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HEPATIC TUBERCULOSIS
OP Kapoor
Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
A Abdominal tuberculosis (TBs) is protean in its manifestation. TBs of the pancreas, however is rarely seen. All the other abdominal organs can be affected by the disease.In the past TBs of the liver was not highlighted. It was not referred to in a discussion of abdominal TBs Why was this so? Was it infrequent or uncommon? Is there a change in pattern with TBs infections of the intestines becoming less than those solid organs like the liver and spleen. Perhaps it is on account of the newer imaging techniques of the liver which detect more and more cases of TBs of the liver.
Many years ago, in the autopsy room, I had observed four types of TBs of the liver in cases of abdominal TBs These were:
1. Liver looking absolutely normal to the naked eye with no gross pathology whatsoever. However histopathology of section taken as a routine showed a tuberculous hepatitis.
2. Liver showing small miliary lesions. These, in the absence of other tuberculous lesions at the autopsy, could not be differentiated from secondary malignant deposits or lymphomas, except by recourse to histopathology.
3. Liver with multiple nodular lesions, of the size of pea. These again could not be differentiated from secondaries or lymphomas, except again by histology.
4. A huge single or two solid abscesses which
could not be differentiated from solid amoebic abscesses. Only when histopathology showed tuberculous granulomas, did we label them retrospectively as "tuberculomas". Some of these lesions were solid but others had caseous pus.
How does TBs of the Liver present clinically?
Group I - The presentation is with PUO and often an associated hepatomegaly.
No imaging can diagnose Group I cases. Only if a liver biopsy is done in every case of PUO, such cases will be picked up.
Group II cases are a similar problem. All the modem imaging techniques like an isotope liver scan, sonography, CT scan and MRI will miss these miliary lesions. It is however worth keeping in mind, that laparoscopy would pick up these lesions. Adequate liver biopsy tissue taken under direct vision helps in differentiating this from other causes of PUO by histopathology.
Group III is one group where CT scan or MRI imaging will pick up the lesions. It is uncommon for these lesions to be picked up on isotope Ever scan or sonography. Again, it is always advisable to do a laparoscopy and take a biopsy under vision.
Group IV - Any form of imaging like sonography or isotope liver scan can pick up the lesion. The first diagnosis thought of in such cases is amoebic liver abscess or a malignant deposit. Only a shrewd clinician who is aware of this form of TBs would investigate to exclude a tuberculous aetiology. These investigations would include any other site of abdominal TBs X-ray of the chest may show an old shadow of Koch's. A Mantouxtest and finally, histopathology of the liver tissue taken with closed liver biopsy or preferably with the help of laparoscopy will help.
Nowadays you cannot afford to miss TB of the liver. Although most of the antituberculous drugs are hepatotoxic, they bring about a dramatic relief,
only when-combined with steroids. Rarely surgery may be required in cases of Group IV to enucleate the solid necrotic tissue especially if the response to medical treatment is poor. In others, aspiration of yellow thick pus combined with chemotherapy o TB should suffice.
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