bubble_chart Overview

Tuberculous peritonitis often occurs secondary to mesenteric lymph node or intestinal tuberculosis, and can also spread hematogenously to become part of systemic miliary tuberculosis. It is more common in older children, with varying clinical manifestations divided into three types, without strict boundaries between them.

bubble_chart Clinical Manifestations

The onset is slow, with subcutaneous nodules and toxic symptoms, accompanied by abdominal pain, abdominal distension and fullness, alternating constipation and diarrhea.

1. Exudative type (1) Generalized emaciation, enlarged abdomen, and shallow breathing (due to elevation of the liver and diaphragm). (2) Disappearance of the umbilical fossa and distension of abdominal wall veins. (3) Presence of ascites, fluctuation sensation, and shifting dullness on percussion. (4) Abdominal palpation reveals a doughy sensation (in early stages) and tenderness. (5) Lower limb edema may occur due to compression of abdominal veins by ascites; reduced urine output is seen in cases with significant exudate.
2. Adhesive type (1) Abdominal palpation reveals a characteristic, resilient doughy sensation with varying-sized masses, varying degrees of tenderness, and relatively fixed positions. (2) Recurrent partial intestinal obstruction occurs due to extensive adhesions of intra-abdominal organs caused by adhesive masses compressing the intestines. Manifestations include abdominal distension and fullness, abdominal pain, nausea, vomiting, visible intestinal peristaltic waves on the abdominal wall, and hyperactive borborygmi. (3) Percussion over different abdominal regions may yield tympanic or dull sounds due to adhesions of the peritoneal membrane, greater omentum, and mesenteric lymph nodes. (4) Adhesive masses may cause compression symptoms, leading to lower limb edema or, in severe cases, urinary tract obstruction.
3. Caseous ulcer type (1) Severe condition, rapid progression, fever, weakness, emaciation, anemia, and marked cachexia. (2) Prominent symptoms of abdominal pain and diarrhea. (3) Abdominal palpation reveals a doughy sensation or board-like rigidity with marked tenderness. (4) Complications include umbilical or intestinal fistulas, formed by caseous lesions perforating the intestinal lumen or abdominal wall.

bubble_chart Auxiliary Examination

1. Exudative peritonitis with a large amount of exudate: Abdominal paracentesis can yield straw-yellow serous exudate with a specific gravity above 1.018. The cell classification is predominantly lymphocytes. Ascites smear may reveal subcutaneous node bacteria, or culture/animal inoculation can confirm the presence of subcutaneous node bacteria.
2. Laparoscopy may show hyperemia, edema, and foxtail millet-like subcutaneous node nodules in the peritoneum, indicating acute sexually transmitted disease changes, or chronic changes such as peritoneal thickening and adhesions. If observation is unsatisfactory, a small piece of peritoneal tissue can be taken for pathological biopsy.
3. Increased erythrocyte sedimentation rate.

OT or PPD test strongly positive. In cases of excessive reaction, local necrosis may occur. If subcutaneous node peritonitis is highly suspected, the small OT or PPD can be further diluted to 0.005mg for intradermal injection.

X-ray examination

Abdominal plain films may reveal calcified lymph nodes. Barium meal or enema in most cases shows peritoneal thickening and adhesions, as well as intestinal binding nuclei, intestinal obstruction, intestinal fistula, etc., which aid in diagnosis.

bubble_chart Treatment Measures

﹝Treatment﹞

(1) General treatment: Bed rest is required during fever, and a nutritious, easily digestible diet should be provided, supplemented with vitamins A, B, C, and D. (2) Anti-subcutaneous node treatment: INH is administered orally for 1.5 years, combined with SM intramuscular injection for 2–3 months. After discontinuing SM, EMB or PAS is added for 1 year. The dosage and administration are the same as for primary pulmonary subcutaneous nodes. (3) Application of hormones: For the ascites type, adrenal corticosteroids such as prednisone at 1 mg/(kg·d) (< kg/d) can be added, divided into 2–3 oral doses daily for 2–4 weeks. This accelerates ascites absorption and reduces adhesions, followed by tapering off the medication. (4) Abdominal paracentesis for drainage: If excessive ascites affects breathing, paracentesis can be performed to relieve the child’s discomfort.

bubble_chart Differentiation

(1) Malignant tumors in the abdominal cavity often exhibit progressive and rapid enlargement. Ascites is mostly bloody, and tumor cells may be detected. (2) Large cystic tumors in the abdominal cavity, such as mesenteric cysts or ovarian cysts, present with a rounded abdominal bulge. Percussion reveals dullness in the central area and tympany on both sides, with no shifting dullness. Palpation may outline the mass, and abdominal X-rays or barium enema may show displacement of the intestines due to compression. (3) Suppurative peritonitis has an acute onset, with significant fever and abdominal pain, as well as marked abdominal muscle rigidity, tenderness, and rebound tenderness. Blood tests show a significant increase in total white blood cells and neutrophils. Ascites is purulent, and smears or cultures may identify suppurative bacteria. (4) Other conditions, such as portal cirrhosis, cardiorenal diseases, and nutritional edema, may present with ascites as an exudate. Symptoms of the primary disease are prominent.