診断的腹腔鏡が有用であった肝硬変合併結核性腹膜炎の1例

Tuberculous peritonitis associated with liver cirrhosis diagnosed by effective laparoscopic examination

◆要旨：患者は70歳代，男性．C型肝硬変の経過中に腹水貯留をきたし入院した．肝性腹水を考え，利尿薬投与を行ったが反応不良であった．鑑別のために施行した腹水穿刺にて滲出性腹水があり，白血球分画や腹水中ADA高値より結核性腹膜炎を強く疑い，診断的腹腔鏡を施行した．腹腔内観察にて腹膜に白色粟粒結節を認め，腹膜生検検体の病理組織検査で多数のLanghans巨細胞，類上皮細胞肉芽腫を認めた．腹膜組織の結核菌DNA（PCR）陽性であり，結核性腹膜炎と診断した．

　肝硬変患者の腹水貯留は肝性腹水を安易に疑ってしまうが，腹水検査を行い本症が疑われる場合は，積極的に診断的腹腔鏡を施行することが重要であると示唆された．

　A 73-year-old male was hospitalized due to the accumulation of ascites in the course of HCV antibody positive liver cirrhosis. Despite the diuretic administration under the diagnosis of hepatic ascites, its response was poor. For differential diagnosis, abdominal puncture was performed. The result showed exudative ascites with lymphocytic predominance in differential count of leukocytes and high value of Adenosin Deaminase（ADA）. Tuberculous peritonitis was suspected and diagnostic laparoscopic examination was performed. White military nodes were observed on the peritoneal membrane, and histopathological examination of the biopsied tissue of the membrane showed abundant Langhans giant cells and epithelioid cell granulomas. Tuberculosis bacterium DNA was positive by the PCR analysis in the tissue, confirming the diagnosis of tuberculous peritonitis.

　Hepatic ascites is highly suspected for patients with liver cirrhosis showing accumulation of ascites. However, even in such patients, it is important to perform abdominal puncture. Diagnostic laparoscopic examination is also effective especially when tuberculous peritonitis is suspected.