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Review Article
Hepatobiliary Tuberculosis
Sanjay Bandyopadhyay1, Pranab K Maity2
Abstract
Hepatobiliary tuberculosis refers to the localized form of hepatic tuberculosis and is a distinct entity in which
hepatobiliary involvement overwhelmingly dominates the clinical picture. Presentations are often delayed,
and manifestations can be nonspecific. Fever is the most common symptom followed by abdominal pain, and
hepatomegaly is the most common abnormality found on clinical examination. Abnormalities of the liver function
tests are non-specific and hence not diagnostic. Ultrasound or computed tomography reveals single or complex
masses, and guided biopsy is diagnostic either by demonstrating caseating granuloma or the organism by staining
and culture. Treatment is with standard first-line antituberculous drugs. Endoscopic stenting gives an excellent
outcome for symptomatic biliary strictures. The outcome in patients infected with Human Immunodeficiency
virus depends on the level of underlying immunosuppression.
Special Issues
Hepatobiliary tuberculosis in HIV infection
There has been a resurgence of tuberculosis in recent years,
primarily because of acquired immunodeficiency syndrome
(AIDS), and 50% of AIDS patients diagnosed with tuberculosis
Fig. 2 : ERCP showing stricture at mid-CBD caused by extrinsic have extrapulmonary involvement.31 AIDS patients may run
compression from tuberculous lymph nodes an unusually aggressive course. Unusual forms of hepatic
Magnetic resonance cholangiopancreatography (MRCP) has tuberculosis are more common as also high rate of disseminated
now replaced endoscopic retrograde cholangiopancreatography disease, drug resistance and adverse drug reactions.11 The
(ERCP) or percutaneous transhepatic cholangiography (PTC) comparative incidence of M tuberculosis versus M avium-
as a diagnostic tool for biliary involvement.24 The bile ducts intracellulare complex in various series differs greatly owing
involved shows irregular tortuous stricture with marked to the fact that these infections occur in different stages of
proximal dilatation.14,24 While this cholangiographic appearance immunosuppression. Geographic, racial and socioeconomic
is difficult to differentiate from malignancy, the presence of factors may also influence these differences in comparative
associated scattered hepatic calcifications favors the diagnosis incidence.31
of tuberculosis.1 Alternatively, the common bile duct may
appear beaded (19% in one series), with areas of dilatation and Tuberculosis occurring in liver transplant patients
constriction.25 Obstruction is usually found at porta (67-86%) Both pediatric and adult liver transplant recipients appear
or at distal bile duct (14-33%).25 Constriction at the proximal to be at risk because of their immunosuppressed state. The
common bile duct or the hepatic ducts is rarely reported. prevalence of new onset tuberculosis in liver transplant
Biliary tract involvement in the majority of cases is due to recipients is 0.7% over five year period. However, tuberculosis
enlarged tuberculous lymph nodes located periductally at the is a rare cause of hepatic granuloma in post-transplant patients.32
hepatoduodenal ligament and at the porta hepatis (Figure 2).26 Of greater concern is the risk of hepatotoxicity associated with
Direct tubercular involvement of biliary epithelium is rare.27 isoniazid therapy or prophylaxis. Hepatic enzyme abnormalities
ERCP or PTC is restricted for use in jaundiced patients with associated with drug therapy can be confused with transplant
therapeutic intentions.25 rejection.32
Associated and coincidental hepatic lesions)
Treatment Nearly 30% patients dying of cirrhosis have demonstrable
Hepatobiliary tuberculosis is a treatable infection. Successful tuberculous infections.33 Korn et al suggested that the fatty
therapy, however, requires an accurate microbiologic diagnosis changes in the liver in patients with hepatic tuberculosis may
and compliance with a regimen of demonstrated efficacy.11 be the result of concomitant alcohol ingestion.19 Alcohol also
The treatment regimen does not differ from that of pulmonary increases the risk of hepatotoxicity from INH and other anti-
tuberculosis. Initially, quadruple therapy (containing isoniazid, tuberculous therapy.34 Cirrhosis has been described as a possible
rifampicin, pyrazinamide and ethambutol) is recommended risk factor for the development of drug-resistant tuberculosis.34
for at least two months due to increasing incidence of drug In patients with underlying liver disease, ofloxacin may be better
resistance.11 Total duration of therapy is generally one year. than traditional antituberculous therapy.34
For those patients with obstructive jaundice, in addition to Hepatic injury due to ATT
the use of ATT, biliary decompression should be done by stent
placement during ERCP.28 Strictures resulting from biliary INH causes acute hepatocellular jaundice in about 1% of all
involvement or hepatic tuberculoma tend to be multiple and recipients, and at least 10% experience more trivial anicteric
may require multiple stent placements. Conversely, lymph node hepatic injury.34 Clinical features are indistinguishable from
compression tends to be at the hilum and is usually singular, acute viral hepatitis.34 Case fatality rate may be as high as 10%.34
making stenting an ideal treatment.2 Percutaneous drainage The mechanism appears to be metabolic idiosyncrasy rather
may be used as a temporary measure and later combined with than hypersensitivity. Risk factors are advanced age, female
endoscopic internalization of the stents. Surgery is attempted sex, alcoholism, concomitant use of other hepatotoxic drugs or
if there is dilated proximal common bile duct or hepatic ducts rifampicin and pyrazinamide.34
accessible for biliary-enteric anastomosis.1 Rifampicin increases the likelihood of INH-induced hepatic
Prognostic factors for adverse outcome include age younger injury but occasionally can itself produce acute idiosyncratic
than 20 years, acute presentation, coagulopathy, and high injury. It can also interfere with bilirubin uptake and excretion
mean caseation score.6 The outlook of patients with AIDS is as a benign physiologic effect.
problematic. The level of underlying immunosuppression Pyrazinamide also potentiates hepatotoxicity of INH and
appears to be the most important variable influencing long-term rifampicin. Case fatality rate is higher (compared to those not
survival in this group.29 receiving pyrazinamide) and the survival is inversely related to
A good clinical response is documented by reduction in the the time to onset of jaundice.34
size of the liver, and increases in appetite and weight gain.1 Tuberculosis of the gallbladder
Quadruple therapy results in response in 67%.5 Despite ATT, The gallbladder is an uncommon site of tuberculous infection.
406 © JAPI • june 2013 • VOL. 61
Journal of the association of physicians of india • june 2013 • VOL. 61 47
The majority of patients are women over 30 years of age.35 and Wilkins. Philadelphia, pp 537-47.
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