Liver tuberculosis
Introduction
Introduction to liver tuberculosis Liver tuberculosis (tuberculosisoftheliver) is relatively rare, due to the lack of specific symptoms and signs, so the rate of clinical misdiagnosis and mistreatment is higher. Most of the liver tuberculosis is a part of the whole body miliary tuberculosis, which is called secondary hepatic tuberculosis. The patient mainly presents with clinical manifestations caused by tuberculosis such as extrahepatic lung and intestine. Generally, there is no clinical symptoms of liver disease. After anti-tuberculosis treatment, intrahepatic tuberculosis It can be cured, and it is difficult to make a diagnosis of liver tuberculosis clinically. basic knowledge The proportion of illness: 0.002% Susceptible people: no specific population Mode of infection: droplet infection Complications: jaundice fatty liver abdominal pain shock peritonitis liver abscess hypersplenism abdominal mass ascites
Cause
Causes of liver tuberculosis
Pathogen infection (50%):
Mycobacterium tuberculosis belongs to actinomycetes, Mycobacterium genus of mycobacteria, and is a pathogenic acid-tolerant bacteria. It is mainly divided into human, cattle, bird, and mouse. People who are pathogenic to humans are mainly human. Bacteria, bovine bacteria rarely infected, tuberculosis morphology is slender and curved, both ends are obtuse, no spores or capsules, no flagella, length of about 1 ~ 5m, width of 0.2 ~ 0.5m, scattered or formed in the specimen Heap or arranged in a chain shape, Mycobacterium tuberculosis is an aerobic bacteria, does not multiply in the absence of oxygen, but can still survive for a long time, under good conditions, about 18 ~ 24h breeding generation, bacterial lipid composition It accounts for 1/4 of its weight. It is acid-resistant when dyed. Tuberculosis is very resistant to dryness and strong acid and strong alkali. It can exist in the external environment for a long time. It can survive for 20~30h in the sputum. Survival for 6-8 months, but the resistance to damp heat is very low, boil for 5min or direct exposure in the sun for 2h to kill, UV disinfection effect is better, human and bovine tuberculosis strains are obligate parasites, Human and bovine are the natural storage hosts, respectively, which have the same intensity for humans, monkeys and guinea pigs. The resistance of tuberculosis to drugs can be formed by the development of congenital drug-resistant bacteria in the flora, or it can be produced quickly by using an anti-tuberculosis drug alone in the human body. Drug-resistant bacteria and drug-resistant bacteria can cause treatment difficulties and affect the curative effect. The long-term exposure of Mycobacterium tuberculosis to streptomycin can also produce dependence, that is, the so-called Lai medicine, but Lai medicine is rare in clinical practice.
Liver tuberculosis is caused by a variety of extrahepatic tuberculosis bacteria spread to the liver, sometimes because the primary liver outside the small or has recovered, can not detect the primary lesion, according to statistics can find the original lesion only accounted for 35% .
Pathogenesis
Liver blood supply and lymphatic richness, tubercle bacilli generally entering the human body can reach the liver, but the liver has strong regeneration and repair ability, and has a rich mononuclear phagocytic system. Bile also inhibits the growth of tuberculosis, so it is not invading the liver. Tuberculosis can form lesions, and liver tuberculosis is more likely to occur when the body's immune function is low or a large number of tuberculosis invades the liver or the liver itself has certain pathological changes such as fatty liver, liver fibrosis, cirrhosis or drug damage.
In recent years, the incidence of liver tuberculosis in human immunodeficiency virus (HIV) infected patients or their patients has increased significantly, suggesting that cellular immunity plays an important role in the development of liver tuberculosis.
The ways in which Mycobacterium tuberculosis invades the liver are: 1 Hepatic artery: the main pathway for causing liver tuberculosis, disseminated tuberculosis in the whole body, or active tuberculosis in any part of the body, due to decreased immunity or due to some local factors. Tuberculosis lesions rupture, Mycobacterium tuberculosis enters the blood circulation, enters the liver through the hepatic artery, 2 portal veins: a small number of liver tuberculosis can be infected through the portal vein, organs or tissue at the source of the portal system, tuberculosis such as intestinal tuberculosis or mesenteric lymph node tuberculosis Portal vein invades the liver, 3 umbilical veins: Mycobacterium tuberculosis in fetal placental tuberculosis lesions enters the fetus through the umbilical vein to cause congenital hepatic tuberculosis, 4 lymphatic system: intrahepatic lymphatic vessels directly communicate with the peritoneal lymphatic plexus and retroperitoneal lymph nodes, so Intra-abdominal tuberculosis can form infections through the lymph into the liver, 5 direct spread: tuberculosis lesions adjacent to the organs of the liver can directly invade the liver.
The basic pathological changes of liver tuberculosis are granulomas, which can be developed into different pathological types due to the difference in the number of invasive tuberculosis, location and immune function status. Generally, it can be divided into: 1 miliary type: the most common, systemic blood line Part of disseminated miliary tuberculosis, the lesion is miliary size up to 2cm, hard, white or grayish white multiple nodules, widely distributed in the whole liver, this type of disease is serious, clinical diagnosis is difficult, mostly during autopsy or laparotomy Found, 2 nodular type: less common, lesions are more limited, forming more than 2 ~ 3cm, hard, grayish white single or multiple nodules, and even into a mass, resembling a tumor, also known as tuberculoma, 3 abscess : The center of tuberculosis necrosis forms white or yellow-white cheese-like pus, which can be single or multiple. The abscess is mostly single room, and the multiple rooms are rare. 4 bile duct type: tuberculosis lesions involving the bile duct or abscess into the bile duct to form bile duct tuberculosis , manifested as thickening of the bile duct wall, ulcer or stenosis, this type is rare, 5 liver serosal type: manifested as hepatic capsule miliary tuberculosis or hyperplasia of capsule formation The "sugar-coated liver" is relatively rare.
Prevention
Liver tuberculosis prevention
1. Control of infectious sources: The discovery and management of infectious sources is an important link in the prevention and treatment of tuberculosis. Early detection and early treatment should be done. For this reason, collective lung health check should be carried out regularly, and a registration management system should be implemented.
2. Cut off the route of transmission: management and treatment of the patient's sputum, the main method is: carry out mass health campaigns, widely publicize the knowledge of flood control, develop good health habits, do not spit, TB patients should vomit Burn on paper, or cough in a cup to add 2% coal phenol soap or 1% formaldehyde solution (about 2h to sterilize), the contact directly exposed to sunlight (sterilized for several hours).
3. Vaccination with BCG: Inoculation of BCG can enhance the body's resistance to tuberculosis, which is conducive to the prevention of tuberculosis. At present, China is vaccinated with BCG vaccine after birth, and the negative ones are added. For ethnic minorities, border residents entering the inland cities, or new recruits, the tuberculin test must be carried out, and the negative ones should be vaccinated with BCG.
Complication
Hepatic tuberculosis complications Complications jaundice fatty liver abdominal pain shock peritonitis liver abscess spleen function hyperthyroidism abdominal ascites
1. Astragalus: generally mild or moderate, mostly persistent, a few may have fluctuations, and more often associated with acute fulminance, the reasons are:
(1) Tuberculosis lymph nodes compress the extrahepatic bile duct.
(2) Intrahepatic tuberculous granuloma destroys the liver parenchyma or ruptures to the bile duct.
(3) The small bile duct in the liver is blocked.
(4) toxic liver cell damage, fatty liver, etc., specific to a patient, may be caused by several factors.
The terminal stage of chronic disseminated tuberculosis and tuberculosis is associated with liver tuberculosis, and 80% of them have jaundice, indicating that Huang Qi said that the condition is serious.
2. Hepatomegaly: The vast majority of patients have hepatomegaly (76% to 95%), of which 2 to 6 cm under the rib are more common (42%), the liver surface is mostly medium hardness, and generally smooth, a few There are obvious nodules, the liver may have tenderness, sometimes tuberculosis involves the liver capsule, and there is friction sound. If there is intrahepatic tuberculous abscess formation, liver pain and tenderness are more obvious; when the abscess ruptures, there is often severe abdominal pain, shock and peritonitis. The cause of hepatomegaly, tuberculous liver abscess, tuberculoma, tuberculous granuloma, non-specific reactive hepatitis, fatty liver, amyloidosis.
3. Splenomegaly: About half of the cases, the swelling is more significant, mostly under the ribs 0.5 ~ 9cm, can also exceed the umbilicus, splenomegaly associated with liver tuberculosis generally indicates spleen tuberculosis, mainly due to infiltration of tuberculous granuloma And the proliferation of spleen medulla cells, splenomegaly often accompanied by hypersplenism, the three blood formation components have varying degrees of reduction.
4. Ascites and abdominal mass: mainly due to tuberculous peritonitis and lymph node tuberculosis.
Symptom
Hepatic tuberculosis symptoms Common symptoms Unexplained fever, night sweats, cachexia, liver surface, calcification, jaundice, low heat, loss of appetite, lack of oxygen, lack of stress, coma, ascites
The main symptoms of this disease are fever, loss of appetite, fatigue, liver area or right upper quadrant pain and hepatomegaly, fever in the afternoon, sometimes accompanied by chills and night sweats; those with low fever also have relaxation type, high fever up to 39 ~ 41 °C, 91.3% of people with fever symptoms, those who have tuberculosis or have a history of tuberculosis, long-term repeated fever, and exclude other causes, often have the possibility of liver tuberculosis.
Hepatomegaly is the main sign, more than half of which have tenderness, hepatic hard, nodular mass; about 15% of patients may have mild jaundice due to nodular compression of the liver and bile duct, and 10% of cases have ascites.
Examine
Liver tuberculosis examination
Laboratory inspection
1. Blood: The total number of white blood cells is normal or low, a small number of patients can be increased, and even leukemia-like reactions occur. More than 80% of patients have anemia, and erythrocyte sedimentation rate is often accelerated.
2. Liver function test: ALT, ALP and bilirubin increased, there may be albumin reduction, globulin increased.
3. Serum anti-tuberculosis pure protein derivative (anti-PPD) IgG antibody determination: positive results can aid diagnosis.
4. Skin test: skin test including OT (old tuberculin) or PPD (purified protein derivative), continuous observation for 12h, positive for diagnostic reference.
5. Liver biopsy: the diagnosis of diffuse or miliary lesions is of great value.
6. Bacteriology examination: Anti-acid staining of liver tissue sections obtained by puncture or surgery to find Mycobacterium tuberculosis, the positive rate of bacterial lesions of miliary lesions can reach 60%.
7. Polymerase chain reaction (PCR): amplification of Mycobacterium tuberculosis DNA in vitro: PCR technology has been used for the diagnosis of tuberculosis, in addition to the detection of Mycobacterium tuberculosis DNA in body fluids and effluents, but also for detection Mycobacterium tuberculosis DNA in biopsy pathological specimens, this technology is still developing, and it is expected to improve the diagnostic level of liver tuberculosis.
Physical examination
1. X-ray abdominal plain film: intrahepatic calcification may be found, and 48.7% of patients with liver tuberculosis have intrahepatic calcification.
2. B-ultrasound: Hepatic enlargement and large lesions in the liver can be found, and the lesion can be examined under the guidance of the lesion.
3. CT scan: can detect intrahepatic lesions.
4. Abdominal examination: yellow-white point-like or flaky lesions on the surface of the liver can be found, and the lesions are taken under direct vision for further examination of pathology and bacteriology.
5. Exploratory laparotomy: Individual difficult cases, if necessary, can obtain a clear diagnosis through surgical approach.
Diagnosis
Diagnosis and diagnosis of liver tuberculosis
Diagnostic criteria
The clinical manifestations of liver tuberculosis lack specificity, difficult diagnosis, young adults with unexplained fever, liver enlargement, liver area or upper abdominal pain, liver function damage, anemia, suspected and the disease, white blood cells can be reduced Or normal, increased erythrocyte sedimentation rate, toxin test can be positive, but severe cases can be negative, nearly half of patients can be diagnosed by liver biopsy, if necessary, laparotomy or early application of anti-tuberculosis drugs experimental treatment.
Differential diagnosis
It needs to be differentiated from hepatitis, typhoid fever, malaria, brucellosis, chronic schistosomiasis, and leptospirosis.
