Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Bhanu K Bhakhri

"The Journal of Clinical and Diagnostic Research (JCDR) has been in operation since almost a decade. It has contributed a huge number of peer reviewed articles, across a spectrum of medical disciplines, to the medical literature.
Its wide based indexing and open access publications attracts many authors as well as readers
For authors, the manuscripts can be uploaded online through an easily navigable portal, on other hand, reviewers appreciate the systematic handling of all manuscripts. The way JCDR has emerged as an effective medium for publishing wide array of observations in Indian context, I wish the editorial team success in their endeavour"



Dr Bhanu K Bhakhri
Faculty, Pediatric Medicine
Super Speciality Paediatric Hospital and Post Graduate Teaching Institute, Noida
On Sep 2018




Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dematolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011

Important Notice

Original article / research
Year : 2012 | Month : August | Volume : 6 | Issue : 6 | Page : 987 - 989

A Study on the Efficacy of an Open Peritoneal Biopsy for Abdominal Tuberculosis in a Tertiary Medical Centre: Analysis of 69 Cases

Abhijit Mandal, Sujit Kumar Bhattacharyya, Debasis Deoghuria, Sourindra Nath Banerjee, Anupam Patra, Panchanan Kundu

1. Associate Professor, Chest Medicine Bankura Sammilani Medical college, Bankura, West Bengal, India. 2. Assistant Professor, Chest Medicine NilRatan Sircar Medical College, Kolkata, West Bengal, India. 3. Assistant Professor, Radiology Department Bankura Sammilani Medical College, Bankura, West Bengal, India. 4. Post Graduate Trainee in the Department of Pulmonary Medicine NilRatan Sircar Medical College, Kolkata, West Bengal, India. 5. Post Graduate Trainee in the Department of Pulmonary Medicine NilRatan Sircar Medical College, Kolkata, West Bengal, India. 6. Prof of Anatomy Bankura Sammilani Medical College, Bankura, West Bengal, India.

Correspondence Address :
Dr. Sujit Kumar Bhattacharyya
Vill-Aminpur, P.O., Khamarchandi
P.S-Haripal, Hooghly (DISTRICT),
West Bengal, India - 712405.
Phone: 9433151875.
E-mail: drsujit.haripal@yahoo.in

Abstract

Background: The diagnosis of abdominal tuberculosis is often empirical, based on indirect evidences. A polymorphous clinical presentation, non-specific biological markers, a minimally contributive bacteriology and non-specific radiographic signs raise diagnostic difficulties in abdominal tuberculosis. A peritoneal biopsy may be useful in confirming the diagnosis of abdominal tuberculosis.

Aims: In this study, we evaluated the efficacy of an open peritoneal biopsy for the confirmation of abdominal tuberculosis.

Methods and Materials: We selected 69 cases of suspected abdominal tuberculosis. Among them, 28 cases were diagnosed by Ultrasound (USG) guided Fine Needle Aspiration Cytology (FNAC) from the abdominal lymph nodes or lumps and 38 cases were diagnosed by the examination of the lymphocytic exudative ascitic fluid with a high adenosine deaminase content. 3 cases could not be diagnosed by either means. All the 69 cases were subjected to open peritoneal biopsies.

Results: Abdominal pain and tenderness were the presenting clinical features in all the cases. The histopathological examination of the open peritoneal biopsy material confirmed the diagnosis by revealing caseating granulomas in 33 (47.83%) cases. These included 2 cases among 3 which could not be diagnosed by FNAC of the abdominal lymph node or by ascitic fluid examination. Mycobacterial cultures which were done from the biopsy materials were positive in 18(26.08%) cases and all of them had caseating granulomas. The peritoneal biopsies were confirmatory in 19 out of the 38(50%) cases with ascites and in 14 out of the 31(45.16%) cases without ascites. One case could not be diagnosed by either of these three means. She was put on empirical anti tuberculour drugs to which she responded.

Conclusion: The classical biological and radiological investigations are not specific and their contributions remain little in the diagnosis of abdominal tuberculosis. Open peritoneal biopsies are safe and helpful in confirming abdominal tuberculosis, particularly in the ascitic cases and the mycobacterial cultures did not improve the diagnostic yield over the histopathological examination of the biopsy materials.

Keywords

Peritoneum, Abdominal tuberculosis, Biopsy, Abdomen

How to cite this article :

Abhijit Mandal, Sujit Kumar Bhattacharyya, Debasis Deoghuria, Sourindra Nath Banerjee, Anupam Pa tra, Pa nchanan Kundu. A STUDY ON THE EFFICACY OF AN OPEN PERITONEAL BIOPSY FOR ABDOMINAL TUBERCULOSIS IN A TERTIARY MEDICAL CENTRE: ANALYSIS OF 69 CASES. Journal of Clinical and Diagnostic Research [serial online] 2012 August [cited: 2018 Oct 18 ]; 6:987-989. Available from
http://jcdr.net/back_issues.asp?issn=0973-709x&year=2012&month=August&volume=6&issue=6&page=987-989&id=2315

INTRODUCTION
Abdominal tuberculosis is quiet frequent in India, accounting for approximately 1/3rd of all the cases of tuberculosis in some series. The diagnosis of abdominal tuberculosis is difficult as its presentation is non-specific and as it is often masked by the manifestations of tubeculosis in other parts of body, mainly in the lungs. The clinical manifestations vary from acute abdomen and non-specific symptoms (vague abdominal pain and discomfort, diarrhoea, malabsorption syndrome and weight loss) to ascities and sub-acute intestinal obstruction. A diagnostic criteria was laid down by Ligenfelser et al in 1993, which is as follows: 1. Histopathological (H.P) evidence of caseating granulomas/ demonstration of acid fast bacilli (AFB). 2. The presence of Mycobacterium tuberculosis in sputum/ tissue/ascitic fluid and 3. The clinical/radiological/operative evidence of tuberculosis in any other site with a good therapeutic response. This criteria is difficult to follow as the H.P evidence needs a surgical intervention in every case. M tuberculosis is rarely isolatedfrom ascitic fluid and active pulmonary tuberculosis is present in less than 50% of the cases of abdominal tuberculosis. Therefore, abdominal tuberculosis is usually diagnosed on the basis of clinical suspicion and it is confirmed by successful therapeutic trials. Abdominal tuberculosis can present in two forms; 1) intestinal and 2) peritoneal. Peritoneal tuberculosis accounts for about 25% to 60% of the abdominal tuberculosis cases. The gross examination of the peritoneum shows multiple white tubercles and adhesion of the organs with the peritoneum or with the miliary nodules in the peritoneum. The mesentery is usually thickened and oedematous and there may be a collection of pus or caseous material. Peritoneal tuberculosis can be of two types; 1) the exudative or the moist type and 2) the plastic or the dry type. In this study, our objective was to find out the role of open peritoneal biopsy in the diagnosis of abdominal tuberculosis.

Material and Methods

All the cases of suspected abdominal tuberculosis patients who attended the Chest Department of a tertiary medical centre in thedistrict of Bankura in West Bengal, India, from July 2001 to June 2004 were included in this study with a due concurrence sanction from the ethical committee. The diagnosis of abdominal tuberculosis in the patients with abdominal symptoms was corroborated by USG guided FNAC from the abdominal lymph nodes or from the mass which demonstrated AFB and/or from caseating granulomas and by ascitic fluid examination (lymphocytic exudative fluid with a high adenosine deaminase content (ADA>60U/L). Those who had active tuberculosis in the lungs or in any other site, those who had disseminated tuberculosis, other associated diseases such as diabetes, HIV infection, etc., those who refused to give a informed written consent and those who had contraindications for surgery under general anaesthesia were excluded from the study. Finally, we selected 69 cases for the final analysis.

Every patient underwent the following protocol: i) A detailed history and clinical examination. ii) Routine laboratory investigations which included a complete haemogram, the tuberculin test , chest X-ray, sputum studies for AFB and smears from the DOT’s centre. iii) Straight X-ray of the abdomen and USG of the whole abdomen. iv) Examination of the ascitic fluid for the cell type, cell count, protein, sugar, ADA, gram staining and Ziehl-Neelsen staining. v) USG guided FNAC from the lymph node or the abdominal mass. vi) A peritoneal biopsy, followed by a histopathological examination and a mycobacterial culture.

The peritoneal biopsy was done by open surgery through an infraumbilical midline incision under local anaesthesia. The material which was obtained was divided into two parts. One half was sent in formalin solution for the H.P. examination and the other half was sent in normal saline without delay for the mycobacterial culture in Lowenstein-Jensen media. Once the diagnosis was established, the patients were referred to specialized centres to receive free treatment as per the RNTCP guidelines.

Results

In this study, we selected 69 patients who were suspected to have abdominal tuberculosis. Of them, 47(68.11%) were females and 22 (31.89%) were males.12 patients(17.39%) were below 15 years of age, 39 (56.52%) were between 16 to 30 years of age, 12(17.39%) were between 31 to 45 years of age and 6 (8.70%) were above 45 years of age. The duration of the symptoms was less than 2 months in 30 cases (43.48%), it was between 2 to 6 months in 26 cases (37.68%) and it was more than 6 months in 13 cases (18.84%). All the cases had abdominal pain, 48(69.57%) cases had fever, 46(66.67%) cases had weight loss, 43( 62.32%) cases had anorexia, 36(52.17%) cases had alternate bowel habits, 27(39.13%) cases had constipation, 14(20.29%) cases had nausea or vomiting, 13(18.84%) cases had cough and 8(11.6%) cases had diarrhoea.

A history of contact was present in 13(18.84%) cases and a past history of tuberculosis was present in 8(11.6%) cases. All the cases had abdominal tenderness, 12(17.39%) cases had abdominal distension and visible peristalsis, 29(42.03%) had a doughy abdomen, 3(4.35%) had an abdominal lump and 21(30.43%) cases had detectable ascites. A general survey revealed anaemia in 48(69.57%) cases and malnutrition in 42(60.87%) cases. Haemoglobin values of less than 10 gm/dl were noted in 54(78.26%) cases, leucocytosis was noted in 9(13.04%) cases, leucopaeniawas noted in 3(4.35%) cases and a raised ESR was noted in 54(78.26%) cases, among whom 17 (24.63%) cases had an ESR of more than 100mm in the first hour. 9(13.04%) cases were found to have fibrotic lesions on chest X-ray. USG of whole abdomen revealed ascites in 38(55.07%) cases, abdominal lymphadenopathy in 36(52.17%) cases and abdominal lumps in 6(8.70%) cases. Ascites with abdominal lymphadenopathy and ascites with abdominal lumps were found in 6 and 2 patients respectively. The diagnosis of abdominal tuberculosis was confirmed by FNAC in 28 cases (40.59%) under image guidence. In 24 cases (34.78%), the FNAC was done from the abdominal lymph nodes and in 4 cases (5.79%), it was done from the abdominal lumps. In 38(55.07%) cases, the diagnosis was made by the examination of the ascitic fluid (lymphocytic exudative fluid with a high ADA content).

Open peritoneal biopsies was done in all the cases. The histopathological examination (Table/Fig 1) revealed caseating granulomas in 33(47.83%) cases, non caseating granulomas in 8 (11.6%) cases, non-specific chronic inflammation in 17(24.64%) cases and no abnormality in 11(15.94%) cases. The Mycobacterial culture was positive in 18(26.09%) cases and all of them had caseating granulomas. Surprisingly, we did not find any additional benefit of the Mycobacterial culture in our study. The peritoneal biposies were helpful in confirming the diagnosis in 33(47.83%) cases in19 out of 38 ascitic cases (50%) with a high ADA content and in 14 out of 31(45.16%) non-ascitic cases. We found open peritoneal biopsy to be a safe method. Only one patient developed a mild form of paralytic ileus and another had a wound infection- both responded satisfactorily to the postoperative management.

Discussion

Open peritoneal biopsy has the advantage of direct visualization of the peritoneum and selection of the biopsy site, with a low operative risk (1). The positive yield of the open peritoneal biopsy was around 50% in the ascitic cases, but it was only 45.16% in the non ascitic cases. Aguado et al., reported a similar observation with an increased yield of caseating granulomas (85-90%) (2). P. Das et al., found that the open peritoneal biopsy was a safe procedure (3). On the other hand, laparoscopic peritoneal biopsy has the advantage of direct inspection and sampling from the abnormal site. The diagnostic yield of laparoscopic peritoneal biopsy was found to be between 80%-95% and the biopsy specimens revealed AFB in 70% to 75% of the cases and caseating granulomas in 90% of the patients (4). A review of the literature showed that peritoneal deposits were observed in 66%-100% of the patients (5). A peritoneal biopsy can be done by a blind percutaneous needle insertion but it may involve the risk of bowel perforation and a chance of lowering the diagnostic yield because of the non visualization of the peritoneum.

We found that a chronic, non-specific, abdominal pain and diffuse abdominal tenderness were the reliable clinical manifestations of abdominal tuberculosis. The presence of other factors such asgeneral ill health, disturbed bowel habits, a present or past history of tuberculosis, a doughy abdomen, ascites, anaemia, malnutrition etc. augmented the probability of abdominal tuberculosis, particularly in India. USG of the abdomen was found to be a useful tool as we could detect abdominal lymphadenopathy or lumps in approximately half of the cases in which USG-guided FNAC could be performed. The ascitic fluid examination revealed a lymphocytic predominantly exudative fluid in all the cases. This finding was similar to that which was observed by Marshall GB et al., (6). Mycobacterium could be isolated in 3 cases(4.3%) in our study and this was comparable with the reports of Mohammed El Abkari et al and Dhiman RK (5),(7). Khan R et al., observed that the mycobacterial culture was positive in 7 % (8) of the cases.

When the findings of various studies were compared, the yield of the peritoneal biopsy under laparoscopy or laparotomy which detected the proportion of caseating and non caseating granulomas was found to vary from 47.83% to 86.18% and from 4.88% to 20% respectively (4),(9). It is apparent from (Table/Fig 2) that the yield of the caseating granulomas was higher as compared to that of the non caseating granulomas. Surprisingly, in one study which was done by Nafehma et al., the ratio between the caseating and the noncaseating granulomatous lesions was seen just in a reverse fashion (10). In our study, the mycobacterial culture was positive in 18% of the cases, whereas Khan et al., (8) found that it was positive in 7% of the cases.

Overall, our yield by open peritoneal biopsy through a small incision below the umbillicus was 52.2% and this was comparable with the yield of Singh et al. They found caseating granulomas in 64% of the subjects by making incisions in the right iliac fossa. P.Das and Shukla et al found significantly better yields of 88% and 42% in the ascitic and the non-ascitic cases respectively. We found open peritoneal biopsy to be safe with a few incidences of manageable minor complications.

References

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Chow K, Chow V, Hang I. The tuberculour peritonitis associated mortality is high among the patients who wait for the reports of the mycobacterial cultures of the ascitic fluid samples. Cli In Dis 2002; 35:409-33.
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Aguado J, Pons F, Casafont F . Tuberculous peritonitis: a study which compared the cirrhotic and the non-cirrhotic patients. J Cli Gas 1990;12:550-54.
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DasP, Shukla H. Abdominal tuberculosis: demonstration of the tubercle bacilli in tissues and the experimental production of hyperplastic enteric lesions. Br J Surg 1975;62(8):610-17.
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Udwadia T. Diagnostic laparoscopy. Surg Endo 2004;18: 6-10.
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Abkari M E, Benajah D A, Aqodad N, Bennouna S, Oudghri B, Adi I. Peritoneal tuberculosis in the Fes hospital (Morocco). Gastro Clin Bio 2006;30:377-815.
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