Intestinal and Liver Tuberculosis Treatment in Indore
The most common presenting symptoms of hepatic TB are hepatomegaly, fever, respiratory symptoms, abdominal pain, and weight loss; splenomegaly, ascites, and jaundice may also be seen but are less common. Diffuse abdominal pain is more common in localized hepatic TB, whereas respiratory symptoms (such as cough with or without sputum production) are more common in miliary hepatic TB. The relatively nonspecific presentation makes the diagnosis difficult in the absence of a high index of suspicion. Alkaline phosphatase elevations and hyponatremia usually are prominent features. Inverted albumin to globulin ratio (A/G), in which serum globulin is 1.25 to 1.86 times higher than serum albumin, is common. In 65% to 78% of patients with hepatic TB, respiratory symptoms or chest radiographs suggest pulmonary TB as well. Abdominal computed tomography imaging shows multiple hypodense micronodules throughout the liver or hepatomegaly without nodules, whereas in localized TB it shows one large solitary nodule or 2 to 3 hypodense nodules. Liver calcifications are seen in approximately half of the patients. Presentation with acute liver failure is rare but has been reported.
Liver biopsy with mycobacterial culture is considered the most specific diagnostic test for hepatic TB. Caseating granulomas are a hallmark of hepatic TB (seen in 51% to 83% of cases), particularly miliary TB in the setting of primary infection; in reactivation TB, noncaseating granulomas may be present instead. The granulomas may reside in the lobules or in portal tracts; the former location may be more common in miliary TB, whereas the latter may be more common in localized TB. In TB-endemic countries, such as Iran, India, and Saudi Arabia,
TB is the most common cause of hepatic granulomas (accounting for approximately 50%), as opposed to non–TB-endemic countries where histoplasmosis, sarcoidosis, or PBC are more common etiologies. Sinusoidal congestion and peliosis hepatis may also be seen.
Acid-fast bacilli (AFB) smears are positive in 0% to 59% of cases (median 25%), and organisms are more likely to be found with caseating necrosis, but smears may be positive due to infection from nontuberculous mycobacteria. Cultures provide the strongest evidence of hepatic TB, but the sensitivity may be less than 10%.
Histologic evidence of caseating granulomas has a median sensitivity of 68% (range: 14% to 100%) and is generally sufficient to establish the diagnosis in TB-endemic areas. PCR for M. tuberculosis DNA has a 53% to 88% sensitivity and a 96% to 100% specificity for detecting hepatic TB.
Immunocompromised patients may present with a wasting syndrome in which multiple organs, including the liver, contain necrotic miliary nodules surrounded by histiocytes that do not aggregate into well-formed granulomas. AFB stain shows numerous organisms in these lesions.186 Prompt initiation of four-drug anti-TB therapy should lead to clinical improvement in most patients with hepatic TB.