Endoscopic diagnosis and management of hepatobiliary tuberculosis

Primary hepatobiliary tuberculosis is difficult to diagnose and treat. We describe a woman with obstructive jaundice, a common hepatic duct stricture, and granulomatous hepatitis diagnosed with biliary tract tuberculosis when acid-fast bacilli were found in bile aspirated during endoscopic retrograde cholangiopancreatography (ERCP). The hilar stricture resulted from either primary biliary tuberculosis or secondary inflammation related to tuberculous periportal adenitis and persisted despite adequate medical treatment for tuberculosis, apparently the result of postinflammatory stenosis. After 20 months, the patient had persistently elevated bilirubin due to the stricture, and liver biopsy revealed early secondary biliary cirrhosis. Placement of a permanent metal biliary stent produced excellent results. Both diagnosis of hepatobiliary tuberculosis by bile aspirate and treatment of a biliary stricture with a permanent metal biliary stent are newly described advances in the management of biliary tuberculosis made possible by ERCP.