Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 
Home Print this page Email this page Small font size Default font size Increase font size Users Online: 4


 
  Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 18  |  Issue : 1  |  Page : 17-18  

Obstructive jaundice due to tuberculosis of distal CBD and periampullary region mimickcholangiocarcinoma


Nil Ratan Sirrcar Medical College and Hospital, Kolkata, India

Date of Web Publication30-Apr-2012

Correspondence Address:
Sajib Chatterjee
143/1 D South Sinthi Road, Kolkata - 700 050
India
Login to access the Email id


DOI: 10.4103/1117-6806.95478

PMID: 24027386

Get Permissions

  Abstract 

Abdominal tuberculosis (TB) commonly affects the intestinal tract, lymph nodes, peritoneum, and solid organs in varying combinations. Hepatobiliary or pancreatic TB is rare and the preoperative diagnosis is difficult. Though rare, there have been a few citations of intrahepatic tuberculosis, but isolated bile duct tuberculosis is extremely rare. Here we report a case of obstructive jaundice which was initially thought to be due to lower-end cholangiocarcinoma but postoperatively it was found to be tuberculosis.

Keywords: Bile ducts, obstructive jaundice, tuberculosis


How to cite this article:
Ray S, Chatterjee S, Saha AK, Samanta S. Obstructive jaundice due to tuberculosis of distal CBD and periampullary region mimickcholangiocarcinoma. Niger J Surg 2012;18:17-8

How to cite this URL:
Ray S, Chatterjee S, Saha AK, Samanta S. Obstructive jaundice due to tuberculosis of distal CBD and periampullary region mimickcholangiocarcinoma. Niger J Surg [serial online] 2012 [cited 2014 Sep 21];18:17-8. Available from: http://www.nigerianjsurg.com/text.asp?2012/18/1/17/95478


  Background Top


Abdominal tuberculosis (TB) commonly affects the intestinal tract, lymph nodes, peritoneum and solid organs in varying combinations. Hepatobiliary or pancreatic TB is rare and the preoperative diagnosis is difficult. There are few citations of intrahepatic tuberculosis, but isolated bile duct tuberculosis is extremely rare. We report a case of obstructive jaundice due to tuberculosis of distal common bile duct (CBD) and periampullary region with clinical features mimicking cholangiocarcinoma.


  Case Report Top


A 55 year old north Indian male patient presented with history of painless progressive jaundice for 6 months and few episodes of intermittent fever for 3 months. There was loss of appetite and weight loss of 5 kg over the previous 6 months. There was no history of hematemesis or malaena. The patient did not drink alcohol, was a non smoker, and nondiabetic.

His performance status was 80% on Karnoffsky scale. On clinical examination, the patient was deeply jaundiced with pallor; no lymph nodes were palpable. He had mild hepatomegaly with palpable gallbladder. Blood parameters were as follows: Hemoglobin 8.9 g%, total bilirubin 18.4 mg/dl (conjugated12.4, unconjugated 6.0), alkaline phosphatase 850, aspartate aminotransferase 110, alanine aminotransferase 85. Viral markers for hepatitis were nonreactive. Serology for HIV I and II was nonreactive.

Ultrasonography showed dilated proximal (CBD) with dilated intrahepatic biliary radicles and soft tissue shadow in lower end of CBD. There were multiple echogenic shadows in proximal CBD.

Endoscopic retrograde cholangio pancreatogram (ERCP) revealed a stricture at the lower end of CBD, biliary stenting was not possible through the tight stricture.

Magnetic resonance cholangio pancreaticogram (MRCP) showed soft tissue lesion in the terminal end of CBD suggestive of cholangiocarcinoma.

Guided FNA from the lesion for cytological evidence was not carried out.

Surgical resection for lower end CBD stricture was planned and a pylorus preserving pancreaticoduodectomy (PPD) was successfully carried out. Intraoperative findings did not suggest any metastasis or stigma of tuberculosis.

Postoperative recovery was complicated by minor pancreatic leakage and wound infection. Oral feeding (fluids) was resumed on third postoperative day and the patient was able to eat normal diet by 7 th postoperative day. Within 2 weeks, the pancreatic leakage dried up and abdominal drains were removed.

Histopathology revealed granulomatous inflammation at lower end of CBD and periampullary region along with granulomatous lymphadenitis, both consistent with tuberculosis.

The patient was started on antitubercular medication (four drug regime of INH, rifampicin, pyrazinamide, and ethambutol) without significant adverse effects. He had a steady recovery - his serum alkaline phosphatase and bilirubin level reaching normal values by 8 th postoperative week.

The patient is on follow up for the last 7 months, has gained weight and doing well.


  Discussion Top


Abdominal tuberculosis is common in the Indian subcontinent and tropical countries. It usually affects intestine, mesentery, lymph nodes, and peritoneum, but involvement of hepatobiliary system is rare. Isolated tubercular involvement of common bile duct and ampulla is extremely rare and only a few cases have been reported in published literature. [1],[2],[3],[4],[5]

Tuberculosis of lower end of common bile duct and periampullary region often forms pseudotumor [6] and strictures mimicking cholangiocarcinoma. Clinically the patients present with features of obstructive jaundice. Preoperative diagnosis of tuberculosis as the cause of obstructive jaundice is extremely difficult. There are several proposed investigations for accurate preoperative diagnosis, e.g., ERCP with brush cytology and PCR for tuberculosis of the bile sample, FNAC, and frozen section. However, in most of the cases, diagnosis is reached in the postoperative period by the histological finding of caseation necrosis and epitheloid granuloma formation.

The disease responds well to antitubercular medications. Diagnostic difficulties often compel major resectional surgery such as pancreatoduodenectomy and final diagnosis is established with histopathology. However, if preoperative diagnosis is established, major surgery can be avoided and the disease cured with antitubercular medications. [7] Prognosis is excellent.


  Conclusion Top


Tuberculosis should be considered as a cause of obstructive jaundice in endemic regions.

 
  References Top

1.Chong VH, Telisinghe PU, Yapp SK, Jalihal A. Biliary strictures secondary to tuberculosis and early ampullary carcinoma. Singapore Med J 2009;50:e94-6.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Pombo F, Soler R, Arrojo L, Juega J. US and CT findings in biliary obstruction due to tuberculous adenitis in the periportal area. 2 cases. Eur J Radiol 1989;9:71-3.  Back to cited text no. 2
[PUBMED]    
3.lvarez SZ. Hepatobiliary tuberculosis. J Gastroenterol Hepatol 1998;13:833-9.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Kohen MD, Altman KA. Jaundice due to a rare cause: Tuberculous lymphadenitis. Am J Gastroenterol 1973;59:48-53.  Back to cited text no. 4
[PUBMED]    
5.Murphy TF, Gray GF. Biliary tract obstruction due to tuberculous adenitis. Am J Med 1980;68:452-4.  Back to cited text no. 5
[PUBMED]    
6.Adsay NV, Basturk O, Klimstra DS, Klöppel G. Pancreatic pseudotumors: Non-neoplastic solid lesions of the pancreas that clinically mimic pancreas cancer. Semin Diagn Pathol 2004;21:260-7.  Back to cited text no. 6
    
7.Inal M, Aksungur E, Akgul E, Demirbas O, Oguz M, Erkocak E. Biliary tuberculosis mimicking cholangiocarcinoma: Treatment with metallic biliary endoprothesis. Am J Gastroenterol 2000;95:1069-71.  Back to cited text no. 7
    




 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Background
Case Report
Discussion
Conclusion
References

 Article Access Statistics
    Viewed794    
    Printed117    
    Emailed0    
    PDF Downloaded53    
    Comments [Add]    

Recommend this journal