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Introduction

Hepatobiliary tuberculosis (HBTB) is an uncommon manifestation of Mycobacterium tuberculosis infection. It can present as an isolated involvement of the liver, bile duct, gallbladder, or, more commonly, as part of a disseminated process. HBTB poses a diagnostic challenge due to its varied clinical manifestations and potential for mimicking other hepatic disorders, particularly malignancies. Despite advancements in diagnostic techniques, no finding is considered pathognomonic, making the definitive diagnosis of HBTB reliant on histologic or microbiologic confirmation.

Aims & Methods

The records of patients with bacteriologically confirmed or biopsy-proven HBTB were reviewed for the following data: demographic features, clinical manifestations, laboratory and imaging results, and clinical follow-up. The histologic findings of granulomatous inflammation and Langhan’s type giant cells, identification of acid-fast bacilli, or a positive PCR test result were used to diagnose HBTB.

Results

Eight patients were included; most were male (n = 5), with a mean age of 39.6 years. Three patients had a prior history of treatment for pulmonary TB. Among them, the most common site of hepatobiliary involvement was the liver (n=7), followed by bile ducts (n = 4) and gallbladder (n =1). All patients exhibited extrahepatic involvement, primarily pulmonary (n=7). Three patients had a prior history of treatment for pulmonary TB. The average duration from the onset of symptoms to the initial presentation was 4.8 months. The most common symptoms were abdominal pain and jaundice, followed by weight loss, fever, and anorexia. Most patients presented with a cholestatic pattern of elevation of liver function tests. Other findings include hypoalbuminemia, anemia, and leukocytosis. The most common imaging findings were the presence of lymphadenopathies, followed by intrahepatic biliary dilation, extrahepatic biliary dilation, and hepatic nodules with internal calcifications. All patients were started on anti-tubercular therapy (ATT). Four patients improved with ATT. Two patients developed secondary biliary cirrhosis despite completing ATT. Two patients succumbed to complications, one due to pulmonary embolism and the other to bacterial peritonitis.

Age/Sex	Site/s of Involvement	Other Organ Involvement	History of Prior PTB Treatment	Duration from onset of symptoms to presentation	Imaging Findings	Diagnosis of HBTB	Treatment Outcome
32/M	Liver	Lungs	Yes	2 months	Multiple, hypodense nodular densities with internal calcifications	Biopsy of liver nodule Sputum MTB PCR	Improved
36/F	Gallbladder Bile ducts	CNS Lymph nodes	None	8 months	Gallbladder hydrops Intrahepatic and extrahepatic bile duct ectasia secondary to stricture formation. Retroperitoneal lymphadenopathies	Biopsy of brain mass Bile TB PCR	Improved
39/M	Bile ducts Liver	Lungs Lymph nodes	None	2 months	Multiple, hypodense nodular densities with internal calcifications and hepatic abscess Intrahepatic and extrahepatic bile duct ectasia secondary to stricture formation. Intra-abdominal and retroperitoneal lymphadenopathies	Hepatic abscess AFB staining Sputum AFB staining	Improved
31/F	Liver	Duodenum Lymph nodes Lungs	None	5 months	Multiple, hypodense nodular densities with internal calcifications Intra-abdominal lymphadenopathies	Biopsy of liver nodule	Improved
39/M	Liver Bile ducts	Lungs Lymph nodes	Yes	3 months	Intrahepatic and extrahepatic bile duct ectasia secondary to stricture formation. Hepatic mass with associated capsular retraction Intra-abdominal lymphadenopathies	Biopsy of liver mass	Developed liver cirrhosis
39/M	Liver Bile Ducts	Lungs	None	12 months	Intrahepatic bile duct ectasia secondary to stricture formation. Hepatic mass with internal calcifications	Biopsy of liver mass Bile AFB staining	Developed liver cirrhosis
50/M	Liver Bile Ducts	Lungs Lymph nodes	None	3 months	Hepatic mass with internal calcifications Intrahepatic and extrahepatic bile duct ectasia secondary to stricture formation. Intra-abdominal lymphadenopathies	Biopsy of liver mass Bile AFB staining	Mortality
51/F	Liver	Lungs Lymph nodes	Yes	3 months	Intrahepatic bile duct ectasia secondary to stricture formation. Multiple, hypodense nodular densities with internal calcifications	Biopsy of liver mass	Mortality

Conclusion

The cases presented shed light on the complexities of diagnosing HBTB, emphasizing the importance of histologic or microbiologic testing to ascertain a definitive diagnosis. The importance of a multidisciplinary approach cannot be underscored in these cases. As delineated in this series, HBTB usually presents with non-specific clinical features and often exhibits extra-hepatic involvement, more commonly in the lungs. Although the majority of patients demonstrated a favorable response to ATT, patients can develop complications such as secondary biliary cirrhosis and even fatal outcomes, highlighting the importance of a high index of suspicion, particularly in endemic regions, in avoiding treatment delays and potential complications. Further studies are warranted to better understand the clinical spectrum and optimal management strategies for this uncommon yet significant manifestation of tuberculosis.

References

Sollano JD, Luspo-Quiblat MMB, Ismael AE. Epidemiology and clinical profile of gastrointestinal tuberculosis in the past 10 years. 2000. Philippine Journal of Internal Medicine, 38(2), 108
Chaudhary P. Hepatobiliary tuberculosis. Ann Gastroenterol. 2014;27(3):207-211. PMID: 24976240; PMCID: PMC4073015.
Chong VH. Hepatobiliary tuberculosis: a review of presentations and outcomes. South Med J. 2008 Apr;101(4):356-61. doi: 10.1097/SMJ.0b013e318164ddbb. PMID: 18360350.
Ch'ng LS, Amzar H, Ghazali KC, Siam F. Imaging appearances of hepatic tuberculosis: experience with 12 patients. Clin Radiol. 2018 Mar;73(3):321.e11-321.e16. doi: 10.1016/j.crad.2017.10.016. Epub 2017 Nov 22. PMID: 29174175.
Malikowski T, Mahmood M, Smyrk T, Raffals L, Nehra V. Tuberculosis of the gastrointestinal tract and associated viscera. J Clin Tuberc Other Mycobact Dis. 2018 Apr 14;12:1-8. doi: 10.1016/j.jctube.2018.04.003. Erratum in: J Clin Tuberc Other Mycobact Dis. 2020 Sep 09;21:100177. PMID: 31720391; PMCID: PMC6830173.

CLINICAL FEATURES AND TREATMENT OUTCOMES OF HEPATOBILIARY TUBERCULOSIS: A CASE SERIES AND LITERATURE REVIEW

Tristan Paulo Madrigal 1, Cyruz Jan David 1, Ariane Marielle Valle 1, Mara Teresa Panlilio 1

1 University of the Philippines - Philippine General Hospital, Manila, Philippines

Conference

UEG Week Vienna 2024

Topics

Hepatobiliary

Submission format

Abstract

Session

Clinical features and outcomes in liver disease (Posters)

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

UEG Podcast Episode

UEG Podcast

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The downsides of weight loss drugs (Metabolism)

Carel le Roux, Pradeep Mundre

Published

2024

UEG Mistakes In Articles

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Parenteral nutrition (PN) is the intravenous delivery of nutrients, commonly used to treat intestinal failure (IF). IF occurs when gut function is insufficient to absorb macronutrients, water, or electrolytes, requiring IV supplementation to maintain health. The European Society for Clinical Nutrition and Metabolism (ESPEN) classifies IF into acute (type 1) and chronic (types 2 and 3), with chronic cases often needing long-term home parenteral nutrition (HPN). Although IF is rare, its prevalence in Europe is rising. PN formulations are complex, requiring skilled management by a specialized multi-disciplinary team to avoid complications.

Mistakes in intestinal failure and parenteral nutrition

Samreen Malik, Sarah Williams, Shameer Mehta

Topics

Small Intestine & Nutrition

Citation

Williams S, Malik S and Mehta S. Mistakes in intestinal failure and parenteral nutrition and how to avoid them. UEG Education 2024; 24: 18-23.

Published

2024

UEG Standards and Guidelines

Clinical Practice Guideline

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Main Recommendations

1 ESGE recommends that the initial assessment of patients presenting with acute lower gastrointestinal bleeding should include: a history of co-morbidities and medications that promote bleeding; hemodynamic parameters; physical examination (including digital rectal examination); and laboratory markers. A risk score can be used to aid, but should not replace, clinician judgment.

Strong recommendation, low quality evidence.

2 ESGE recommends that, in patients presenting with a self-limited bleed and no adverse clinical features, an Oakland score of <= 8 points can be used to guide the clinician decision to discharge the patient for outpatient investigation.

Strong recommendation, moderate quality evidence.

3 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and no history of cardiovascular disease, a restrictive red blood cell transfusion strategy, with a hemoglobin threshold of <= 7 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of 7–9 g/dL is desirable.
Strong recommendation, low quality evidence.

4 ESGE recommends, in hemodynamically stable patients with acute lower gastrointestinal bleeding and a history of acute or chronic cardiovascular disease, a more liberal red blood cell transfusion strategy, with a hemoglobin threshold of <= 8 g/dL prompting red blood cell transfusion. A post-transfusion target hemoglobin concentration of >= 10 g/dL is desirable.

Strong recommendation, low quality evidence.

5 ESGE recommends that, in patients with major acute lower gastrointestinal bleeding, colonoscopy should be performed sometime during their hospital stay because there is no high quality evidence that early colonoscopy influences patient outcomes.

Strong recommendation, low quality of evidence.

6 ESGE recommends that patients with hemodynamic instability and suspected ongoing bleeding undergo computed tomography angiography before endoscopic or radiologic treatment to locate the site of bleeding.

Strong recommendation, low quality evidence.

7 ESGE recommends withholding vitamin K antagonists in patients with major lower gastrointestinal bleeding and correcting their coagulopathy according to the severity of bleeding and their thrombotic risk. In patients with hemodynamic instability, we recommend administering intravenous vitamin K and four-factor prothrombin complex concentrate (PCC), or fresh frozen plasma if PCC is not available.

Strong recommendation, low quality evidence.

8 ESGE recommends temporarily withholding direct oral anticoagulants at presentation in patients with major lower gastrointestinal bleeding.

Strong recommendation, low quality evidence.

9 ESGE does not recommend withholding aspirin in patients taking low dose aspirin for secondary cardiovascular prevention. If withheld, low dose aspirin should be resumed, preferably within 5 days or even earlier if hemostasis is achieved or there is no further evidence of bleeding.

Strong recommendation, moderate quality evidence.

10 ESGE does not recommend routinely discontinuing dual antiplatelet therapy (low dose aspirin and a P2Y12 receptor antagonist) before cardiology consultation. Continuation of the aspirin is recommended, whereas the P2Y12 receptor antagonist can be continued or temporarily interrupted according to the severity of bleeding and the ischemic risk. If interrupted, the P2Y12 receptor antagonist should be restarted within 5 days, if still indicated.

Strong recommendation, low quality evidence.

Diagnosis and management of acute lower gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Konstantinos Triantafyllou

Publisher

European Society of Gastrointestinal Endoscopy

Guideline

Clinical Practice Guideline

Topics

Endoscopy

Citation

Endoscopy 2021; 53(08): 850-868

Published

2021

UEG Standards and Guidelines

Clinical Practice Guideline

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Introduction

Ulcerative colitis [UC] is a chronic inflammatory bowel disease [IBD] characterised by colonic inflammation extending to a variable extent from the rectum. Care of the patient with UC requires appropriate input from across the multiprofessional team. These guidelines summarise the recommended medical treatment for adults with UC. Other ECCO guidelines consider the approach to UC diagnosis and monitoring, nursing care, management of disease complications, risk of infection, and technical aspects of surgery. This document was prepared as part of a process that also led to the publication of a related guideline with recommendations on the surgical care of the patients with UC and on the medical aspects of the management of the patient hospitalised with severe UC. ECCO Guidelines on Therapeutics in Ulcerative Colitis: Surgical Treatment.

ECCO Guidelines on Therapeutics in Ulcerative Colitis: Medical Treatment

Tim Raine

Publisher

European Crohn’s and Colitis Organisation

Guideline

Clinical Practice Guideline

Topics

IBD

Citation

Journal of Crohn's and Colitis, Volume 16, Issue 1, January 2022, Pages 2–17

Published

2021

UEG Standards and Guidelines

Clinical Practice Guideline

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Introduction

The introduction and broad use of new immunosuppressive agents, including biologic agents and JAK inhibitors, have revolutionised treatment of inflammatory bowel disease [IBD] in recent decades. With such immunosuppression, the potential for opportunistic infection is a key safety concern. Opportunistic infections pose particular problems for the clinician; they are potentially serious, often difficult to recognise, associated with appreciable morbidity or mortality, and are challenging to treat effectively. The first guideline on opportunistic infections was published in 2009 followed by an update in 2014. New evidence in this field and in vaccination strategies for immunosuppressed IBD patients led the European Crohn’s and Colitis Organization [ECCO] to update the previous consensus on opportunistic infections in IBD. The current document is focused on viral, mycobacterial, bacterial, fungal, and parasitic infections and on vaccination strategies for immunosuppressed IBD patients. The target audience includes IBD specialists, gastroenterologists, surgeons, and paediatricians.

ECCO Guidelines on the Prevention, Diagnosis, and Management of Infections in Inflammatory Bowel Disease

Torsten Kucharzik

Publisher

European Crohn’s and Colitis Organisation

Guideline

Clinical Practice Guideline

Topics

IBD

Citation

Journal of Crohn's and Colitis, Volume 15, Issue 6, June 2021, Pages 879–913

Published

2021

UEG Standards and Guidelines

Clinical Practice Guideline

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Summary

Liver transplantation (LT) is an established life-saving procedure. The field of LT has changed in the past 10 years from several perspectives, with the expansion of indications, transplantation of patients with acute-on-chronic liver failure, evolution of transplant oncology, the use of donations after cardiac death, new surgical techniques, and prioritisation of recipients on the waiting list. In addition, the advent of organ perfusion machines, the recognition of new forms of rejection, and the attention paid to the transition from paediatric to adult patients, have all improved the management of LT recipients. The purpose of the EASL guidelines presented here is not to cover all aspects of LT but to focus on developments since the previous EASL guidelines published in 2016.

Keywords

Liver transplantation, recipient, donor, recurrence, transplant oncology, immunosuppression

EASL Clinical Practice Guidelines on liver transplantation

Publisher

European Association for the Study of the Liver

Guideline

Clinical Practice Guideline

Topics

Hepatobiliary

Citation

Journal of Hepatology, December 2024. vol. 81 | 1040–1086

Published

2024

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