Spontaneous biliary tract perforations: an unusual cause of peritonitis in pregnancy. Report of two cases and review of literature
The most common non-obstetric cause of peritonitis in pregnancy is appendicitis. Biliary tract perforations are unusual causes of peritonitis in pregnancy. The signs and symptoms are often nondiagnostic, especially during pregnancy, and diagnosis may be delayed with possible fatal consequences . Gall bladder or CBD perforations as a cause of peritonitis in pregnancy have been rarely reported in literature and their exact incidence in pregnancy is not known. Even when the gall bladder perforates, the usual outcome is a local abscess, on account of the adhesion that form between the gall bladder, greater omentum and the parietal peritoneum . Although gall bladder perforation has been reported to occur in 3 to 10% cases of acute cholecystitis in adults, gall bladder perforation into the general peritoneal cavity is even rare, occurring in only 0.5% of the patients undergoing conservative management for acute cholecystitis. The initiating event in majority of these patients is impaction of the stone leading to epithelial injury and ischemia due to distension of the gall bladder. The site of perforation is either at the fundus, which is farthest away from the blood supply, or less commonly at the neck from the pressure of an impacted stone . Abdominal Paracentesis is helpful in diagnosis of biliary peritonitis. In the presented case, abdominal paracentesis lead to a timely diagnosis of biliary peritonitis and patients were operated without delay. But gall bladder perforation was not suspected preoperatively. The surgical management consists of cholecystectomy, copious irrigation and drainage of the abdominal cavity .
Only about 40 cases of spontaneous rupture of the CBD have been reported earlier and it is extremely rare in pregnancy . It may result from increases intraductal pressure due to stones, thrombosis of a mural vessel, intraluminal infection in the bile duct wall, infected diverticulum of the duct or reflux of pancreatic secretions . In the present case of CBD perforation, no gall stones were found. Recommended treatment includes cholecystectomy and CBD exploration with T-tube drainage in cases of small perforations. Roux-en-Y biliary-enteric anastomosis is indicated if the ductal disruption is large .
A high index of suspicion and an early surgical intervention are the mainstays of therapy of peritonitis in pregnancy and may be associated with decreased maternal and fetal morbidity. In a pregnant lady with peritonitis, if a biliary tract perforation is detected intra-operatively, the treatment should be based on the conventional surgical principles of treating such conditions.
1. CBD common bile duct.
2. g/dL grams per deciliter.
3. mL milliliter.
4. % percent.
5. cm centimeter.
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Purulent Appendicular Peritonitis in Pregnancy: Management and Pregnancy Outcome
Appendicitis represents the most common cause of acute abdomen in pregnancy, accounting for 25% of non-obstetric surgery in pregnant women, with an incidence between 0.06% and 0.28% [1,2]. Forty per cent of cases takes place on the second trimester . Diagnosis of appendicitis during pregnancy remains challenging, for the low sensitivity of ultrasound (US) and low predict value of typical symptoms, due to the change of appendix location and to the physiological mild leukocytosis [4-7]. Therefore, complications occur more frequently during pregnancy than in non-pregnant women .
In the current case we report our experience of the challenging diagnosis and subsequent laparotomic treatment of purulent appendicular peritonitis in the second trimester, reflecting an optimal management of this threatening situation.
A gravida 2, para 2, 40-year-old white woman at 23 weeks of gestation, presented to the emergency room of our Hospital with abdominal discomfort and gastrointestinal symptoms such as nausea and vomiting. At the time of admission to hospital, her blood pressure was 110/70 mmHg, heart-frequency 72 bpm, body temperature 37 °C and laboratory tests indicated a mild leukocytosis with neutrophilia, low monocytes and lymphocytes. The local examination showed a regular vagina without pathological loss, a posterior cervix and a soft uterine body. On abdominal examination she presented right back pain; Giordano’s test was positive at the same side. At ultrasound evaluation, she presented dilatation of the right renal pelvis and proximal ureter, and palpable inguinal lymph nodes at the same side, as well as good fetal parameters. She was hospitalized with the diagnosis of right renal colic. A treatment with antibiotics, antiemetics and antalgic drugs was started. The day after admission her conditions get worse, and she presented temperature (37.8 °C). This time abdominal US showed moderate fluid in all quadrants.
So, the patient was taken for emergency exploratory laparotomy. We decided to perform laparotomy in consideration of her two previous cesarean section and the possible difficulties we could have found due to adhesions. Intraoperatively we found out a diffuse purulent peritonitis secondary to acute appendicitis. Appendix was even dislocated in the retrocecal site. Appendicectomy and thorough abdominal washing were performed. The postoperative course was normal. The patient’s symptoms regressed. She was treated with large spectrum antibiotics for seven days. Histological examination found acute purulent appendicitis.
The patient was discharged on the 8th day after surgery and was constantly followed by our Division. At 39 weeks of pregnancy she underwent cesarean section. This time we found a clean abdominal cavity, without signs of inflammations or adhesions. A healthy female child, weighting 3.300 gr, was born. The surgery was uneventful, the postoperative course and her blood exams were normal. The patient and her baby were discharged home three days after cesarean section in healthy conditions.
In cases such as the one of the present case report diagnosis may be even more difficult. Appendicular compromise should be kept in mind when a pregnant woman in which appendix is dislocated in the retrocecal site, presents with an unclear back pain. In these patient’s decisions about surgery become more challenging, because most of the signs of appendicitis as pain or hyperemesis are also found during normal pregnancy period. Surgery is usually unavoidable, but what type of technique, laparoscopy or laparotomy has to be used, is still debated. Laparoscopic surgery for pregnant women is usually considered safe, with low rate of intraoperative complications in all trimesters , but it is associated with significantly higher rate of fetal loss compared to laparotomic appendectomy .
To the midwives Mrs Maria Pia Arcese and Mrs Tina Facchini for their collaboration and logistic support.
Conflict of Interest
No conflict of interest.
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Note: The Pregistry website includes expert reports on more than 2000 medications, 300 diseases, and 150 common exposures during pregnancy and lactation. For the topic Peritonitis, go here. These expert reports are free of charge and can be saved and shared.
Peritonitis, one of the causes of so-called acute abdomen, is a condition in which the inner lining of the abdominal cavity, called the peritoneum, becomes inflamed. It’s usually caused by an infection of some kind, most often bacterial, but fungal and viral infections may also be to blame. If you are concerned that you might have peritonitis, read on to learn more about the symptoms, causes, and treatment options for this disease.
Recognize the symptoms
The symptoms of peritonitis (listed below) are good to know, but if you’re pregnant, you may notice something unfortunate: some of these symptoms are actually par for the course during pregnancy. Except in the case of fever or not making urine—both of which are dangerous and should be addressed immediately with a health professional—it’s tough to know whether you’re experiencing the normal discomforts of pregnancy or whether there might be something more serious going on.
One way is to differentiate peritonitis symptoms from normal pregnancy complaints is to tune in to both the onset of the symptom and its severity. For most people, pregnancy discomforts come and go. While they can be overwhelming and really uncomfortable, they’re not often excruciatingly painful. If you experience any of the listed symptoms in a way that comes on suddenly or feels out of the norm for you and your pregnancy, please call your doctor or midwife. Perhaps nothing is wrong and you get reassurance, but maybe you can get checked out and catch a problem before it becomes more serious.
Look out for the following symptoms:
Peritonitis can be caused by bacterial, fungal, or viral infections, or occasionally by a reaction to chemicals in the environment. Another common causes of peritonitis is a perforated appendix following untreated acute appendicitis.
Know the causes
As discussed briefly above, peritonitis can be caused by bacterial, fungal, or viral infections, or occasionally by a reaction to chemicals in the environment. Another common causes of peritonitis is a perforated appendix following untreated acute appendicitis—an inflammation of the appendix that can present differently in pregnant women. You’re used to hearing about appendicitis manifesting as pain on the lower right side of the abdomen, but the truth is that as your baby and uterus grow and push other things in your abdomen out of the way, that pain might feel very different. Therefore, any severe abdominal pain should be discussed with your care provider as soon as possible, so that it can be addressed before it gets more serious. The chances of developing peritonitis go up if your appendix bursts. You can also learn more about appendicitis during pregnancy in this blog post from The Pulse.
How is peritonitis treated?
If you are diagnosed with peritonitis, your care providers will likely try to determine the cause. If it’s appendicitis, you will probably have surgery. If not, your doctors may do a biopsy of your peritoneum in order to see whether your peritonitis is caused by a bacterium, fungus, or virus. If it’s caused by a fungus or a bacterium, you’ll likely receive antifungals or antibiotics. It’s likely also that you’d stay in the hospital while you are receiving treatment and until your symptoms improve.
If you’ve been diagnosed with peritonitis, try not to worry. In the case studies that are available to read online, pregnant women who get treatment as soon as possible tend to continue with otherwise healthy pregnancies and have healthy babies.
For instance, in a study published in Archives in Biomedical Engineering & Biotechnology in January 2019, a 40-year-old woman who was 23 weeks pregnant developed peritonitis caused by acute appendicitis. After receiving surgery and antibiotics, she recovered and returned home, eventually having a healthy baby girl by cesarean section at 39 weeks of pregnancy.
In another example, published in the Journal of Medical Case Reports in January 2014, a 31-year-old woman 22 weeks along in her pregnancy had abdominal pain in the six months leading up to her diagnosis. She also received antibiotics specific to the bacterial strain causing her peritonitis, which reduced her symptoms, and later gave birth to a healthy baby boy. In this example, the patient initially attributed her abdominal discomfort to pregnancy, until it became so severe that it no longer seemed consistent with a normal, healthy pregnancy.
Tuberculous peritonitis in pregnancy: a case report
This article has been cited by other articles in PMC.
Tuberculous peritonitis is one of the least common forms of extrapulmonary tuberculosis. In the literature, few cases in pregnancy have been previously published. Tuberculous peritonitis in pregnancy is a diagnostic challenge, especially in the absence of lung involvement. It mimics other diseases and clinical presentation is usually non-specific, which may lead to diagnostic delay and development of complications.
We report here a new case of tuberculous peritonitis that occurred in a 31-year-old Caucasian pregnant woman at 22 weeks' gestation. She was complaining of abdominal pain, nausea and vomiting. These symptoms appeared 6 months prior to presentation. Initially, they were attributed to pregnancy, but they progressively became more severe during subsequent weeks. A laparoscopy showed the presence of yellow-white nodules on the peritoneal surface and a biopsy demonstrated caseous necrotic granuloma. She made a good physical recovery after being placed on antituberculous chemotherapy and gave birth to a healthy male neonate of 3100g at 37 weeks' gestation by vaginal delivery.
Extreme vigilance should be used when dealing with unexplained abdominal symptoms to ensure timely diagnosis of tuberculous peritonitis. Diagnosis often requires a histopathological examination. In these patients early diagnosis with early antituberculous therapy are essential to prevent obstetrical and neonatal morbidity.
Keywords: Diagnosis, Laparoscopy,Peritoneal tuberculosis, Pregnancy
Peritoneal tuberculosis is one of the least common forms of extrapulmonary tuberculosis . Few cases of tuberculous peritonitis in pregnancy have been recorded. In these patients early diagnosis is important to prevent obstetrical and neonatal morbidity . We report here a new case of tuberculous peritonitis that occurred in a Caucasian pregnant woman at 22 weeks' gestation. The diagnostic and therapeutic problems are discussed, and the relevant literature is briefly reviewed.
A 31-year-old primigravida woman (22 weeks’ pregnant) presented at our Maternity Department complaining of abdominal pain, nausea and vomiting. These symptoms appeared 6 months ago. Initially, they were attributed to pregnancy, but they progressively became more severe during subsequent weeks. A clinical examination revealed a cachectic conscious anicteric woman with mild fever (38°C). The cardiovascular and pleuropulmonary examination were normal. Her abdomen was distended, deep tenderness was elicited in both iliac fossae, and a fluid thrill with shifting dullness confirmed the presence of intraperitoneal free fluid. An abdominal ultrasound confirmed the pregnancy and showed intra-abdominal fluid, mainly in her lower abdomen and a thickened peritoneum (Figure 1). No ovarian mass was identified on ultrasound. A laboratory investigation showed mild normochromic and normocytic anemia (hemoglobin level 10g/dL) and high C-reactive protein without leucocytosis. Her liver function was normal. Serology of viral hepatitis (B and C) and human immunodeficiency virus (HIV) were negative. Of tumor markers, only cancer antigen 125 (CA-125) was found to be high (500U/mL). Ascitic fluid was exudative with a white cell count of 860/mm3 (lymphocyte dominant: 480/mm3). Her serum-ascites albumin gradient was calculated to be 0.9. Ziehl–Neelsen stain which was investigated in three samples of sputum and in ascitic fluid was negative. The result of a tuberculin skin test was positive. The chest X-ray picture showed no active lesion or old lesion compatible with pulmonary tuberculosis. A diagnostic laparoscopy showed multiple extensive yellow-white nodules on her peritoneal surface with miliary deposits on the intestine (Figure 2), and the biopsy demonstrated caseous necrotic granuloma (Figure 3). She was prescribed antituberculous chemotherapy with rifampicin, isoniazid, and pyrazinamide for 2 months and 4 months of rifampicin-isoniazid. She was given pyridoxine supplementation (25mg/day). After 4 days her general condition improved significantly and her pregnancy continued without any problem. At term a spontaneous vaginal delivery occurred of a live healthy male neonate weighing 3100g. Treatment was well tolerated during pregnancy and after delivery we saw no adverse effects of antituberculosis therapy in either the mother or the neonate.
Peritoneal tuberculosis is an uncommon site of extrapulmonary infection caused by Mycobacterium tuberculosis. The risk is increased in patients with cirrhosis, HIV, diabetes mellitus, malignancy, following treatment with anti-tumor necrosis factor and peritoneal dialysis . It is estimated that the incidence of peritoneal tuberculosis among all forms of tuberculosis varies from 0.1% to 0.7% worldwide . Few cases of tuberculous peritonitis in pregnancy have been recorded, suggesting that it is rare . Infection occurs most commonly following reactivation of latent tuberculous foci in the peritoneum that were established from hematogenous spread from a primary lung focus. It can also occur via hematogenous spread from active pulmonary or miliary tuberculosis. Much less frequently, the organisms enter the peritoneal cavity transmurally from an infected small intestine or contiguously from tuberculous salpingitis . The clinical manifestations of tuberculous peritonitis progress insidiously. Pain, fever, chills, weight loss and abdominal pain are common complaints . In pregnant women, diagnosis of tuberculosis may be delayed by the non-specific nature of early symptoms and because they are often attributed to pregnancy . In pregnant women with suggestive symptoms and signs of tuberculosis, a tuberculin skin test should be carried out. This has since been accepted to be safe in pregnancy . A chest radiograph with abdominal lead shield may be done after the tuberculin skin testing, although pregnant women are more likely to experience a delay in obtaining a chest X-ray due to concerns about fetal health . Microscopic examination of sputum or other specimen for acid-fast bacilli remains the cornerstone of laboratory diagnosis of tuberculosis in pregnancy. Three samples of sputum should be submitted for smear, culture, and drug-susceptibility testing . The traditional culture on Lowenstein–Jensen’s medium may take 4 to 6 weeks to obtain a result. This may, however, still be useful in cases of diagnostic doubts and management of suspected drug-resistant tuberculosis . Molecular line probe assay as well as the use of polymerase chain reaction is presently facilitating the specific identification of the tubercle bacilli . As in our patient, the most common clinical presentation of peritoneal tuberculosis is ascites; the fluid is exudate (protein >2.5g/dL) with predomination of mononuclear cells, however 10% of patients may have an initial neutrophilic response . Bacteriologic examination of the ascitic fluid is not always diagnostic: acid-fast smears are rarely positive in tuberculous peritonitis, and conventional cultures yield the pathogen in only 25% of cases . Tuberculous peritonitis may be mistaken for ovarian carcinoma or peritoneal carcinomatosis . Elevation of the serum CA-125 (increased levels indicate ovarian cancer) in pregnancy is not pathognomonic because the serum level of CA-125 can be elevated even in benign diseases including peritonitis . However, the levels of CA-125 have been less than 500U/mL, and it could be used as a follow-up marker in patients treated for peritoneal tuberculosis . The presence of adenosine deaminase activity is also a useful test in the diagnosis: levels above 33U/L are 100% sensitive and 95% specific to the diagnosis . The sensitivity of a computed tomography (CT) scan in the prediction of tuberculosis is 69%. Patients with tuberculosis were likely to show mesenteric changes, macronodules (>5mm in diameter), splenomegaly, and splenic calcification on CT imaging . Accurate diagnosis requires histopathological examination following image-guided biopsy, laparotomy or laparoscopy . Bacteriologic examination of the biopsy specimen should be performed, because this could be positive for tuberculosis when histological examination is negative [11,12]. For the treatment of tuberculosis in pregnant women, the initial regimen should be isoniazid, rifampin, and ethambutol for at least 6 months. Although teratogenicity data for pyrazinamide are limited, it is probably safe to use in pregnancy ; in this case the treatment was well tolerated during pregnancy and after delivery and we saw no adverse effect of antituberculosis therapy in the mother or in the neonate. Breastfeeding should not be discouraged for women receiving antituberculosis treatment. Pyridoxine supplementation (25mg/day) is recommended for all pregnant and breastfeeding women taking isoniazid .
Tuberculous peritonitis in pregnancy is a diagnostic challenge, especially in the absence of lung involvement. It mimics other diseases and clinical presentation is usually non-specific, which may lead to diagnostic delay and development of complications. Extreme vigilance should be used when dealing with unexplained abdominal symptoms to ensure timely diagnosis of tuberculous peritonitis. Diagnosis often requires a histopathological examination. Early diagnosis with early antituberculous therapy are essential to prevent obstetrical and neonatal morbidity.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
CA: Cancer antigen; CT: Computed tomography; HIV: Human immunodeficiency virus.
The authors declare that they have no competing interests.
LM, MK and BJ analyzed and interpreted the patient data and wrote the manuscript. All authors have read and approved the final manuscript.
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In pregnancy peritonitis
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