Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis. Although it mainly affects the lungs, it can also spread to other parts of the body, including the abdomen. [1, 2]

In Algeria, the national tuberculosis control program set up since 1962 has reduced the prevalence of pulmonary tuberculosis, but extrapulmonary forms of tuberculosis are constantly increasing, accounting for more than 64.5% of cases. [3]

During the last ten years, several patients have been treated in our establishment for abdominal tuberculosis (peritoneal and/or digestive) and some cases of tuberculosis of the bladder (histological diagnosis), as well as rare cases of tuberculosis of the lymph nodes of the hepatic pedicle responsible for the compression of the bile ducts. 

Tuberculosis of the bile duct is a rare localization, which can occur by dissemination through the blood or by direct extension from nearby infected structures, such as the liver or lymph nodes. [1, 4]

Jaundice is a common symptom associated with weight loss and asthenia.  In the absence of active pulmonary tuberculosis, morphological diagnosis of biliary tuberculosis by imaging is difficult. Bacteriological examination by PCR of endoscopic retrograde bile and/or histopathological study of a possible surgical resection make it possible to confirm the diagnosis by identifying the presence of specific caseous necrosis. Anti-bacillary treatment is sufficient in most cases to eradicate the infection. This condition may simulate neoplastic stenosis such as cholangiocarcinoma. [5]

Bile stenosis can be managed by endoscopy retrograde cholangiopancreatography (ERCP). In case of failure of this pathway, surgery remains the only therapeutic option to resect the stenosis and perform a biliodigestive bypass.

In the following section, we report the case of a patient treated for tuberculosis of the bile duct discovered during iterative biliary repair.

A 40-year-old patient was referred to our care for the management of postoperative biliary stenosis following laparoscopic cholecystectomy. The histopathological study of the cholecystectomy piece concluded chronic cholecystitis. The consequences were marked by disturbances of liver function (cholestasis and cytolysis), and the occurrence of early jaundice. The morphological assessment was in favor of biliary stenosis associated with a subhepatic biliary collection (CT scan and MRI). Surgical drainage of the bilious effusion was performed by the same team without any clinical improvement. In fact, symptomatology (jaundice, pruritus, cytolysis and cholestasis) worsened, which is why the patient was referred to us. The CT scan, MRI, and ERCP objectified biliary stenosis under convergence (Figure 1 a, b c, d).

Figure 1 (a, b, c, d):  MRI, CT scan, and ERCP shows biliary stenosis and biliodigestive fistula.

Faced with the failure of retrograde endoscopic drainage attempts, and the persistence of increasingly disabling jaundice with deterioration of liver function, a surgical approach to ensure the emptiness of the bile duct was advised. On surgical exploration, we discovered of total stenosis of VBP 15mm from the main convergence and hepatogastric fistula on a dilated bile duct. Mesenteric lymphadenopathy was collected for histopathological study. After disconnection of the biliogastric fistula, the bile duct was identified, and intraoperative cholangiography (Figure 1 e).

Figure 1 e: Intraoperative cholangiography.

Performed the resection of biliary stenosis proved laborious because of inflammatory phenomena and fibrosis in contact with the right hepatic artery. This resection is done at the level of well-vascularized convergence. (Figure 2 a, b).

Figure 2 (a, b):  intraoperative images show: biliary stenosis, the extent of fibrosis, and fistula between the bile duct and stomach.

The biliary repair was done by a hepatico-jejunal anastomosis (at the level of the biliary convergence with divided ducts), on a loop mounted in Y a la Roux. (Figure 2 c).

Figure 2 c:  biliary repair

The postoperative follow-up was simple, the patient left the hospital on Day 10 postoperatively. The anatomopathological study of the resected specimen of the bile duct was suggestive of caseous-follicular tuberculosis of the bile ducts: specific chronic inflammatory lesions composed of a tuberculous granuloma consisting of epithelial giant-cellular follicles of variable size, abundant in giant cells, surrounded by a homogeneous eosinophilic and granular substance corresponding to caseous necrosis. (Figure 3).

Figure 3 a: Follicular structure epitheliogigantocellular X40.

Figure 3 b: Epitheliogigantocellular follicles x100.

Figure 3 c and d:  Caseous necrosis and giant cells".

Following the diagnosis, the patient was initiated on anti-bacillary treatment to address the tuberculosis infection. A radiological follow-up was conducted 3 months after the surgery using MRI. The results indicated that the intrahepatic bile ducts were not dilated, and the hepaticojejunal anastomosis remained patent and functional.

Extrapulmonary tuberculosis represents most tuberculosis cases still recorded in Algeria. Pulmonary tuberculosis has experienced a clear decline and represents less than 30% of the cases recorded thanks to the national prevention program implemented for several years. [3] Abdominal tuberculosis (TB) usually affects the digestive tract, lymph nodes, peritoneum, and solid organs. Two-thirds of patients with abdominal tuberculosis have abdominal lymphadenopathy or peritoneal disease in addition to intestinal involvement [2]. One-third of patients may also have extra-intestinal involvement [6]. Abdominal localization is not uncommon in areas with a high prevalence of pulmonary tuberculosis and may also be associated with active pulmonary tuberculosis [7]. It affects mainly young adults [8]. After ingestion of the pathogen, granulomas can develop in the digestive tract and then spread to lymphatics affecting all organs [9]. The spread can also occur through the hematogenous route. [10]

In highly endemic areas, in front of any biliary stenosis, the search for elements that may include tuberculosis (aspiration of bile or tissue biopsy) is very useful for preoperative diagnosis. [11] The presence of active extra-abdominal tuberculosis may guide the diagnosis in cases of biliary stenosis.

Symptomatic forms are very difficult to differ from primary bile duct cancer or primary sclerosing cholangitis. [2, 12-14] The images of biliary stenosis can mimic a cholangiocarcinoma. In young patients, the authors suggest carrying out a laparoscopic biopsy of the lymph nodes which can reveal lesions compatible with a tuberculous origin. [15]

In addition to the possibility of taking samples of bile or tissus, ERCP has the advantage of allowing the placement of biliary stents.

Despite advances in exploration, the preoperative diagnosis of obstructive tuberculosis of the bile duct is extremely difficult to save postoperatively by the histological discovery of caseous necrosis and epitheloid granulomas. [5, 13]

Anti-bacillary treatment will cure the disease in almost all patients. However, patients with signs of biliary obstruction would need endoscopic or surgical intervention to ensure emptiness of the bile ducts. [2, 16, 17] If the diagnosis is made preoperatively, a major surgical procedure can be avoided. [16, 18]

The standard regimen usually includes a combination of four drugs: isoniazid, rifampicin, pyrazinamide and ethambutol. The duration of treatment is usually about six to nine months, but it can be longer in some cases. [19]

Cumulative mortality for hepatobiliary tuberculosis is much more related to factors associated with poor prognostics [4, 20].

The rarity of tuberculosis of the bile ducts makes its diagnosis difficult, and is often confused with other biliary strictures, such as cholangiocarcinoma and sclerosing cholangitis. In some cases, retrograde explorations allow the realization of samples of bile for bacteriological study (PCR) or biopsies in search of caseous necrosis. This endoscopic route also allows the unblocking of the bile duct and the placement of prostheses. This situation is not always possible and surgery remains the only option to have a diagnosis of certainty and treatment of biliary stenosis.

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