经皮超声引导下腹膜穿刺活检诊断结核性腹膜炎的临床实用性分析

目的:评价腹膜活检在结核性腹膜炎诊断中的临床实用性.方法:152例腹水原因待查患者,采用超声穿刺探头引导下经皮于增厚的腹膜处进行活检,活检组织行病理学检查,所有患者均进行PPD、血沉、血清C反应蛋白(CRP)和腹水乳酸脱氢酶(LDH、腹部X线检查.结果:腹膜活检的成功率为96.05%,结核性腹膜炎64例.占腹膜活检者的42.11%.152例腹膜活检患者中,诊断为结核性腹膜炎者64例,占总不明原因腹水42.11%,腹膜活检阳性率明显高于目前用于临床提示结核性腹膜炎的一般性辅助检查包括血沉增快(x2=1.265,P=0.261)、PPD阳性(x2=26.669,P=0.000)、CRP升高(x2=8.125,P=0.004),腹水LDH增高(x2=20.403,P=0.000)、腹部X线检查阳性所见(x2=7.169,P=0.007),统计处理差异显著.腹膜活检病理组织内可见结核的病理改变:干酪样坏死,朗罕氏细胞、类上皮细胞及多核巨细胞,组织内有大量纤维脂肪组织.结论:经皮腹膜穿刺活检可以确诊结核性腹膜炎,安全可靠,使用限制少,是一种最具有临床实用价值的检查手段.     

多功能腹膜检查针的研制及临床应用研究

目的旨在提高腹水病因的诊断率和鉴别诊断率。方法自行研制多功能腹膜检查针并对临床上１５８例腹水患者进行检查。结果这种多功能腹膜检查针对４２例怀疑腹水由结核性腹膜炎引起的病理诊断率达９０．４８％;对４７例不明原因腹水的临床病因确诊率达６３．８３％;对２２例肝硬化伴腹痛和发烧怀疑原发性腹膜炎的确诊率达４０．９％,单纯腹水生化检查的诊断率只占１８．２％,前者明显优于后者;４５例原因不明腹水患者单纯腹水细胞学检查仅５例发现癌细胞,进行腹膜刷检后１３例找到癌细胞,显著优于腹水细胞学检查。结论多功能腹膜检查针对结核性腹水,癌性腹水和肝硬化合并原发性腹膜炎有重要的临床诊断价值,而且操作简单,在病床边即可检查,可在基层医院广泛使用。     

腹膜活检对结核性腹膜炎的诊断价值

目的评价经皮腹腔穿刺腹膜活检对结核性腹膜炎的诊断价值。方法使用自动弹簧活检针对34例临床上考虑为结核性腹膜炎患者进行腹膜活检,并进行病理诊断。结果34例患者均经一次穿刺取出腹膜壁层组织,经病理证实结核性腹膜炎26例、转移性腺癌3例、恶性淋巴瘤1例和大致正常腹膜组织4例,一次穿刺活检成功率为100％,经活检明确腹水病因的诊断率为88．2％。结论腹膜活检对结核性腹膜炎诊断及鉴别诊断,有重要的临床诊断价值。     

卵巢癌抗原在结核性腹膜炎中的诊断意义

为探讨CA125在结核性腹膜炎中的诊断意义。方法应用酶微粒法测定结核性腹膜炎患者的血清及腹水中CA125水平。以多功能腹膜检查针取腹膜活检,作病理诊断。结果显示CA125>600 kU/L中,结核性腹膜炎血清、腹水阳性率分别为16％(8/50)、30％(15/50);CA125<600 kU/L中,结核性腹膜炎血清、腹水分别为133.53±56.52 kU/L、432.32±59.45 kU/L。结论提示CA125水平在结核性腹膜炎中明显升高。     

腹膜活检针的研制及其临床应用价值——附95例检查分析

本文介绍自行设计腹膜活检针并对临床95例不同原因引起的腹水病人进行检查,结果表明:这种活检针对临床上组织病理学确诊结核性腹膜炎有较大价值(诊断率达92.86％);对原因不明的腹水有较高鉴别诊断价值(70.37％);对肝硬化腹水病人原发性腹膜炎的诊断优于腹水常规检查,同时操作简单、安全、适合基层医院使用.     

腹腔内镜检查对不明原因腹水的诊断价值

目的 探讨腹腔内镜检查及直视下腹膜活检对不明原因腹水的诊断价值,评价超细胃镜代替硬式腹腔镜检查的可行性。方法对35例不明原因腹水的患者进行腹腔内镜探查手术,并取可疑组织送病理检查。结果35例腹腔内镜探查确诊33例,确诊率94．3％,其中确诊结核性腹膜炎10例,转移性腹膜癌7例,肝癌5例,肝硬化3例,原发性腹膜癌3例,卵巢癌2例,肝血管肉瘤1例,脾淋巴瘤1例,嗜酸性肠炎1例,所有患者术后恢复顺利,无并发症。结论腹腔内镜检查安全,靶向性腹膜活检确诊率高,对不明原因腹水的诊断有重要价值。     

腹膜活检52例分析

对52例不明原因的腹水及腹块病人用Vim Silverman双分叶片状针经皮、腹腔镜直视下及腹部小切口开窗腹膜活检,诊断率分别为6.7％、93.3％和100％.其中结核性腹膜炎19例,腹膜转移癌16例,腹膜间皮瘤1例,16例未获得诊断。作者认为,腹腔镜直视下腹膜活检和腹部小切口开窗活检对腹内肿瘤性或结核性疾病的鉴别诊断有重要价值.并对其适应症、优缺点进行了讨论.     

诊断性腹腔镜的临床应用研究

目的：评价诊断性腹腔镜的检查方法、效果及安全性，提高腹部疑难疾病的早期诊断率。方法：回顾分析58例腹部疑难疾病患者的腹腔镜检查情况，其中腹水原因待查35例，腹水＋腹部包块23例。结果：58例患者中诊断为结核性腹膜炎31例，恶性腹膜间皮瘤23例，腹膜转移癌2例，盆腔结核及慢性盆腔炎各1例。不同疾病在腹腔镜下有不同表现。操作时间25－70min，平均38min。并发症为活检处出血4例，其中3例为自限性因，1例经局部喷洒凝血酶后停止，术后伤口漏水5例。对腹腔镜下有肯定判断的12例患者同时进行治疗。结论；腹腔镜检查具有安全、简便、微创、痛苦小、确诊率高等优点。诊断性腹腔镜值得进一步推广应用。     

结核性腹膜炎的诊断现状

结核性腹膜炎的诊断在结核病较常见的国家仍是一项挑战。该病的临床表现无特异性。以淋巴细胞为主的腹膜炎和低血清-腹水白蛋白梯度(＜11g/L)的患者应考虑结核性腹膜炎可能。腹水培养结核杆菌和经腹腔镜取腹膜活检标本是诊断结核性腹膜炎的重要方法。并讨论多聚酶链反应,腺苷脱氨酶和其他方法诊断结核性腹膜炎的价值。     

腹膜刷检,腹膜活检在恶性腹水诊断中的意义

为提高恶性腹水诊断的阳性率，我们研制了腹膜细胞刷，并结合腹膜活检、腹水脱落细胞学等检查。对48例腹水患者进行了检查，现将结果报告如下。材料与方法一、病例选择腹水原罔待查患者48例，其中男39例，女9例，年龄为32～75岁，平均4s土5岁．二、检查方法H腹膜活检方法：部位与常规处理与腹水诊断性穿刺一致．应用Abram胸膜活检针行经皮腹膜活检，将带针芯的穿刺针（即套管）刺人腹腔，当取出针芯有腹水流出时，即可插人活检针，并使活检针前端四槽面紧贴腹壁。助手用拇指按压活检针四槽处腹壁，后拔出活检针，在四槽处取出腹膜组织．依…     

Diagnostic value of fibrolaparoscopy and direct-vision peritoneal biopsy in atypical tuberculous peritonitis]

Fifty-three cases of atypical tuberculous peritonitis were diagnosed by Machida FLA-8 fibrolaparoscope and direct-vision peritoneal biopsy in our hospital during the last few years. The misdiagnosis rate of this disease is very high. The rate of accurate clinical diagnosis was only 39.6% in patients of this study, while 60.4% was misdiagnosed as other diseases, such as cirrhosis, chronic hepatitis, hepatic carcinoma ovarian cyst etc. In addition, many patients with other diseases were misdiagnosed as tuberculous peritonitis by clinical consideration, for instance, 56 cases who were diagnosed or doubted as tuberculous peritonitis by clinical consideration were diagnosed as other diseases by laparoscopy and liver and peritoneal biopsy under direct-vision. Among them chronic hepatitis accounted for 32 cases, peritoneal carcinoma 11 cases, cirrhosis 7 cases, normal peritoneum, liver, gall bladder and spleen 6 cases. Therefore, the patient who is presumptively diagnosed as tuberculous peritonitis by clinical consideration should have laparoscopy and direct-vision peritoneal biopsy performed.     

腹腔镜检查对腹膜病变的诊断价值

目的 研究腹腔镜检查及直视下腹膜活检对腹膜病变的诊断价值。方法 应用MachidaFLA-8腹腔镜及直视下腹膜活检诊断腹膜病变。结果 腹腔镜检查及直视下腹膜活检131例中，122例（93.1%)活检病理诊断阳性，其中结核性腹膜炎（TBP）63例，腹膜癌（PC）56例，腹膜恶性间皮瘤2例，腹膜恶性淋巴瘤1例，TBP临床误诊率为58.8%。而PC为91.1%。TBP的腹腔镜性间皮瘤2例，腹膜恶性淋巴瘤1例，TBP临床误诊率为58.8%，而PC为91.1%，TBP的腹腔镜所见主要为腹膜与邻近脏器表面有比较均匀一致的粟粒样白色结节，常散在或成群地分布于腹膜上活检时组织较软。而PC的所见主要是腹膜与邻近脏器表面有大小不一的灰白色斑块和结节，活检时有明显的坚硬感。结论 腹膜病变临床诊断困难，误诊率高，腹腔镜检查及直视下腹膜活检是最有效的诊断方法，可以确定诊断。     

Clinical review of 23 patients with tuberculous peritonitis: presenting features and diagnosis

OBJECTIVE: To better identify which clinical, laboratory, radiological and invasive procedures were most useful in diagnosing tuberculous peritonitis and to assess the methods in order to reach the diagnosis in future cases. METHODS: Tuberculous peritonitis cases diagnosed between 2000 and 2006 were reviewed retrospectively. Their clinical presentation, physical examination, laboratory and diagnostic methods were evaluated. RESULTS: Twenty‐three cases of tuberculous peritonitis were diagnosed. The mean age of the patients were 30 ± 11 years and 16 were women. The mean duration of symptoms prior to diagnosis was 3.6 months. All patients presented with abdominal pain. Abdominal swelling (91.3%), loss of appetite (87%) and weight loss (82.6%) were the other commonest symptoms. The major physical findings were ascites (78.3%) and fever (60.9%). The serum ascites albumin gradient was <1.1 g/dL in all. An ascites fast bacilli smear was positive in 12 (52.2%) patients. Skin tests with purified protein derivative, adenosine deaminase and polymerase chain reaction were performed in seven, four and five patients, respectively. The tuberculous culture was positive in only two. The most common radiological findings were ascites (100%) and omental involvement (65.2%). A laparoscopy was performed in nine of 23 patients. A total of 22 patients completed anti‐tuberculous therapy successfully and were cured, except one with cirrhosis. CONCLUSION: Tuberculous peritonitis may be fatal but is medically cured if diagnosed in a timely fashion. Although both non‐invasive and invasive tests have additional benefits, clinician suspicion is still the first step for the diagnosis of tuberculous peritonitis.     

Tuberculous peritonitis--reports of 26 cases, detailing diagnostic and therapeutic problems

OBJECTIVE: To evaluate the clinical presentation, biochemical (ascites and serum) and laparoscopic findings, and to assess the efficacy of triple antituberculous therapy without rifampicin for 6 months in patients with tuberculous peritonitis. METHODS: Twenty-six tuberculous peritonitis patients (11 male, 15 female) with a mean age of 34.8 +/- 3.4 years (range 14-77) were assessed with regard to diagnostic and therapeutic features. RESULTS: The most common symptoms and signs were abdominal pain (92.3%) and ascites (96.2%), respectively. Tuberculin skin test (TST) was positive in all patients. An abnormal chest radiography suggestive of previous tuberculosis was present in five patients (19.2%), and two patients (7.7%) had extra-peritoneal (cerebral, pericardial) active tuberculous involvement. In 24 of the 25 patients who underwent laparoscopy with directed biopsy, whitish nodules suggested tuberculous peritonitis; 76% of the biopsy specimens revealed caseating, 20% non-caseating granulomatous inflammation, and 4% non-specific findings. The ascitic fluid of one patient (3.8%) was positive for acid-resistant bacilli, and culture was positive in two patients (7.7%). Twenty-four of the patients were treated for 6 months with isoniazid, streptomycin (total dose 40 g) and pyrazinamide (for the first 2 months and then substituted with ethambutol). Eighteen patients also received methyl prednisolone, initially 20 mg/day, for 1 month. The follow-up period was 19 +/- 1.7 months after the end of therapy (range 6-36). Ascites and abdominal pain abated earlier in patients on steroid therapy. All but two of the 24 patients responded to treatment. CONCLUSION: Non-invasive tests such as acid-fast stain and culture of the ascitic fluid are usually insufficient, hence invasive laparoscopy and peritoneal biopsy are necessary for the diagnosis of tuberculous peritonitis if non-invasive tests such as ascites adenosine deaminase activity measurement are not easily available. Triple therapy without rifampicin for 6 months is sufficient to treat tuberculous peritonitis.     

Tuberculous peritonitis in Egypt: the value of laparoscopy in diagnosis.

Abdominal laparoscopy was performed on 200 patients with undiagnosed ascites. It was unsuccessful in one patient with tuberculous peritonitis because of extensive adhesions. A presumptive diagnosis of tuberculous peritonitis based on clinical findings and peritoneal tubercles or adhesions visualized during laparoscopy was made in 90 of these patients. The diagnosis was confirmed in 88 by histopathology, bacteriology, or therapeutic response. Two of the 109 remaining patients who had other presumptive diagnoses made during laparoscopy were eventually confirmed to be cases of tuberculous peritonitis. Of 91 patients with tuberculous peritonitis included in this series, 79% were females, with the majority (79%) of them being of child-bearing age. Half had been ill for longer than one month. The most frequent complaints were abdominal pain, fever, anorexia, night sweats, abdominal swelling, and weight loss. Ascites, fever, wasting, pallor, and abdominal tenderness were common findings. Ultrasonography demonstrated ascites in all patients who underwent this procedure; 21% also had adhesions. Pleural effusion was present in 15% and pulmonary tuberculosis was detected in only two patients. Biopsy samples taken during laparoscopy showed that 60% had noncaseous granulomas and 33% had caseous granulomas. Mycobacterium tuberculosis was detected in 77%, with guinea pig inoculation having the highest sensitivity, followed by culture, and lastly by acid-fast smear. Mycobacterium tuberculosis was isolated more easily from biopsy samples than from ascitic fluid. Nine of 20 M. tuberculosis isolates that were identified as to species were M. bovis. Tuberculous peritonitis, a frequent cause of febrile ascites in Egyptian women, was easily diagnosed by histopathologic and bacteriologic studies of biopsy samples taken at laparoscopy. All patients responded rapidly to antituberculosis therapy.     

欠发达地区结核性腹膜炎40例

目的:总结结核性腹膜炎(tuberculous peritonitis,TBP)临床特点,进一步提高临床医生对TBP的认识水平.方法:收集40例TBP患者的病例资料,对其发病情况、临床表现、实验室和辅助检查、诊疗经过等方面进行回顾性分析并复习文献.结果:本组TBP患者年龄以20-40岁为高发(57.5%),仅22.5%的病例既往有结核病史或慢性疾病史.发病以慢性起病多见(85.0%),症状以腹胀(85.0%)、食欲减退(67.5%)、发热(52.5%)、腹痛(47.5%)常见.体征以腹水(67.5%)、腹痛(65.0%)多见,腹壁柔韧感少见(35.0%).血清学检查特异性低,腹水多呈渗出液的特点,但腹水ADA>33U/L,单核细胞占优势等有助于诊断TBP的特点较少见(16.0%-34.0%).腹水抗酸杆菌涂片和结核菌培养阳性率低(4.75%,0%).PPD实验和胸部X线的阳性率均为37.5%.CT和B超检查多数表现为腹水、腹膜增厚、粘连等(78%),女性患者子宫、附件受累常见(72.7%).本组TBP患者误诊5例,误诊率为12.5%,最常见是误诊为妇科肿瘤(n=3).仅4例患者(10%)获病原学或病理确诊,其余90%依靠试验性抗结核治疗获得诊断.结论:在欠发达地区,目前依靠腹腔镜、B超引导下活检等手段获得病理标本,确诊TBP的比例仍很低.绝大部分TBP病例诊断主要依靠试验性抗结核治疗及对疗效的动态观察.临床医生能够怀疑到TBP的可能并积极试验性抗结核治疗是TBP诊断的关键.对2wk试验性抗结核治疗效果不好的病例,要动员患者接受更积极的腹腔镜检查,以免贻误病情.     

A case of tuberculous peritonitis diagnosed by ultrasonography-guide peritoneal biopsy

The diagnosis of tuberculous peritonitis is quite difficult because the symptoms are not specific for the disease and the incidence of occurrence are relatively rare. We report a case of tuberculous peritonitis diagnosed by ultrasonography-guided peritoneal biopsy. A 64-year-old male was admitted to our hospital because of fever, dyspnea and abdominal pain. Laboratory findings revealed an elevated ESR (53 mm/1 hr.) and positive CRP. The tuberculin skin test was negative. The chest radiograph revealed bilateral pleural effusion. Abdominal ultrasonographic examination and computed tomography showed ascitic fluid, thickening of the mesentery and peritoneum, and inflammatory pseudotumor of the omentum. Ascitic fluid was exudate with a high lymphocyte count and elevated ADA (184 IU/l). Microbiological studies with the fluid were negative. Peritoneal biopsy guided by ultrasonography was performed, and the specimens showed central caseous necrosis surrounded by epitheloid cells and acid-fast bacilli were demonstrated. The size of the pseudotumor, pleural effusion and ascites decreased after antituberculous chemotherapy with corticosteroid was given. Diagnosis of tuberculous peritonitis has often been made by laparotomy or laparoscopy. In a case of this kind, percutaneous peritoneal biopsy guided by ultrasonography is safe and useful.     

Peritoneoscopy in the diagnosis of tuberculous peritonitis

Seventy-four patients with tuberculous peritonitis were examined by peritoneoscopy (laparoscopy). The characteristic features were uniform miliary tubercles studding the visceral and parietal peritoneum together with numerous adhesions between bowel loops, liver capsule, and abdominal walls. Guided biopsy yielded a definitive diagnosis in 56 cases. Special precautions are urged to avoid an increased risk of complications by peritoneoscopy and biopsy in tuberculous peritonitis.