Liver Tuberculosis in Southern Taiwan

Correspondence and requests for reprints : Dr. Seng-Kee Chuah

Address : Division of Hepatogastroenterology, Department of Internal Medicine, Chang Gung Memorial Hospital-Kaohsiung 123, Ta-Pei Road,

Liver Tuberculosis in Southern Taiwan：

15-years Clinical Experience

Wei-Chen Tai, Chung-Mou Kuo, Cheng-Hsiang Lee

, Seng-Kee Chuah, Chao-Cheng Huang

, Tsung-Hui Hu, Jin-Hung Wang, Kuo-Chin Chang,

Por-Lin Tseng, Chi-Sin Changchien, and Chuan-Mo Lee

Division of Hepato-gastroenterology,

Division of Infectious Diseases, Department of Internal Medicine,

Department of Pathology, Chang Gung Memorial Hospital-Kaohsiung Medical Center,

Chang Gung University College of Medicine, Taiwan

Introduction

Tuberculosis（TB）is a worldwide health problem with particularly high prevalence in de- veloping countries. As the population of human

immunodeficiency virus（HIV）infected people increases, and with the more users of immuno- suppressive therapy, the incidence of TB is also increasing worldwide

. Abdominal TB is a

Abstract

Liver tuberculosis（TB）is defined as Mycobacterium tuberculosis infections in the liver and is usually secondary from TB of the lung or other organ. The aims of this retrospective study were to review hepatic TB diagnosed and treated in our hospital and analyze the clinical presentations, image studies and therapeutic outcomes. From January 1992 to December 2006, 1251 patients with pathological diagnosis of TB infection were admitted. Among them, ten patients（5 males and 5 females）with the diagnosis of liver TB were enrolled. The mean age of patients with hepatic TB was 52.7 years（20-76 years）. The clinical manifestations were abdominal pain（40%）, poor appetite （40%）, nausea or vomiting（40%）, fever

（30%）, body weight loss（20%）. Three patients were found to have hepatic TB infection incidentally without relevant abdominal symptoms. Four patients had isolated hepatic TB and others had extra-hepatic TB infection. Coexistent pulmonary TB was found in 4 patients. Abdominal sonography and computed tomography（CT）in 9 patients revealed solitary liver tumors with or without calcification, or multiple liver tumors. Diagnostic methods included ultrasound-guided liver biopsy（50%）, laparotomy and liver biopsy or hepatectomy（50%）, positive liver TB-PCR（30%）, positive AFB stain（20%）. All 9 patients who had received complete antituberculosis therapy were cured of the disease. In conclusion, liver TB is a rare condition but curable disease. The diagnosis of liver TB is difficult due to non-specific symptoms, signs, and variations on image findings. Therefore, determination of histopathology is necessary for definite diagnosis of liver TB supplemented with TB-PCR and AFB stain. Once the diagnosis is confirmed, the disease is usually associated with good prognosis and long-term outcome under complete anti-TB treatment.(J Intern Med Taiwan 2008; 19: 410-417)

Key Words：Liver tuberculosis; Clinical presentations; Image studies; Therapeutic outcomes

rare manifestation among various forms of extrapulmonary TB. The diagnosis of abdominal TB is made based on the demonstration of tubercle bacilli in the gastrointestinal tract, peritoneum, or intra-abdominal solid organs. The confirmation of abdominal TB is difficult to make because of its nonspecific symptoms, and it often requires invasive procedures such as laparotomy. Liver TB is considered very rare among abdominal TB patients. Usually it is associated with foci of infection in the lungs or gastrointestinal tract

. The diagnosis of liver TB is often overlooked because liver TB can have a relatively nonspecific clinical presentation and its lower positive acid-fast smear from liver tissue and culture rate from bile juice

. Therefore, it attracted our interest to perform this retrospective study on our experiences with liver TB in the past 15 years. In the current study, we analyzed the clinical presentations, image studies, pathological findings and therapeutic outcomes of liver TB.

Patients and Methods

Over a period of 15 years ( January 1992 - December 2006 ) , a total of 1251 patients with pathological diagnosis of TB infection were included from the files of the Department of Pathology, Chang Gung Memorial Hospital- Kaohsiung, Taiwan. We focused on patients with liver CT, and the diagnosis of liver TB was made based on clinical features of liver TB infection and at least one of the following criteria: (1) positive acid-fast bacilli (AFB) stain from the tissue biopsies; (2) histopathological demonstration of typically caseating granulomatous necrosis; or (3) positive polymerase chain reaction (PCR) for M. tuberculosis on liver tissue. We recorded the demographics and clinical manifestations, including age, sex, medical history, symptoms and signs, physical findings, laboratory and image findings (radiography and sonography) , and therapeutic

outcomes by chart review retrospectively. Patients without definite diagnosis or incomplete chart recording were excluded.

Results

This study enrolled 10 patients（5 males and 5 females）with the diagnosis of liver TB among 1251 patients with pathological diagnosis of TB infection over 15 years. The ages ranged from 20 to 76 years with a mean age of 52.7 years. The clinical manifestations in these 10 patients were abdominal pain (40%), poor appetite (40%) , nausea or vomiting (40%), fever (30%),body weight loss (20%), abdominal distension (10%), and ascites (10%). The concurrent diseases included: 5 patients with hypertension, 4 with diabetes mellitus, 2 with cancer both with end stage renal disease;

chronic hepatitis B; chronic hepatitis C; old stroke;

alcoholism; and ulcerative colitis. None of them was HIV-infected.

Hepatic TB infections were found incidentally in 3 patients with abdominal symptoms (Table 1) . A 44 year-old female (Patient 2)with diabetes and old pulmonary TB, was receiving abdominal total hysterectomy for uterine myoma when nodular liver surface was observed by the surgeon during operation and the frozen section of liver biopsy revealed hepatic TB. The other patient (Patient 4) was a 76-year-old male with diabetes, hyperten sion, old stroke and old pulmonary TB, who was receiving surgical intervention for gastric angiodysplasia bleeding. Cirrhotic liver surface was observed during operation and liver biopsy revealed hepatic TB with positive TB-PCR. Patient 6 was a 20 year-old female who was receiving ultrasound- guided liver biopsy for evaluating living-related liver donation and liver TB was incidentally found.

Among these 10 patients, 4 patients had

isolated hepatic TB（Patients 6, 7, 8, 9）, the

other six patients had concomitant extra-hepatic TB

infection. Coexistent pulmonary TB was found in 4

patients ( Patients 1, 2, 4, 10 ), and one had active military pulmonary TB(Patients 4). Two patients had gallbladder(GB)involvement(Patients 3, 5).

Involvement of duodenum ( Patient 3), omentum ( Patient 5 ) and mesentery ( Patient 10)was

found in the other three patients respectively.

Image studies used for hepatic TB evalua- tion were abdominal sonograph (Figure 1), computed tomography(CT) ( Figure 2), angio- graphy,esophagogastroduodenoscopy(EGD)and

Patient Age(years) erExtra-hepatic TB Underlying Clinical Abdomen image finding Diagnosis Therapy Outcome

/Gender infection diseases manifestations* methods

1 55/M Pulmonary TB ESRD, HTN 1, 2 Echo, CT: liver tumor Pathology via Anti-TB agents Cured echo-guided

liver biopsy

2** 44/F Pulmonary TB DM, old 7 None Pathology via Anti-TB agents Cured

pulmonary TB laparotomy

3 55/F GB, duodenum HTN 1, 3, 5 Echo, CT: both lobe Pathology via Anti-TB agents Cured liver tumors, echo-guided Surgical resection

cholangiocarcinoma liver biopsy, GB wall thickening AFB(+) Liver

TB-PCR(+)

4*** 76/M Pulmonary TB DM, HTN, old , 7, 8 Echo, CT: ascites, no Pathology via Anti-TB agents Cured

pulmonary TB liver tumor laparotomy

old stroke Liver TB-PCR(+)

5 44/M GB, omentum DM, HTN 1, 3, 5 Echo, CT: liver tumor Pathology via Anti-TB agents Cured with calcification laparotomy Surgical resection cholangiocarcinoma and

GB wall thickening Angiography: liver tumor

6**** 20/F — Alcoholism 7 Echo, CT, MRI, Pathology via Anti-TB agents Lost to f/u

Angiography: normal echo-guided liver biopsy

7 71/F — DM, HTN, 3, 4, 5, 6 Echo, CT: liver tumor Pathology via Anti-TB agents Cured

Gastric cancer laparotomy, AFB(+)

8***** 41/M — Chronic hepatitis 2 Echo: Mild fatty liver Pathology via

C,ulcerative colitis echo-guided liver Anti-TB agents Cured biopsy

9****** 51/M — Bladder cancer 2, 3, 4 Echo: hepatosplenomegaly Pathology via Anti-TB agents Cured echo-guided liver

biopsy

10 70/F Pulmonary TB, Chronic hepatitis 1 Echo, CT: liver tumor with Pathology via Anti-TB agents Cured mesentery B,old pulmonary TB calcification laparotomy Surgical resection

Cholangiocarcinoma. TB-PCR(+)

L't IHDLiverstones Angiography: liver hypovascular tumor

F: female, M: male, TB: tuberculosis, GB: gallbladder, ESRD: end stage renal disease, HTN: hypertension, DM: diabetes mellitus, Echo: echography, CT: computed tomography, CHD: common hepatic duct, CxR: chest X-ray, IHD: intra-hepatic duct, EGD: esophagogastroduodenoscopy, MRI: magnetic resonance imaging, AFB: acid-fast bacilli, TB-PCR: polymerase chain reaction for TB, Anti-TB: antituberculosis, f/u: follow-up.

*Clinical manifestations: 1. abdominal pain, 2. fever, 3. poor appetite, 4. body weight loss, 5. nausea or vomiting, 6. abdominal fullness, 7. incidental finding, 8. ascites

**Patient no.2: Nodular liver surface noted during operation (Abdominal total hysterectomy)

***Patient no.4: Cirrhotic liver surface noted during operation (Gastric angiodysplasia bleeding)

****Patient no.6: For living related liver donation evaluation

***** Patient no.8: Liver biopsy for pre-hepatitis C virus treatment evaluation

******Patient no.9: Liver biopsy for fever evaluation

magnetic resonance imaging（MRI）. Abdominal sonography and CT were performed in 9 patients and their features are summarized in Table 1.

There were variations such as solitary liver tumors with calcification (Patient 5, 10) or without calcification (Patient 1, 7), multiple liver tumors (Patient 3), GB wall thickening (Patient 3, 5), mild fatty liver (Patient 8), hepatosplenomegaly (Patient 9), ascites (Patient 4) and normal study (Patient 6). Hepatic angiography was performed for two patients (Patients 5, 10) that revealed hypovascular masses with calcification

in these 2 patients that were initially thought to be cholangiocarcinoma. EGD was performed in one（Patient 3）for gastrointestinal bleeding evaluation and ulceration with irregular base was found on the posterior wall of duodenal bulb.

The subsequent endoscopic biopsy revealed granulomatous inflammation. This patient received liver biopsy, laparotomy with cholecystectomy and duodenorrhaphy, and all the pathological reports proved TB infection in the liver, the GB and the duodenum.

Patient 8 was a 41-year-old male with under- lying chronic hepatitis C and ulcerative colitis, who received liver biopsy for pre-treatment evaluation for chronic hepatitis C. Liver pathology revealed hepatic TB with granulomatous inflamma- tion and positive AFB stain. He received complete anti-TB therapy before anti-viral treatment.

Patient 9 was a 51-year-old male with bladder cancer, who suffered from prolonged fever with unknown origin and abnormal liver function test.

Ultrasound-guided liver biopsy was performed for fever evaluation and hepatic TB was diagnosed.

The patient became afebrile and normalization of liver function test was noted after completion of anti-TB treatment.

All liver tissue underwent histopathological examination, AFB stain, and/or TB-PCR to confirm the diagnosis of hepatic TB. All patients had pathologic evidence of hepatic TB infection with the histopathological finding of epithelioid cell granuloma and central caseous necrosis, 30% were positive for TB-PCR, and 20% were positive for AFB stain. In addition, two GB TB were diagnosed by laparotomy and cholecystectomy, and one duodenal TB was diagnosed by EGD with biopsy.

Six patients received surgical intervention and there were no significant postoperative complications or mortality.

All patients received antituberculosis therapy.

Nine patients received at least 6 months of

tuberculosis (TB) varies from hypoechoic tumor with or without hyperechoic ring to hyperechoic tumor. This is the sonographic finding in a nodular hepatic TB which reveals a hypoechoic liver tumor with hyperechoic ring (white arrow).

Fig.2.There is no characteristic feature on computed tomography scan specific for hepatic TB, even in the nodular form of liver mass. Figure 2A reveal solitary liver tumor with calcification (white arrow). Figure 2B reveals solitary liver tumor without calcification (white arrow).

antituberculosis drugs. A patient（Patient 6）took two months antituberculosis therapy but was lost to follow-up. All those patients who completed a full course of anti-TB treatments survived in the current study. The subsequent abdominal echo revealed negative findings in these 9 patients after completed antituberculosis therapy.

Discussion

TB spreads to the liver through the hepatic artery, the portal system and the lymphatic system.

Liver TB commonly involves the hepatic parenchyma and sometimes the biliary tree. The presentations of liver TB are divided into three types: miliary hepatic TB, nodular hepatic TB and biliary tract TB

. The miliary hepatic TB, which is hematogenously disseminated from the lungs via hepatic artery

, is the most common type of hepatic TB. Besides, TB can also spread through the portal system or the lymphatic system from the coexistent gastrointestinal tract TB

. However, among the 4 patients with coexisting pulmonary TB in the current study, only one of them had miliary pulmonary TB. This might result from non-specific symptoms and signs of hepatic TB. Besides, patients with pulmonary TB may not check liver status with routine examinations such as liver biochemistry tests, abdominal sonography or CT.

Thus, the number of miliary hepatic TB patient is usually underestimated. Isolated hepatic TB nodules were presented in 4 patients, and one had multiple nodular pattern which involved both lobes of the liver.

Coexisting GB TB were found in two patients in our study. There are four possible different pathways for pathogenesis of GB TB. The hematogenous or lymphatic spread from the primary site, direct involvement or secondary involvement of liver TB, secondary excretion of AFB from the liver to the biliary tract, or secondary to periportal lymph node involvement

. There was

no evidence that hepatic TB directly invaded GB according to pathological findings, nor coexistence of pulmonary TB in these two patients. Therefore, we believed that GB TB in our patients was either secondarily spread from hepatic TB via the hematogenous or lymphatic systems or via excretion of M. tuberculosis to the biliary tract. GB TB is usually presented with cholecystitis, obstructive jaundice or GB mass

. None of these signs were found in our patients but only GB wall thickening was revealed by sonography.

The clinical presentation of hepatic TB is usually insidious and often non-specific

. The non-specific nature of this disease often results in diagnostic delay. In our patients, the duration of symptoms and signs before hepatic TB diagnosis varied from one week to 6 months. Three patients were asymptomatic and hepatic TB was diagnosed incidentally. The clinical triad symptom of fever, abdominal pain and hepatomegaly in patients with hepatic TB has been described before

. However, abdominal pain was found in 4 patients and fever was found in 3 from our series. Besides, only one of our patients（Patient 9）had hepatosplenomegaly, but no liver space-occupying lesion was found on abdominal sonography.

Image studies, such as abdominal sonography

and liver CT, can detect liver solitary masses

but there is no characteristic feature specific for

hepatic TB, even in the nodular form of liver

mass. Sonographic findings in nodular hepatic TB

vary from hypoechoic tumors with or without

hyperechoic ring to hyperechoic tumors

. CT

findings of hepatic TB may reveal hypodense mass

and/or with hyperdense rim after enhancement

study. Some hepatic TB might show heterogenous

density with central necrosis or central calcification

under CT scan

. Maglinte et al

reported that

more than 50% of hepatic TB patients had

calcification on image study. In our patients,

nodular form hepatic TB presented hypoechoic

tumor in abdominal sonography and hypodense mass in CT studies. Liver tumors with calcification were noted in 2 of 5 patients with solitary or multiple nodular hepatic TB. Nevertheless, there was no typical hyperechoic rim in sonography or hyperdense rim in CT study. Angiography in two patients with nodular hepatic TB revealed hypovascular tumors with calcification, but these were not characteristic features suggestive of liver TB. Three patients were initially diagnosed as cholangiocarcinoma based on image studies.

Hepatic TB was confirmed by pathological diagnosis, and 2 patients with solitary pseudotumor received left hepatectomy plus anti-TB therapy.

Another one with multiple liver pseudotumors received anti-TB treatment. There was no liver tumor found on all image studies in the other 4 patients.

Therefore, pathologic and bacteriological evidence is necessary to confirm the diagnosis of hepatic TB. Due to low positive yield of culture and AFB stain, pathologic examination is the best way to confirm the diagnosis. In our study, of 10 patients with pathologically proven hepatic TB, only 2 had positive AFB stain. TB-PCR is a rapid and useful tool in the diagnosis of hepatic TB. In the literature, the diagnostic sensitivity of TB PCR in detecting culture confirmed and clinically diagnosed TB infection was 75.9% and 81.3% respectively. The specificity of TB PCR in diagnosing TB infection is 100%.

Diaz et al.

reported that over 50% of hepatic TB patients had positive TB-PCR but Popper et al.

and Ghossein et al.

reported that almost all patients with pathologic confirmation of hepatic TB had positive TB-PCR. TB-PCR was performed in 3 of our patients, and all of them had positive TB-PCR.

Conventional antituberculosis therapy for a minimum of 6 months is the recommended therapy once the diagnosis of hepatic TB is established

. Nearly 100% of the disease can be completely

cured with anti-TB therapy. Since the definite diagnosis is difficult with image study alone and occult malignancy is possible, surgical intervention with hepatectomy is an alternative option in treating nodular hepatic TB when necessary. Xing et al.

attained satisfactory results in his 8 hepatic TB pseudotumor patients that received segmentectomy or hepatectomy

. In the current study, all patients received complete anti-TB therapy except for one patient who was lost to follow-up. Among them, two patients with solitary hepatic TB received left hepatectomy.

In summary, liver TB is a rare condition but a curable disease. The diagnosis for liver TB is difficult due to non-specific symptoms, signs, and variations on image findings. Therefore, determination of histopathology is necessary for definite diagnosis of liver TB but TB-PCR and AFB stain do help to confirm this. Once the diagnosis is made, the disease is usually associated with good prognosis and long-term outcome under complete anti-TB treatment.

Acknowledgment

The authors thank the reviewers for they valuable comments on earlier versions of the manuscript and Steve Tredrea MA for his assistance in English editing.

References

1.Barnes PF, Barrows SA. Tuberculosis in the 1990s. Ann Intern Med 1993; 119: 400-10.

2. Maartens G, Wilkinson RJ. Tuberculosis. Lancet 2007; 370:

2030-43.

3. Wagner KR, Bishai WR. Issues in the treatment of Mycobacterium tuberculosis in patients with human immunodeficiency virus infection. AIDS 2001; 15(Suppl 5):

S203-12.

4. Reed DH, Nash AF, Valabhji P. Radiological diagnosis and management of a solitary tuberculous hepatic abscess. Br J Radiol 1990; 63: 902-4.

5. Saluja SS, Ray S, Pay S, et al. Hepatobiliary and pancreatic tuberculosis: A two decade experience. BMC Surg 2007; 7: 10.

6. Chien RN, LinPY, Liaw YF. Hepatic tuberculosis comparison

of miliary and local forms. Infection 1995; 23: 5-8.

7. Achem SR, Klots BE, Grisnik J, et al. Pseudotumoral hepatic tuberculosis: atypical presentation and comprehensive review of literature. J Clin Gastroenterol 1992; 14: 72-7.

8. Corrales Torres AJ, Fernandez Martinez A, Serrano D, et al.

Tuberculosis hepatica pseudotumoral. Ann Med Int 1997; 8:

559-61.

9. Terry RB, Gunnar RM. Primary miliary tuberculosis of the liver. JAMA 1957; 164: 150-7.

10.Hersch C. Tuberculosis of the liver. A study of 200 cases. S Afr Med J 1964; 38: 857-63.

11.Rankin FW, Massie FM. Primary tuberculosis of the gallbladder. Ann Surg 1926; 83: 800-6.

12.Ben RJ, Young T, Lee HS. Hepatobiliary tuberculosis presenting as a gallbladder tumour. Scand J Infect Dis 1995;

27: 415-7.

13.Fan ST, Ng IOL, Choi TK, et al. Tuberculosis of the bile duct:

a rare cause of biliary stricture. Am J Gastroenterol 1989; 84:

413-4.

14.Bearer EA, Savides JT, McCutchan JA. Endoscopic diagnosis and management of hepatobiliary tuberculosis. Am J Gastroenterol 1996; 91: 2602-4.

15.Kohen MD, Altman KA. Jaundice due to a rare cause:

tuberculous lymphadenitis. Am J Gastroenterol 1973; 59:

48-53.

16.Murphy TF, Gray GP. Biliary tract obstruction due to tuberculous adenitis. Am J Med 1980; 68: 452-4.

17.Stanley JH, Yantis PL, Marsh WH. Periportal tuberculosis adenitis: A rare cause of obstructive jaundice. Gastrointest Radiol 1984; 9: 227-9.

18.De Melo VA, De Melo GB, SilvaRL, et al. Tuberculosis of the cystic duct lymph node. Braz J Infect Dis 2004; 8: 112-4.

19.Alvarez SZ. Hepatobiliaary tuberculosis. J Gastroenterol Hepatol 1998; 13: 833-9.

20.Fang X, Li J, Fan S. Clinical characteristics of hepatic tuberculosis. Zhonghua Nei Ke Ka Zhi 1995; 34: 34-7.

21.Buxi TB, Vohra RB, Sujatha Y, et al. CT appearance in macronodular hepatosplenic tuberculosis: a review with five additional new cases. Comput Med Imaging Graph 1992; 16:

381-7.

22.Chan HS, Pang J. Isolated giant tuberculomata of liver detected by computed tomography. Gastrointest Radiol 1989;

14: 305-7.

23.Tan TC, Cheung AYC, Wan WYL, et al. Tuberculoma of the liver presenting as a hyperechoic mass on ultrasound. Br J Radiol 1997; 70: 1293-5.

24.Maglinte DT, Alvarez SZ, Ng AC, et al. Patterns of calcifications and cholangiographic findings in hepatobiliary tuberculosis. Gastrointest Radiol 1988; 13: 331-5.

25.Cheng VC, Yam WC, Hung IF, et al. Clinical evaluation of the polymerase chain reaction for the rapid diagnosis of tuberculosis. J Clin Pathol 2004; 57: 281-5.

26.Diaz ML, Herrera T, Vidal YL, et al. Polymerase chain reaction for the detection of Mycobacterium tuberculosis DNA in tissue and assessment of its utility in the diagnosis of hepatic granulomas. J Lab Clin Med 1996; 127: 359-63.

27.Popper H, Winter E, Hofler G, et al. DNA of Mycobacterium tuberculosis in formalin fixed paraffin-embedded tissues in tuberculosis and sarcoidosis detection by polymerase chain reaction. Am J Clin Pathol 1994; 101: 738-41.

28.Ghossein RA, Ross DG, Salomon RN, et al. Rapid detection and species identification of mycobacteria in paraffin- embedded tissue by polymerase chain reaction. Diagn Mol Pathol 1992; 1: 185-9.

29.Lazarus AA, Thilagar B. Abdominal tuberculosis. Dis Mon 2007; 53: 32-8.

30.Xing X, Li H, Liu WG. Hepatic segmentectomy for treatment of hepatic tuberculous pseudotumor. Hepatobiliary Pancreat Dis Int 2005; 4: 565-8.

台灣南部之肝臟結核感染： 15年臨床研究報告

戴維震

郭仲謀 李禎祥

蔡成枝 黃昭誠

胡琮輝 王景弘

張國欽 張簡吉幸 李全謨

長庚紀念醫院高雄分院

胃腸肝膽科系

2臨床病理科

長庚大學醫學院

摘 要

肝臟結核的定義為肝臟中發現結核分枝桿菌感染，通常續發於肺結核或其他器官結核。

此回溯性研究的目的在於回顧本院肝臟結核的診斷與治療，並分析臨床表徵、影像學檢查及 治療結果。從

1992年1月至2006年12月，1251位病人經由病理診斷為結核菌感染，其中10位

( 40% )、食慾不振 ( 40% ) 、噁心或嘔吐 ( 40% )、發燒 ( 30% ) 及體重下降 ( 20% ) 。3位

核，有

4位病人合併肺結核。9位病人的腹部超音波及電腦斷層檢查呈現單發性或多發性肝腫

瘤。診斷方法包含超音波指引肝切片 ( 50% )，開腹探查術合併肝切片或肝切除（50% )，肝 組織結核菌聚合酵素鏈鎖反應陽性

( 30% )，抗酸菌染色陽性 ( 20% )。九位病人均接受完整

但結核菌聚合酵素鏈鎖反應與抗酸菌染色可以提供幫助。肝臟結核經完整抗結核菌治療後通 常有良好預後與治療效果。