S1802 Obstructive Jaundice Secondary to Hepatic Hilar Tuberculosis

Introduction: Tuberculosis is an infectious disease caused by mycobacterium tuberculosis. It usually involves the lung, but extrapulmonary involvement is not uncommon. Hepatobiliary tuberculosis is a rare form of extrapulmonary tuberculosis that can be mistaken for hepatic hilar malignant tumors. Case Description/Methods: A 38-year-old gentleman, originally from India, presented to the hospital with right upper quadrant pain for 10 days that was associated with itching, and dark urine; he had no history of fever or weight loss. He was a cigarette smoker but has no history of alcohol drinking; he was not taking any medications. On examination, he was vitally stable. His sclera was icteric, and his abdomen was soft with no tenderness. His laboratory investigations were remarkable for direct hyperbilirubinemia with elevated AST, ALT, and ALP (Table). His ultrasound abdomen showed mildly prominent central intrahepatic biliary duct and prominent upper CBD (measuring 9 mm) with no obvious cholelithiasis. Magnetic resonance cholangiopancreatography (MRCP) showed narrowing in the CBD with a cluster of necrotic conglomerate peripancreatic lymph nodes. Endoscopic ultrasound (EUS) demonstrated a 24x19 mm lesion that is adjacent to the pancreatic head and neck, at the liver hilum, compressing the proximal CBD (Figure). EUS-guided fine-needle biopsy showed necrotizing granulomatous inflammation. TB PCR and culture from the same lesion were positive, and the patient was started on an anti-TB medication regimen. Discussion: Extrapulmonary tuberculosis can be associated with pulmonary tuberculosis or occur in an isolated form. The absence of constitutional and pulmonary symptoms makes the diagnosis more challenging. Few cases reported compression of the common bile duct due to tubercular hilar adenopathy leading to obstructive jaundice. In such cases, the endoscopic ultrasound plays an important role in obtaining a tissue biopsy to establish the diagnosis and to exclude malignant hepatic hilar tumors that can present in a similar fashion.Figure 1.: Endoscopic ultrasound images showing the tuberculous lymphadenopathy in close proximity to the common bile duct. Table 1. - Laboratory investigations Laboratory test Patient's value Normal range WBC 6.50 × 109/L 4.5 - 11 Hgb 15.3 gm/dL 13.0 - 17.0 Platelet 298 × 109/L 150 - 400 Creatinine 1 mg/dL 0.7 to 1.3 Total bilirubin 79.70 µmol/L 3.50 - 24 Direct 46.30 µmol/L 0.0 - 5.10 ALT 478.20 U/L 0.0 - 40.0 AST 270 U/L 0 - 37 Alkaline phosphatase 413 U/L 40.0 - 129.0 CRP 11.20 mg/L 0.0 - 5.0 Hepatitis C Ab Non-reactive Non-reactive Hepatitis B Surface Ag Non-reactive Non-reactive