Tuberculous peritonitis (TBP) is a continuing problem in populations with high prevalence of tuberculosis and is difficult to diagnose early. Here, we report a case of confirmed TBP that presented as intestinal ileus and pneumatosis intestinalis. The 79-year-old woman had a history of atrial fibrillation, chronic ischemic heart disease, and chronic renal failure (chronic kidney disease, stage V). She complained of abdominal fullness and pain for 1 week prior to hospitalization. A computed tomography (CT) scan revealed pneumatosis intestinalis. Laparoscopic surgery was performed, and multiple whitish nodules covering the peritoneum were discovered. Biopsy results were consistent with caseating granulomatous inflammation. A modified anti-tuberculosis regimen (isoniazid, 300 mg daily; rifampicin 600 mg daily; ethambutol 800 mg three times per week; and pyrazinamide 1200 mg three times per week) was initiated, stabilizing the condition of the patient. The total duration of anti-tuberculosis therapy was 12 months, with patient condition gradually improving to normal. The elderly, uremic patients recovered fully after the modified anti-tuberculosis regimen for 12 months. For clinical practice, we developed a decision-making algorithm for patients suspecting TBP.