Obstructive jaundice caused by biliary tuberculosis: spectrum of the diagnosis and management

Tuberculosis (TB) of the Porta Hepatis Presenting with Obstructive Jaundice Mimicking a Malignant Biliary Tumor: A Case Report and Review of the Literature

Localized hepatobiliary tuberculosis (TB) is a rare disorder which can present with an obstructive jaundice mimicking other noninfectious causes such as cholangiocarcinoma. Here, we report a case of porta hepatis tuberculosis in 19-year-old female who presented with an obstructive jaundice, and her computed tomography (CT) of the abdomen revealed a hepatic hilar mass with radiological features mimicking a malignant biliary tumor. We also review the literature related to this disorder.

Tubercular biliary hilar stricture: A rare case report

Localized hepatic tuberculosis (TB) with or without bile duct involvement is a rare form of hepatobiliary tuberculosis; accounting for less than 1% of all tuberculous infections. We report an uncommon case of cholestatic jaundice with disseminated TB in an immunocompetent male who presented with simultaneous involvement of liver and biliary system.

Tuberculosis of the Liver, Biliary Tract, and Pancreas

Tuberculosis of the liver, biliary tract, and pancreas is discussed. In addition, tuberculosis in the setting of HIV-AIDS and liver transplantation is explored. Drug-induced liver injury secondary to antituberculosis medication and monitoring and prophylactic treatment for such injury is also considered.

Diagnostic value of nucleic acid amplification tests on bronchoalveolar lavage fluid for smear-negative pulmonary tuberculosis: a meta-analysis

Based on current available evidence, NAAT on BALF plays a role in the diagnosis of smear-negative pulmonary tuberculosis, and further studies should be performed to confirm our findings..

The diagnosis of smear-negative pulmonary tuberculosis (SNPT) remains a clinical challenge. Many studies suggest that nucleic acid amplification tests (NAATs) on bronchoalveolar lavage fluid (BALF) plays a role in diagnosing SNPT, but with considerable varying results. The current study aimed to summarize the overall diagnostic accuracy of NAATs assay on BALF for SNPT. A systematic literature search was performed and data were retrieved. Pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) were calculated. A summary receiver operating characteristic curve and area under the curve (AUC) were used to evaluate the overall diagnostic performance. All the statistical analysis was performed by using STATA 12.0 and Meta-DiSc 1.4 software. A total of nine studies with 1214 subjects were included this meta-analysis. The pooled sensitivity, specificity, PLR, NLR and DOR were 0.54 [95% CI (confidence interval): 0.48–0.59], 0.97 (95% CI: 0.95–0.98), 12.13 (95% CI: 8.23–17.88), 0.36 (95% CI: 0.23–0.56) and 44.71 (95% CI: 22.30–89.63) respectively. The AUC was 0.96. Estimated positive and negative post-probability values for a SNPT prevalence of 20% were 82% and 7% respectively. No publication bias was identified. Current available evidence indicated that NAATs on BALF may play a role in diagnosing SNPT, whereas the results should be interpreted in parallel with clinical information of patients and the results of traditional tests. Further studies should be performed to confirm our findings.

A case of obstructive jaundice caused by tuberculous lymphadenitis: a literature review

Obstructive jaundice caused by tuberculous lymphadenitis is a rare manifestation of tuberculosis (TB), with 15 cases having been reported in Korea. We experienced a case of obstructive jaundice caused by pericholedochal tuberculous lymphadenitis in a 30-year-old man. The patient's initial serum total bilirubin level was 21.1 mg/dL. Abdominal computed tomography revealed narrowing of the bile duct by a conglomerated soft-tissue mass involving the main portal vein. Abrupt obstruction of the common bile duct was observed on cholangiography. Pathologic analysis of a ultrasonography-guided biopsy sample revealed chronic granulomatous inflammation, and an endoscopic examination revealed esophageal varices and active duodenal ulceration, the pathology of which was chronic noncaseating granulomatous inflammation. Hepaticojejunostomy was performed and pathologic analysis of the conglomerated soft-tissue mass revealed chronic granulomatous inflammation with caseation of the lymph nodes. Tuberculous lymphadenitis should be considered in patients presenting with obstructive jaundice in an endemic area.

Tuberculous biliary stricture

Tuberculosis (TB) of the hepatobiliary system is not uncommon, but as a cause of biliary strictures, it is very rare. It poses difficulty in diagnosis and often requires surgical intervention to exclude underlying malignancy. To our knowledge, there are fewer than 20 reported cases in the English literature. We report a 35-year-old Filipino woman who presented with a 3-day history of obstructive jaundice, associated with significant weight loss and anorexia. Computed tomography (CT) revealed dilated intrahepatic biliary system secondary to distal stricture at the confluence of the left and right bile ducts. Magnetic resonance cholangiopancreatography characterised the lesion as an irregular stricturing at several sites in the common bile duct. Incidentally, the scans also showed indeterminate pulmonary nodules in the right lower lobes. CT thorax confirmed bilateral involvement of the lungs. She required percutaneous transhepatic drainage for biliary decompression. Tests on tissue from the lung lesions, the blood, and the bile all confirmed the presence of TB. She was treated with anti-TB medication. This report emphasizes the importance of considering TB as a possibile cause of biliary stricture, especially in South-East Asia.

Biliary tract tuberculosis--a diagnostic dilemma

INTRODUCTION

Most western patients who have not had a previous operation and present with biliary obstruction are thought to have a malignant lesion. However in our country where the disease is common, we found that some of these patients had a tuberculous cause which considerably altered their management as well as their prognosis. We herein present our experience of these patients whom we had operated with a preoperative diagnosis of biliary tract malignancy and discuss, retrospectively, how they might have been detected before operation to have tuberculosis.

METHODS

Between August 1996 and June 2010, we operated on 209 patients with a preoperative diagnosis of carcinoma of the gallbladder and common bile duct. Seven out of these 209 patients had biliary tuberculosis. We retrospectively analyzed the clinical features of these patients from our prospectively maintained database.

RESULTS

There were four males and three females who had a mean age of 54 (32-65) years. The bile duct was involved in four and gallbladder in three patients. In contrast to those with malignancy, patients with tuberculosis had a longer history (122 vs 44 days), an abdominal mass was present less frequently (28% vs 57%), the serum bilirubin was lower (1.6 vs 6 mg/dl), and they also had evidence of tuberculosis elsewhere in the body (28.5%). There was no operative mortality in biliary tract tuberculosis in contrast to 7.5% in biliary tract malignancy.

CONCLUSION

Though tuberculosis of the biliary tract is rare, it needs to be considered in the differential diagnosis of patients with biliary obstruction especially in countries where the disease is endemic.

Role of single-operator peroral cholangioscopy in the diagnosis of indeterminate biliary lesions: a single-center, prospective study

BACKGROUND

Currently available techniques to diagnose indeterminate biliary lesions have many limitations.

OBJECTIVE

To assess the accuracy of single-operator peroral cholangioscopy by using the SpyGlass system to differentiate malignant from benign disease in patients with indeterminate biliary lesions.

DESIGN

Prospective, single-arm, single-center study.

SETTING

Tertiary referral center.

PATIENTS

Thirty-six patients with indeterminate biliary strictures and filling defects who had inconclusive results on previous biliary ductal tissue sampling.

INTERVENTIONS

SpyGlass cholangioscopy with cholangioscopically guided intraductal biopsies.

MAIN OUTCOME MEASUREMENTS

Accuracy of SpyGlass visual impression and SpyBite biopsies for differentiating malignant from benign ductal lesions.

RESULTS

Thirty-six patients (22 men, mean age 48.3 years [range 27-68 years]) with indeterminate stricture and/or filling defects underwent SpyGlass cholangioscopy. Of the 22 patients with a final diagnosis of malignant lesion, cholangioscopic impression was malignant in 21 patients (95%) and benign in 1 patient (5%). Of the 14 patients with a final diagnosis of benign disease, including the 3 patients with common bile duct stones and no stricture, cholangioscopic impression was malignant in 3 patients (21%) and benign in 11 patients (79%). The overall accuracy of SpyGlass visual impression for differentiating malignant from benign ductal lesions was 89% (32/36). The accuracy of SpyBite biopsies for differentiating malignant from benign ductal lesions that were inconclusive on ERCP-guided brushing or biopsy was 82% (27/33) in an intent-to-treat analysis.

LIMITATIONS

No randomized comparison with alternative diagnostic modalities for the nature of biliary strictures.

CONCLUSIONS

SpyGlass cholangioscopy with SpyBite biopsies has a high accuracy with regard to confirming or excluding malignancy in patients with indeterminate biliary lesions.

Tuberculous lymphadenitis as a cause of obstructive jaundice: A case report and literature review

Obstructive jaundice secondary to tuberculosis (TB) is extremely rare. It can be caused by TB enlargement of the head of the pancreas, TB lymphadenitis, TB stricture of the biliary tree, or a TB mass of the retroperitoneum. A 29-year-old man with no previous history of TB presented with abdominal pain, obstructive jaundice, malaise and weight loss. Ultrasonography (US), computer tomography (CT) scan and endoscopic retrograde cholangiopancreatography (ERCP) were suggestive of a stenosis of the distal common bile duct (CBD) caused by a mass in the posterior head of the pancreas. Tumor markers, CEA and CA19-9 were within normal limits. At operation, an enlarged, centrally caseous lymph node of the posterior head of the pancreas was found, causing inflammatory stenosis and a fistula with the distal CBD. The lymph node was removed and the bile duct resected and anastomosed with the Roux-en Y jejunal limb. Histology and PCR based-assay confirmed tuberculous lymphadenitis. After an uneventful postoperative recovery, the patient was treated with anti-tuberculous medication and remained well 2.5 years later. Though obstructive jaundice secondary to tuberculous lymphadenitis is rare, abdominal TB should be considered as a differential diagnosis in immunocompromised patients and in TB endemic areas. Any stenosis or fistulation into the CBD should also be taken into consideration, and biliary bypass surgery be performed to both relieve jaundice and prevent further stricture.

The patient with unexplained elevated serum liver enzymes

The pattern of elevated serum liver enzymes in symptomatic or asymptomatic patients allows for an initial classification of liver diseases into cholestatic or hepatocellular diseases. A female patient with extrahepatic cholestasis due to segmental bile duct strictures and a localized mass lesion within the pancreas is presented. Although many diagnostic procedures were performed in this case the diagnosis was not obtained before surgical laparotomy was initiated with bioptic sampling from bile ducts, lymph nodes and pancreatic tissue. Microscopic examination of the specimen revealed extensive biliary and pancreatic scarring together with periductal infiltrates composed of lymphocytes and plasma cells consistent with sclerosing cholangitis in systemic autoimmune pancreatitis. The patient completely recovered upon treatment with prednisone and azathioprine. The difficult approach to the final diagnosis is discussed in light of established and modern diagnostic tools.

Biliary tuberculosis causing cicatricial stenosis after oral anti-tuberculosis therapy

A 36-year-old Philippine woman presented with dark urine and yellow sclera. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed dilatation of the intrahepatic bile ducts and also showed an irregular stricture of the common hepatic duct at the liver hilum. Histological examination of biopsies from the bile duct revealed epithelioid cell granulomas and caseous necrosis. Tubercle bacilli were then detected on polymerase chain reaction (PCR) testing of the bile, giving the diagnosis of biliary tuberculosis. Although microbiological cure was confirmed, the patient developed cicatricial stenosis of the hepatic duct. She underwent repeated treatments with endoscopic biliary drainage (EBD) tubes and percutaneous transhepatic biliary drainage (PTBD) tubes, and the stenosis was corrected after 6 years. We present a case of tuberculous biliary stricture, a condition that requires careful differentiation from the more common malignancies and needs long-term follow-up due to the risk of post-treatment cicatricial stenosis, although it is rare.

Resolution of tuberculous biliary stricture after medical therapy

Tuberculosis (TB) is a very rare cause of biliary stricture that is difficult to diagnose and usually requires surgical intervention in order to rule out underlying malignant etiology. We report a 56-year-old man presented with jaundice, weight loss and poor appetite. Initial work up showed the dilated biliary system secondary to distal common bile duct stricture. Investigations to define the etiology of this stricture showed inconclusive brush cytology with absent abdominal masses and lymph nodes but enlarged mediastinal lymph nodes. Biopsy from these lymph nodes showed a non-caseating epitheliod granuloma with negative acid fast bacilli (AFB) stain. The patient had a dramatic response to empirical anti-tuberculosis therapy. Six weeks later, culture from lymph nodes was positive for Mycobacterium tuberculosis.

Three months later, follow-up cholangiogram showed complete resolution of the stricture with normalization of liver enzymes 6 mo after starting anti-tuberculosis therapy. Treatment was continued for 12 mo and the patient had a normal life with normal liver enzymes and regression of the mediastinal lymph nodes at the time when he was reported in this paper.

Although 16 cases of tuberculous biliary stricture are available in the English literature, up to our knowledge, this is the second published report of tuberculous biliary stricture, which resolved completely after medical therapy alone and the second reported case from the Middle East. This report emphasizes the importance of keeping TB as a possibility of biliary stricture in this part of the world.

Unusual Cases of Jaundice Secondary to Non-neoplastic Bile Duct Obstruction

Obstructive jaundice secondary to common bile duct stricture is most commonly attributed to malignancy. Here we present three unusual cases that mimicked carcinoma in presentation but were histologically diagnosed as benign inflammatory processes during operative care. The first case was attributed to obstruction-induced chronic pancreatitis secondary to Crohn's disease of the head of the pancreas, the second was due to sarcoidosis within periportal and extrahepatic biliary lymph nodes and distal common bile duct, and the third case was due to tuberculosis of biliary lymph nodes. All were successfully managed surgically, but potentially these patients may have been effectively treated pharmacologically, without the need for invasive surgical intervention, if an earlier diagnosis were available to the clinicians. A retrospective and comparative review of the data of each case demonstrated subtle clues such as multiple enlarged biliary lymph node involvement and only moderately elevated bilirubin levels that pointed toward possible nonmalignant processes.