Laparoscopic partial hepatectomy for the treatment of hepatic tuberculosis: A case report

Abstract

BACKGROUND

Hepatic tuberculosis is rare, and is difficult to diagnose in the early stage of the disease. It is easily masked by the symptoms of pulmonary tuberculosis or other types of tuberculosis, and is often misdiagnosed as hepatitis, liver cancer or liver abscess. At present, there is a lack of relevant epidemiological statistics on the incidence of liver tuberculosis. However, the incidence of liver tuberculosis worldwide is approximately 3.5% of extrapulmonary tuberculosis.

CASE SUMMARY

A 52-year-old male patient underwent laparoscopic partial hepatectomy with release of intestinal adhesions due to hepatic tuberculosis. Prior to surgery, the patient had a past history of pulmonary tuberculosis, which was currently controlled by oral streptomycin and isoniazid. The patient had low fever and night sweats before surgery. Tuberculosis antibody was positive before surgery. Following surgery, the patient’s computed tomography reexamination showed that the liver mass had disappeared, and the symptoms of low fever and night sweats were significantly reduced. Postoperative pathological results showed that the patient had manifestations of tuberculosis and was eventually diagnosed with hepatic tuberculosis. Hepatic tuberculosis is a rare extrapulmonary tuberculosis, which is characterized by abdominal pain, abdominal mass, low-grade fever, night sweats, etc. Following surgical resection, the liver mass disappeared, and the patient was discharged on the seventh postoperative day. He required regular oral anti-tuberculosis drugs after discharge.

CONCLUSION

The specificity and sensitivity of laboratory tests for hepatic tuberculosis are low. Hepatic tuberculosis is difficult to distinguish from fatty liver, viral hepatitis and liver cancer.

Key Words: Hepatic tuberculosis; Laparoscopic partial hepatectomy; Extrapulmonary tuberculosis; Mycobacterium tuberculosis; Case report

Core Tip: We report a patient with hepatic tuberculosis who underwent laparoscopic partial hepatectomy. Following surgery, the patient’s symptoms of fever and abdominal pain were significantly improved.

INTRODUCTION

When the normal immune system of the human body is destroyed due to large doses of glucocorticoids, severe viral infection or human immunodeficiency virus, etc., this may result in low immunity and, such as the use of large doses of glucocorticoids, severe viral infection, and the attack of human immunodeficiency virus, etc., then Mycobacterium tuberculosis can pass through the intestine, stomach, lymphatic vessels, etc., via the blood stream, or due to lymph nodes near the portal vein being ruptured by external causes. This allows Mycobacterium tuberculosis to successfully enter the liver and bile system, and cause liver disease[1,2]. The main reason for the occurrence of secondary liver tuberculosis is reduced immunity. At present, there are few reports on laparoscopic partial hepatectomy for hepatic tuberculosis.

CASE PRESENTATION

Chief complaints

The patient was a 52-year-old woman with the main symptoms of low-grade fever, abdominal pain, low-grade fever, and night sweats.

History of present illness

The patient developed pain in the right upper quadrant of the abdomen without obvious inducement 20 days previously. The pain was intermittent and dull, lasting approximately 2 hours each time, but was tolerable. This was accompanied by low fever and night sweats. Maximum body temperature was 38.3 °C. The patient was diagnosed and treated in Mianyang Central Hospital, and no significant improvement was observed after antibiotic treatment.

History of past illness

The patient was diagnosed with tuberculous peritonitis in a local hospital one year ago. He received long-term isoniazid and rifampicin. No reexamination was carried out.

Personal and family history

The patient had no special medical history and no significant family history.

Physical examination

On physical examination, the patient was conscious and cooperative. The abdomen was soft, with mild tenderness in the right upper quadrant, and there was no obvious rebound or muscle tension.

Laboratory examinations

Laboratory tests showed the following: Hemoglobin 131 g/L, white blood cell count 6460/μL; platelet count 272 × 10⁹/L; high-sensitivity C-reactive protein 35.79 mg/L; procalcitonin 0.060 ng/mL; albumin 39.9 g/L; prealbumin 112 mg/L. Preoperative tuberculin antibody test, purified protein derivative of tuberculin (PPD) skin test, acid fast staining of sputum smear and sputum culture were negative.

Imaging examinations

Abdominal enhanced computed tomography (CT) showed that the medial segment of the left lobe of the liver was clumpy with a slightly low density shadow, an unclear boundary with the surrounding area, uneven internal density, the lesion was approximately 6.4 cm × 3.7 cm in size with a thick wall, uneven continuous circular medium enhancement on the enhanced scan, and a nodular enhancement shadow in the arterial phase. A small amount of perihepatic effusion and slight thickening of adjacent peritoneum were observed (Figure 1). The middle hepatic veins and major hepatic arteries were not invaded by the tumor.

Figure 1 Enhanced computed tomography. A and B: Arterial enhancement phase and portal vein phase of preoperative enhanced computed tomography (arrow).

FINAL DIAGNOSIS

Liver tuberculosis.

TREATMENT

The relevant auxiliary examinations were completed before surgery. Intraoperative ultrasonography again confirmed a hard mass with a diameter of 4 cm × 4 cm and poor mobility in the medial left lobe of the liver. Laparoscopic partial hepatectomy was performed without vascular anastomosis and hepaticojejunostomy. The operation was successfully performed without blood transfusion (Figure 2). The operation time was 207 minutes, and the estimated blood loss was less than 50 mL.

Figure 2 Preoperative and postoperative changes in liver tuberculosis. A: Preoperative (arrow); B: Postoperative (arrow).

OUTCOME AND FOLLOW-UP

Ostoperative laboratory tests showed that the patient’s liver function and coagulation function were only mildly abnormal: Albumin 30.6 g/L; aspartate aminotransferase 159 U/L; plasma prothrombin time 13.3 seconds; prothrombin time activity 65.1%. The patient was discharged six days after surgery, and no recurrence or metastasis was observed during follow-up 1 month, 3 months, and 6 months after surgery (Figures 3 and 4).

Figure 3 Enhanced computed tomography. A and B: Changes in the arterial enhancement phase and portal phase of enhanced computed tomography following hepatic tuberculosis resection (arrow).

Figure 4 The postoperative pathological specimens were consistent with tuberculoma-like changes (magnified 200 times under the microscope).

DISCUSSION

Hepatic tuberculosis is a mycobacterial infection that can occur secondary to tuberculosis due to bile inhibition and liver immune dysfunction. Liver tuberculosis is often occult, and can be divided into nodular type, miliary type and tuberculoma type. Miliary type is the most common type. Hepatoduodenal ligament lymph node tuberculosis is an abdominal lymph node tuberculosis, which can be spread by the blood, lymphatic tract or direct invasion of neighboring organs. Hepatic tuberculosis and hepatoduodenal ligament lymph node tuberculosis can clinically manifest as fever, fatigue, night sweats and other symptoms, and laboratory tests can show accelerated sedimentation rate and positive tuberculin test, but these tests are not specific; thus, the diagnosis is difficult[3].

Liver tuberculosis is very rare and usually occurs due to tuberculosis spread via the hepatic artery or intestinal tuberculosis spread via the portal vein[4].

At present, the classification of hepatic tuberculosis is confusing. Levine classified hepatic tuberculosis into miliary tuberculosis, cumulative pulmonary tuberculosis, primary hepatic tuberculosis, focal tuberculoma or abscess, and tuberculous cholangitis[5]. Shekhar divided liver tuberculosis into common miliary type-related liver tuberculosis, primary miliary type liver tuberculosis, primary liver tuberculosis tumor or abscess, and 50%-80% of liver tuberculosis is common miliary type, while the proportion of primary liver tuberculosis is less than 1%. Common miliary type is spread by Mycobacterium tuberculosis via the hepatic artery, while primary liver tuberculosis is often formed via the portal vein. Hilar vein blood oxygen is low, which is one of the reasons why primary liver tuberculosis is rare[6].

The basic pathological changes in hepatic tuberculosis are chronic granulomatous inflammation, which can be manifested as caseous necrosis, liquefaction necrosis, fibrosis and calcification at different pathological stages. In these different pathological states, the imaging features of liver tuberculosis are different[7,8]. Liver tuberculosis is divided into diffuse type, mass type, abscess type and calcification type by ultrasound, and the diffuse type is characterized by diffuse hyperechoic lesions. The pathological features of mass type are chronic granuloma and caseous necrosis. The ultrasound images show low echoic lesions, a clear boundary and uneven internal echoes. The pathology of abscess type is liquefaction necrosis in the center of the granuloma. The ultrasonographic manifestations are central anechoic or hypoechoic, the internal echo is not uniform, there are internal multiple strong echo spots, accompanied by sound shadows behind, indicating punctal calcification. Calcification type is characterized by strong echoic clusters with clear boundaries, followed by sound shadows, and is the result of fibrosis and necrotic calcification of the lesion[9,10].

Although the diagnosis of primary hepatic tuberculosis is difficult, attention should be paid to the following conditions: Young patients with chronic low fever, wasting, anemia, and hypoproteinemia; Patients with a history of tuberculosis; Color ultrasound/CT/magnetic resonance imaging indicated that the infection was accompanied by scattered internal calcification[11,12]. Tuberculosis antibody detection, PPD, acid fast staining of sputum smear and sputum culture should be performed for the above patients. If the results of the above tests are negative, a puncture biopsy of the mass is required, and when the diagnosis is confirmed, medical treatment is required[13]. A liver puncture biopsy provides a definite diagnosis of the liver nodules. If puncture biopsy fails to confirm the diagnosis or a malignant mass is suspected, laparoscopic exploration can be performed[14]. If an abscess is found, incision and drainage and tissue biopsy are required. If a solid mass is present, a partial hepatectomy is performed and a rapid intraoperative pathologic examination is necessary to determine whether lymph node dissection should be performed. Anti-tuberculosis therapy is routinely given after surgery[15,16]. All patients included in the present study received regular anti-tuberculosis therapy after surgery.

CONCLUSION

Appropriate surgical intervention and regular postoperative anti-tuberculosis therapy are effective in treating liver tuberculosis.