Causes and risk factors
Mycobacterium tuberculosis bacteria enters the lungs through inhalation of droplets released into air [sneeze, cough, sputum, spit] by a tuberculosis infected person. Primary focus is usually formed in the lungs. Secondary focuses occur via blood or lymph to other organs like gastrointestinal tract, kidney, liver, bones, or brain. Tuberculous ascites occurs as a result of abdominal tuberculosis [AT]. Abdominal tuberculosis is most prevalent among extrapulmonary TB sites. Peritoneal tuberculosis [PT] is a type of AT. It involves the omentum, intestinal tract, liver, spleen, female genital tract, along with visceral and parietal peritoneum. PT is characterised with presence of multiple yellow white tubercles. It is thick, hyperaemic with a loss of lustre. Omentum is also thick. There is stricture formation as a result of cicatrical healing of tubercular ulcers. Enlarged mesenteric lymph nodes with caseous necrosis is also seen. PT presents in 3 forms, namely ascites, lobulated type, and fibrotic type. Thus tuberculous ascites is caused as a result of PT.
Clinical presentation
The onset of symptoms is insidious. Patient initially presents with constitutional symptoms like low-grade fever, weight loss, loss of appetite, and night sweats. Anemia and leucopoenia may be present. Abdominal distension occurs. Patient complains of diffuse abdominal pain and tenderness. There is shortness of breath when lying down. Patient experiences bloating, diminished appetite, sudden weight gain, nausea and vomiting, and heartburn. Signs of fluid accumulation in the abdomen such as bulging of the flanks is seen. On physical examination, shifting dullness [difference in percussion notes which shifts when the patient turns on to the other side] and fluid thrill [tapping on one side of the abdomen will create a wave-like effect which is felt on other side of the abdomen] are observed.
Investigation
Medical history by the patient and clinical examination by the doctor helps in diagnosis. Mantoux tuberculin test [though not much reliable technique] is done for screening of high risk patients. Ascitic fluid tapping and examination is recommended. Exudative fluid is present in tuberculous ascites. The ascitic fluid is straw coloured. Protein content is greater than 3g/dl. Total cell count is 150-4000/µl mainly lymphocytes [> 70%]. Ascites to blood glucose ratio is less than 0.96. Serum ascites albumin gradient is less than 1.1 g/dl. Detection of bacteria in the ascitic fluid is done by AFB staining. Procedures for identifying the diagnostic markers for tuberculous ascites are electrophoresis, liquid chromatography/mass spectrometry, immunoblot analysis, and ELISA. High serum ADA [adenosine deaminase] level in ascitic fluid is diagnostic of tuberculous ascites. A chest x-ray and multiple sputum cultures for presence of acid fast bacilli are initial evaluation methods which confirm the diagnosis. An Xpert MTB/RIF rapid, fully automated nucleic acid amplification test has been introduced recently for rapid diagnosis of TB. Imaging studies such as USG abdomen, CT abdomen are useful for further evaluation. Laparoscopy is done in some cases to confirm the diagnosis.
Treatment
Antimicrobial or antitubercular drug is the treatment for tuberculous ascites. Multiple drug therapy is a highly effective treatment. DOT [directly observed therapy] reduces the chances of relapse as it is a supervised therapy. Newer drug regimen is advised for MDR TB and XDR TB. Prevention is done with BCG vaccination at birth. Diuretics are usually administered, which help remove the fluid. Limiting salt in the diet [less than 1500 mg/day of sodium], avoiding drinking alcohol will also help in managing tuberculous ascites. Surgical procedures include ascitic tapping. Complication of the disease may cause strictures which may be removed by a procedure called strictureplasty.
Other Modes of treatment
The other modes of treatment can also be effective in treating tuberculous ascites. Homoeopathy is a science which deals with individualization and considers a person in a holistic way. This science can be helpful in combating the symptoms. Similarly, the Ayurvedic system of medicine which uses herbal medicines and synthetic derivates are also found to be effective in treating tuberculous ascites.
