control during treatment is therefore important and may help support the response to infection.
Why does portal hypertension make treatment more complex?
Portal hypertension may lead to fluid buildup in the abdomen and can cause complications such as esophageal varices. When it occurs with tuberculous peritonitis, both conditions need to be assessed carefully and managed according to the patient's clinical condition.
Is surgery required to treat tuberculous peritonitis?
Surgery is not usually the main treatment for tuberculous peritonitis. Anti-tuberculosis treatment is the primary approach. However, laparoscopy may be performed when tissue is needed to establish the diagnosis or when a specific abdominal complication requires intervention.
Why is good nutrition important during treatment?
Loss of appetite and weight loss can occur during prolonged infections such as tuberculosis. Maintaining adequate nutrition helps preserve muscle strength and supports the body's recovery. Nutritional needs may be assessed individually, especially when there is significant weight or muscle loss.
What monitoring is needed during anti-tuberculosis treatment?
Regular medical reviews may be needed to check whether symptoms are improving and whether the treatment is being tolerated. Blood tests and other assessments may be recommended based on the patient's tuberculosis, liver function, diabetes, and other existing health conditions.
When should a patient seek urgent medical attention?
Urgent medical care should be sought if the patient develops severe abdominal pain, increasing abdominal swelling, repeated vomiting, bleeding from the stomach or intestines, high fever, difficulty breathing, confusion, or a sudden decline in health.
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