Hepatobiliary tuberculosis in the developing world

ARTICLE HIGHLIGHTS

Research background

Tuberculosis (TB) is a highly contagious airborne disease caused by Mycobacterium tuberculosis (M. tuberculosis), and its transmission occurs through the air. The Center for Disease Control has identified several factors affecting TB transmission, including the susceptibility of exposed individuals, infectiousness of TB patients, environmental conditions, and proximity and duration of exposure. Once infected, tubercle bacilli can spread throughout the body, leading to various manifestations, including hepatobiliary tuberculosis (TB affecting the liver and biliary system). Early diagnosis and appropriate treatment of hepatobiliary TB are crucial for preventing complications and ensuring patient safety. Hepatobiliary TB has a significant prevalence, especially in developing countries, and specific populations are at increased risk, such as non-US-born individuals and those with HIV infection, low socioeconomic status, or exposure to TB in high-risk settings.

Research motivation

The main focus of this study is to investigate the spread of M. tuberculosis into the liver, specifically in the context of hepatobiliary TB. Early diagnosis and appropriate management are essential to prevent severe complications and reduce mortality rates associated with TB infection. Addressing the discrepancies in TB treatment outcomes between developed and developing countries is crucial to improving global health and reducing mortality risks, particularly for individuals in low-income countries. Moreover, the high prevalence of TB in certain regions and the challenges posed by multi-drug-resistant TB necessitate urgent action and innovative approaches to combat this public health crisis. By examining hepatobiliary TB in the Philippines and understanding the unique challenges faced in the region, this study aims to contribute to TB control efforts and improve patient outcomes.

Research objectives

The main objectives of this study include identifying common symptoms and laboratory findings associated with hepatobiliary TB to facilitate early detection and diagnosis. By understanding the clinical features and laboratory data, healthcare providers can promptly initiate appropriate diagnostic procedures to confirm hepatobiliary or miliary tuberculosis. The study aims to provide recommendations for expediting TB treatment and improving patient safety and recovery rates. Additionally, the research seeks to shed light on the challenges of TB diagnosis and treatment delays, particularly in developing countries, and identify potential strategies to reduce such delays and enhance patient care. By analyzing liver function test results and imaging findings, the study intends to enhance the evaluation of hepatobiliary TB, leading to more effective management strategies. Through these objectives, the research strives to contribute to the overall efforts to eliminate TB by 2030, as outlined by the World Health Organization.

Research methods

This study conducted a systematic review following PRISMA guidelines to summarize cases of hepatobiliary tuberculosis (HBTB). The research question was framed, and relevant studies were identified using specified search terms without language restrictions. Clinical presentation, diagnostic modalities, interventions, treatment, and outcomes were recorded from selected case reports published between 1992 and 2022. The study quality was assessed based on selection criteria, including histopathologic confirmation and clear outcomes. Data were extracted using a standardized form, and discrepancies in study selection were resolved. The clinical presentation, diagnostic modalities, and acid-fast bacilli detection were analyzed. Medical and surgical management approaches were documented, and outcomes were categorized as improved, recovered, or deceased. The collected materials were carefully assessed for credibility and reliability, focusing on peer-reviewed papers. Descriptive statistics were used to characterize the data, and a narrative synthesis approach was employed to interpret the findings and address diagnostic challenges related to hepatobiliary/miliary tuberculosis.

Research results

The systematic review of 38 case reports and case series on HBTB revealed important findings. Clinical presentation commonly included fever and abdominal pain (37.50%), along with weight loss (29.17%), jaundice (25.00%), and anorexia (16.67%). Hepatomegaly and/or hepatic nodules were observed in 37.50% of the cases, with liver enzyme and bilirubin levels playing a role in further diagnostic investigations. Comorbidities such as pulmonary tuberculosis, gastric cancer, and systemic lupus erythematosus were identified in the patient population. Delays in seeking treatment were observed in five patients, underscoring the importance of early detection and timely intervention. Surgical intervention was required for one patient. Medical management was the primary treatment approach for HBTB, with a combination of Rifampicin, Ethambutol, Isoniazid, and Pyrazinamide being commonly used. The majority of patients (58.33%) showed improvement, 16.67% fully recovered, and 16.67% succumbed to the disease, with delayed diagnosis and septic shock being contributing factors to mortality. The study contributes valuable insights into the clinical presentation, management, and outcomes of HBTB, emphasizing the significance of timely interventions to improve patient prognosis. Further research is needed to address the challenges associated with delayed diagnosis and management to reduce morbidity and mortality rates in HBTB cases.

Research conclusions

This systematic review contributes to the understanding of hepatobiliary tuberculosis by highlighting its clinical presentation and diagnostic challenges, particularly in developing countries with limited resources. It sheds light on the association between miliary tuberculosis and hepatobiliary tuberculosis, with or without pulmonary involvement. The study emphasizes the importance of early detection and timely intervention to improve patient outcomes. The research proposes a systematic approach for managing hepatobiliary tuberculosis and miliary tuberculosis. It recommends using ultrasound as an initial screening tool, followed by computed tomography scan if needed, for detecting hepatomegaly and hepatic nodules. Liver biopsy is crucial in confirming hepatobiliary tuberculosis and distinguishing it from other liver diseases. The study emphasizes the use of a high index of suspicion and bedside procedures for obtaining tissue diagnosis.

Research perspectives

The direction of future research should focus on addressing the challenges in diagnosing hepatobiliary tuberculosis, especially in countries with a high incidence of tuberculosis. Improving diagnostic tools and methods in resource-limited settings is crucial to facilitate early detection and timely treatment. Additionally, further studies should explore the association between miliary tuberculosis and hepatobiliary tuberculosis to better understand the disease’s pathogenesis and clinical manifestations. Research efforts should also aim to identify risk factors associated with delayed diagnosis and management, leading to better strategies for reducing morbidity and mortality rates. Furthermore, investigating the efficacy and safety of different treatment regimens for hepatobiliary tuberculosis will help optimize therapeutic approaches and improve patient outcomes. Collaborative efforts among researchers and healthcare providers are essential in eradicating tuberculosis and implementing effective management protocols worldwide.