Clinical Radiology xxx (2017) 1e6

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Clinical Radiology
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Imaging appearances of hepatic tuberculosis:

experience with 12 patients
L.S. Ch’ng a, *, H. Amzar a, K.C. Ghazali b, F. Siam b
a
Department of Radiology, Sarawak General Hospital, Kuching, Malaysia
b
Department of Hepatobiliary Surgery, Sarawak General Hospital, Kuching, Malaysia

art icl e i nformat ion AIM: To review computed tomography (CT), ultrasound (US), magnetic resonance chol-
angiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP) and
Article history: percutaneous transhepatic cholangiogram (PTC) appearances and their diagnostic value in
Received 14 July 2017 hepatic tuberculosis.
Accepted 23 October 2017 MATERIALS AND METHODS: The imaging studies for 12 patients with biopsy-proven hepatic
tuberculosis from January 2012 till March 2014 were reviewed retrospectively. These cases
were confirmed via ultrasound-guided biopsy.
RESULTS: The patients were aged 24e72 years. Four patients had parenchymal tuberculosis
only and eight patients had mixed parenchymal and biliary duct involvement. The paren-
chymal tuberculosis patients showed poorly enhancing, hypodense nodules on CT with central
calcification and adjacent dilated intrahepatic ducts. Most patients had multiple lesions except
for two patients with a single lesion. The size of the lesions ranged from 0.5 to 6 cm. Seven
patients with biliary duct involvement showed a hilar strictures involving the intrahepatic
ducts and common bile duct. Nine of the patients showed hilar stricture with atrophy of the
ipsilateral lobe of the liver and compensatory hypertrophy of the contralateral lobe. Hep-
atolithiasis was seen in five patients. Tuberculous lung involvement was seen in seven patients.
CONCLUSION: The presence of calcified and hypodense nodules with biliary duct dilatation
associated with lobar atrophy were the most consistent features of hepatic tuberculosis,
especially in the presence of active lung disease.
Ó 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction Hepatic TB is a rare but curable disease. The diagnosis of

Tuberculosis (TB) is a common disease in underdevel-
oped and developing nations, especially in low socioeco-
nomic groups. Once the diagnosis is confirmed, the disease
is usually associated with good prognosis provided anti-TB
treatment is completed.
* Guarantor and correspondent: C. L. Shyan, Department of Radiology,
Sarawak General Hospital, Jalan Hospital, 93586 Kuching, Sarawak, Malaysia.
Tel.: þ603 61454333; fax: þ603 61454111.
E-mail address: lishyanc@yahoo.com (L.S. Ch’ng).
hepatic TB is difficult due to non-specific symptoms and
signs, as well as variations of non-specific imaging findings.
Initial clinical and radiological evaluations provide indirect
evidence of the presence and locations of involvement. For
confirmation, tissue samples need to be obtained for his-
tological and microbiological evaluation. Imaging, such as
ultrasonography (US) and computed tomography (CT),
complemented by endoscopic evaluations, such as endo-
scopic retrograde cholangiography (ERCP) and endoscopic
ultrasonography (EUS), are not only the mainstay of in-
vestigations, but also direct and assist in tissue sampling.

https://doi.org/10.1016/j.crad.2017.10.016
0009-9260/Ó 2017 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Ch’ng LS, et al., Imaging appearances of hepatic tuberculosis: experience with 12 patients, Clinical Radiology
(2017), https://doi.org/10.1016/j.crad.2017.10.016
2 L.S. Ch’ng et al. / Clinical Radiology xxx (2017) 1e6
Many different classifications for hepatic TB have been 107
proposed.1e3
Although some classify hepatic TB into serohepatic type
and parenchymal type, with tuberculous cholangitis being a
separate pathological/radiological entity,1 others classify
tuberculous cholangitis as part of parenchymal type of he-
patic TB.4 The parenchymal type, which is the most com-
mon among the three types, can be further be subdivided
into miliary, nodular, and mixed TB.
Although the imaging features (CT and magnetic reso-
nance imaging [MRI]) of hepatic TB have been described,
the imaging appearance of these lesions is considered non-
specific. Histopathological or bacteriological confirmation is
often required especially when malignancy needs to be
excluded.5,6
Materials and methods
The imaging studies of 12 patients with biopsy-proven
hepatic TB from January 2012 till March 2014 were
reviewed retrospectively. Ethics committee approval was
not required as the liver biopsies and imaging were done to
aid in the diagnosis and management of patients. The pa-
tients were aged between 24e72 years (mean age of 45
years) and there were six male and six female patients.
These patients were initially referred to the hepatobiliary
department for liver masses, so the series only contained
cases of macronodular parenchymal TB.
CT, US, MRI cholangiopancreatography (MRCP), endo-
scopic retrograde cholangiopancreatography (ERCP), and
percutaneous transhepatic cholangiogram (PTC) images of
the 12 patients were reviewed retrospectively and the
diagnostic value of their radiological appearances was
evaluated. No standard protocol was outlined for the scans
as the radiological studies were analysed retrospectively
from two community hospitals.
Ultrasound-guided biopsy of the liver lesions was per-
formed for all 12 patients. Biopsies yielded acid-fast bacilli
(AFB) or showed caseous necrosis with occasional Langhans
giant cell on histology. Alternatively, diagnosis was also
confirmed by polymerase chain reaction (PCR) of the biopsy
tissue.
Results
Four patients with parenchymal TB and eight patients
with mixed parenchymal and biliary duct involvement were
observed. The majority of patients were either farmers or
housewives with two thirds being referred from rural areas
and district hospitals. Besides that, two thirds of patients
were referred from rural areas and district hospitals.
Hepatic (parenchymal) TB
Parenchymal tuberculous patients showed hypodense
nodules on CT with poor rim enhancement, central calcifi-
cation, and adjacent dilated intrahepatic ducts. The hypo-
dense nodules were noted to be hypoechoic on ultrasound,
hypointense on T1-weighted (W) and hyperintense on T2W
Please cite this article in press as: Ch’ng LS, et al., Imaging appearances of hepatic tuberculosis: experience with 12 patients, Clinical Radiology
(2017), https://doi.org/10.1016/j.crad.2017.10.016
sequences. Most patients had multiple lesions except two
patients who had single lesions. The size of the lesions
ranged from 0.5 to 6 cm. The lesions tend to enlarge and
appear more well-defined over time if untreated (Fig 1).
Single lesions tend to be larger (>5 cm) and occur in
older age groups (50 and 70 years old). The location of
single lesions are subdiaphragmatic (S7 and S8) and exo-
phytic. Singular lesions have poor rim enhancement and
may be septated (Fig 1). One lesion had coarse rim calcifi-
cation (Fig 2).
Multiple lesions were located in either/both lobes of the
liver and in difference phases of disease. There were calci-
fications/hepatolithiasis and atrophy/fibrosis in one lobe of
the liver, whereas enhancing lesions were found in the
contralateral lobe (Fig 3).
Biliary (duct) TB
Eight patients with biliary duct involvement showed
strictures involving the intrahepatic ducts and/or common
bile duct (CBD). Intrahepatic strictures usually form later at
areas of previous granulomas (Fig 4). Biliary stricture at the
right or left hepatic duct results in atrophy of the ipsilateral
lobe of the liver with compensatory hypertrophy of the
contralateral lobe noted (Fig 3). Out of nine patients with
lobar atrophy, two patients had a bile lake (Fig 5). The bile
lakes occurred in the atrophied right lobe of the liver
(Table 1). Hepatolithiasis was also seen in five patients.
There were no patients with solely biliary disease.
Extra-hepatic TB manifestations
TB frequently presents as a systemic disease. Therefore
extrahepatic TB needs to be investigated in these patients.
Lung involvement of TB was seen in six patients either on
chest radiography or CT. One of the patients had humeral
bone TB. A splenic focus of TB was seen in one patient.
Upper abdominal lymphadenopathy was seen in four pa-
tients. The nodes did not have the typical matted with
necrotic centre appearance. Two patients had ascites. There
were no cases with associated pancreatic, adrenal, or peri-
toneal involvement in the present series.
Correlation with liver function tests
Bilirubin levels in patients with intra- and extrahepatic
strictures were higher than in patients with only intra-
hepatic strictures (p¼0.05) using the Mann-Whitney. Mean
total bilirubin in patients with intra- and extrahepatic
strictures was 274 mmol/l (SD 50). Patients with only
intrahepatic biliary strictures had a mean total bilirubin of
46 mmol/l (SD 33).
Discussion
Despite advances in TB control through improved
nutrition, reduced crowding, public health measures, and
effective chemotherapy, TB is still common today and re-
sults in significant morbidity and mortality. It has been
 L.S. Ch’ng et al. / Clinical Radiology xxx (2017) 1e6 3

Figure 1 (a) Transverse US image of a 50-year-old woman showed a heterogeneous lesion (*) in segment V/VIII, which is larger and more well-
defined in subsequent US performed 2 months later (b). (c) The CT image shows a multiseptate exophytic lesion (*) in segment V/VIII.

Figure 2 (a) US image of a 70-year-old woman showing an isoechoic lesion (*) in segment VII with wall calcification (thin arrow). (b) A poorly
enhancing hypodense lesion (*) with wall calcification seen on CT. The lesion (*) is hyperintense on the T2W (c) and hypointense on the T1W
sequences (d). The small splenic lesion (thick arrow) was hypodense on CT and hyperintense on T2W imaging.

Figure 3 Longitudinal view of (a) US and (b) CT images of the abdomen of a 24-year-old man showing hypoechoic and hypodense nodules in the
right lobe (arrowhead). Hepatolithiasis (thin arrows) and left lobe atrophy noted. (c) ERCP demonstrating truncated left hepatic duct near
bifurcation (thick arrow) with right intrahepatic duct stricture (*).

Please cite this article in press as: Ch’ng LS, et al., Imaging appearances of hepatic tuberculosis: experience with 12 patients, Clinical Radiology
(2017), https://doi.org/10.1016/j.crad.2017.10.016
4 L.S. Ch’ng et al. / Clinical Radiology xxx (2017) 1e6

Figure 4 (a) US image of a 27-year-old man showing a heterogeneous hypoechoic nodule (thick arrow), which was smaller 3 months ago on CT
(b) and shows central calcification with hypodense rim. Dilated distal intrahepatic ducts noted (thin arrow). MRI images show the lesion with
concentric rings (target appearance), which was predominantly hypointense on T1W (c) and hyperintense on T2W (d). (e) MRCP demonstrates
biliary strictures at the right intrahepatic and left hepatic ducts (arrowhead).

estimated two billion people have latent TB, with approxi-
mately 7e8 million new cases are detected worldwide
annually; however, in underdeveloped nations in particular,
two million affected individuals succumb to this infection
annually even though TB is treatable.7 The increased inci-
dence of TB has been attributed to several causes, including
the acquired immunodeficiency syndrome (AIDS) epidemic,
intravenous drug abuse, and an increase in the number of
immunocompromised patients.8,9
In the present study, TB tended to occur in patients in
the age range of 25e55 years, particularly in the 25e34-
years category, which comprises 19.5% of patients with
TB in Malaysia in the year 2013. Extrapulmonary TB
accounts for 15.5% of the reported TB cases in Malaysia in
2013. Abdominal involvement in TB is one of the most
prevalent forms of extrapulmonary manifestations, and
generally refers to gastrointestinal, splenic, pancreatic,
hepatobiliary, and abdominal lymph node involvement.10
The small bowel was the most commonly affected site
(33.8%), followed by the peritoneum (30.7%), large bowel
(22.3%), liver (14.6%), and the upper gastrointestinal tract
(8.5%).3 Primary hepatic TB is rare because low oxygen
tension in the liver is unfavourable for the growth of
mycobacteria.11
Most of the cases were referred from rural areas with the
majority of patients being farmers.

Figure 5 (a) US images of a 33-year-old man showing a cavity/bile lake (*) in the right lobe of liver with adjacent echogenic (partially calcified)
nodules (thick arrows). Dilated left intrahepatic ducts seen (arrowheads). (b) CT demonstrated a bile lake (*) with calcified and non-calcified
nodules (thick arrows). (c) Cholangiogram showing dilated left intrahepatic ducts (arrowhead) connected to the bile lake (*) via biliary stric-
ture at the hilum (thin arrow). CBD with stent in situ (þ) is in continuity with the bile lake. Multiple filling defects seen in the bile lake are due to
the nodules within.

Please cite this article in press as: Ch’ng LS, et al., Imaging appearances of hepatic tuberculosis: experience with 12 patients, Clinical Radiology
(2017), https://doi.org/10.1016/j.crad.2017.10.016
 L.S. Ch’ng et al. / Clinical Radiology xxx (2017) 1e6
Table 1
Incidence and location of biliary stricture.
Location of biliary stricture No. of patients
Intrahepatic ducts only 2 poor enhancement. These findings are in keeping with
Intrahepatic ducts and common bile duct 3 central caseous necrosis with surrounding granulation tis-
Truncated right or left hepatic duct 3 sue that enhances. Calcifications, which range from small
No biliary stricture 4
Although considered to be a rare clinical entity, hepatic
TB it is the most common manifestation of upper abdomen
parenchymal organ TB and its incidence has also been
increasing. The liver is a common site for granuloma for-
mation owing to its rich blood supply, located at the distal
end of the portal circulation as well as due to large number
of reticuloendothelial cells. Although hepatic TB is reported
to occur in 50e80% of patients who were dying from pul-
monary TB,12 most of the cases were usually clinically silent.
Patients usually become symptomatic when they present
with cholangitis due to biliary obstruction secondary to
biliary stricture. Therefore, hepatic TB is possibly under-
diagnosed and under-reported in clinical practice. Patients
with hepatic TB in this study were relatively young with
mean age of 47 years. Overall, the prevalence of abdominal
TB has been shown to correlate with the severity of pul-
monary TB. Prompt diagnosis and early treatment is needed
to reduce morbidity and mortality in this productive age
group.
Unless there is a high index of suspicion, the diagnosis of
hepatic TB is often overlooked.13 Granulomas were usually
located near the portal tract and there was only mild
perturbation of hepatic function, so most patients were
minimally symptomatic or asymptomatic. Abdominal mass,
hepatomegaly, and jaundice were the most frequent clinical
symptoms and signs. Other clinical manifestation of hepatic
TB include right upper abdominal pain, upper abdominal
tenderness, low-grade fever, night sweat, weight loss, and
fatigue.2,4 Anaemia, raised erythrocyte sedimentation rate
(ESR), abnormal hepatic function, and positive tuberculin
test were other possible manifestations. Similar clinical
presentation was seen in the present series.
The clinical classification and nomenclature of hepatic TB
is still unclear.3,11,14,15 While Levine has classified the cases
into miliary TB, pulmonary TB with hepatic involvement,
primary liver TB, focal tuberculoma or abscess, and tuber-
culous cholangitis [3], Reed divided it into only three forms:
TB of the liver associated with generalised miliary TB, pri-
mary miliary TB of the liver, and primary tuberculoma or
abscess of the liver [14]. In the present study, pathological
classification was chosen, which is divided into serohepatic,
parenchymal, and cholangitis subgroups. Serohepatic refers
to subcapsular miliary liver lesions, which is the least
common presentation. Parenchymal lesions are further
subdivided into micronodular/miliary (<2 cm), macro-
nodular (>2 cm), and mixed micronodularemacronodular
lesions.
In the present series, the parenchymal form was found to
be the dominant type. The main CT features of hepatic TB
were the presence of multiple lesions of varying densities
indicating lesions at different pathologic stages, i.e.,
Please cite this article in press as: Ch’ng LS, et al., Imaging appearances of hepatic tuberculosis: experience with 12 patients, Clinical Radiology
(2017), https://doi.org/10.1016/j.crad.2017.10.016
5
tuberculous granuloma, liquefactive necrosis, fibrosis, and
calcification occurring synchronously.1 The parenchymal
lesions in the present series showed rim enhancement or
isolated specks to coarse calcifications was found in the
present series, with one case of rim calcification.
Parenchymal tuberculous macronodules were generally
hypodense nodules with mild peripheral rim enhancement
on CT16,17; however, their appearance varied and may
appear similar to tumour such as metastases, lymphoma, or
pyogenic abscesses due to its multiplicity.18 Other features
such as adjacent dilated intrahepatic ducts and coarse he-
patic or nodal calcifications may suggest the diagnosis of TB.
The hypodense nodules were hypoechoic on ultrasound,
hypointense on T1W, and hyperintense on T2W sequences.
Most patients had multiple lesions except two patients who
had single lesions. Single lesions were more likely to be
abscesses than granulomas. Caseous material was aspirated
from the singular lesions.
Hepatic TB nodules were noted to be hypointense with
an isointense rim on T1W imaging and hypointense, iso-
intense, or hyperintense with a less intense rim on T2W
imaging. Peripheral enhancement or internal septal
enhancement was noted on contrast-enhanced MRI.16,19
The rim is likely due to peripheral granulomatous tissue.
Pure biliary involvement is said to be extremely rare and
occurs mainly in children. Strictures can be simple or mul-
tiple. Isolated or complex calcifications may be seen along
the course of the bile ducts.20 Management of biliary
strictures includes biliary drainage along with standard
anti-TB therapy and possibly surgery. Although isolated
strictures can be managed easily with sequential placement
of multiple plastic stents, multiple or complex strictures are
more challenging and require combination therapy via
endoscopy, a percutaneous approach, and surgery.
The classical findings were irregular dilated intrahepatic
ducts or diffuse miliary nodules. Even though 70% of patients
had biliary involvement in the present series, this was asso-
ciated with macronodular parenchymal disease in all pa-
tients. It is postulated that biliary strictures form at the site of
granulomas, suggesting stricture formation secondary to
healing of the granulomas. In the present series, the majority
of strictures occurred in the intrahepatic ducts with
involvement of the CBD and hilum being less frequent.
Radiologically, it was difficult to exclude cholangiocarcinoma
in this group of patients.
Hilar stricture causes chronic biliary obstruction lead-
ing to secondary biliary cirrhosis and eventually atrophy
of the affected lobe.7 In addition, bile lakes were also seen
as a sequela to chronic biliary obstruction. Although it is
reported that splenic involvement is common in patients
with hepatobiliary TB, particularly in patients with human
immunodeficiency virus (HIV)/AIDS, the patient with
splenic involvement in the present series did not have
HIV/AIDS. Half of the patients have concomitant pulmo-
nary TB in keeping with the haematogenous spread of
infection.
6 L.S. Ch’ng et al. / Clinical Radiology xxx (2017) 1e6
Hepatobiliary TB presents as a challenge to treat, as pa-
tients may have reactivation at contralateral lobe even
though the disease is quiescent in the ipsilateral lobe. Early
diagnosis and treatment is needed to preserve residual liver
function. Knowledge and awareness of the spectrum of
manifestations and investigative findings are important, as
the timely diagnosis of extra-pulmonary TB remains a
challenge in most cases. A high degree of clinical suspicion
is required to diagnose this entity, which can be medically
managed; however, liver biopsy and histopathological ex-
amination gives the definitive diagnosis. Delayed treatment
can result in hepatic failure and ultimately death. It is often
important to look for the involvement of other organs and
consider the co-existence of other diseases such as
malignancies.
Anti-TB treatment is effective in most of cases with early
diagnosis and prompt treatment. The prognosis of hepatic
TB with early diagnosis and treatment are usually good.
Quadruple therapy (isoniazid, rifampicin, pyrazinamide,
and ethambutol) is the recommended anti-TB protocol. At
least 1 year of medical therapy is generally required.21 In-
dications of surgical treatment of hepatic TB include1: iso-
lated tuberculoma, liver tuberculous abscess with
ineffective anti-TB treatment2; compression of biliary tract
causing obstructive jaundice3; concurrent portal hyper-
tension or biliary tract bleeding or acute abdomen4;
confusion with malignant lesions.22 Surgical procedures
include enucleation, local excision, liver segmentectomy or
lobectomy, abscess drainage, and biliary drainage.
In conclusion, hepatic TB has non-specific clinical man-
ifestations, and therefore, imaging along with image-guided
fine-needle aspiration/biopsy, offer the best diagnostic
value. The presence of calcified and hypodense nodules
with biliary duct dilatation associated with lobar atrophy
were the most consistent features of hepatic TB in the
present series, especially in the presence of active lung
disease. Unless there was a high index of suspicion, the
diagnosis was often overlooked.
Acknowledgements
The authors thank Hospital Sibu, Sarawak, Malaysia, for
providing some of the images used in this review and the
Director General of Health Malaysia for his permission to
publish this article.
Please cite this article in press as: Ch’ng LS, et al., Imaging appearances of hepatic tuberculosis: experience with 12 patients, Clinical Radiology
(2017), https://doi.org/10.1016/j.crad.2017.10.016
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