Liver tuberculosis

　　1. Etiology

　　Mycobacterium tuberculosis belongs to the order Actinomycetales, the family Mycobacteriaceae, and the genus Mycobacterium, which is an acid-resistant pathogenic bacterium. It is mainly divided into human, bovine, avian, murine, and other types. The type that is pathogenic to humans is mainly the human type, and the bovine type is rarely infected. The morphology of the tuberculosis bacterium is slender and curved, with blunt ends, no spores or capsules, no flagella, about 1-5 μm in length, and 0.2-0.5 μm in width. In the specimen, it appears in a scattered state or in clusters or arranged in chains. The tuberculosis bacterium is an aerobic bacterium that does not reproduce under anaerobic conditions but can survive for a relatively long time. Under good conditions, it reproduces one generation every 18-24 hours, and the lipid component of the bacterial body accounts for about 1/4 of its weight, showing acid-fastness during staining. The tuberculosis bacterium has strong resistance to dryness and strong acids and alkalis, and can exist for a relatively long time in the external environment, surviving in sputum for 20-30 hours and in moist places for 6-8 months. However, its resistance to humidity and heat is very low, and it can be killed by boiling for 5 minutes or by direct exposure to the sun for 2 hours. The disinfection effect of ultraviolet light is good. Both the human and bovine tuberculosis strains are obligate parasites, respectively with humans and cattle as their natural reservoir hosts. Both have the same intensity of pathogenicity to humans, monkeys, and guinea pigs. The drug resistance of the tuberculosis bacterium can develop from先天 resistant bacteria in the bacterial population, or it can quickly develop resistance to a single anti-tuberculosis drug used in the human body, resulting in the emergence of drug-resistant bacteria. Drug-resistant bacteria can cause difficulties in treatment and affect efficacy. Long-term contact with streptomycin can also cause dependence, known as drug dependence, but drug-dependent bacteria are rarely seen in clinical practice.

　　肝结核是由各种肝外结核菌播散到肝脏所致，有时因肝外原发灶较小或已痊愈，不能查出原发病灶，据统计能查到原发灶者仅占35％。

　　二、发病机制

　　肝脏血运和淋巴丰富，一般进入人体的结核杆菌均能到达肝脏。但肝脏的再生修复能力较强，并且具有丰富的单核吞噬细胞系统，胆汁也有抑制结核菌生长的作用，因此并非侵入肝脏的结核菌都能形成病灶。只有当机体免疫功能低下或大量结核菌侵入肝脏或肝脏本身存在某些病变，如脂肪肝、肝纤维化、肝硬化或药物损伤时才较容易发生肝结核。

　　近年发现人类免疫缺陷病毒(HIV)感染者或其患者肝结核发病率显著增加，提示细胞免疫在肝结核的发生发展中占有重要地位。

　　结核杆菌侵入肝脏的途径有：①肝动脉：为引起肝结核的主要途径。全身血行播散性结核病，或身体任何部位的活动性结核病灶，由于机体免疫力降低，或由于某些局部因素，结核病灶破溃，结核杆菌进入血液循环，经肝动脉进入肝脏。②门静脉：少数肝结核病可经门静脉途径感染。门静脉系统源头的器官或组织结核病如肠结核或肠系膜淋巴结结核病灶中的结核杆菌通过门静脉而侵入肝脏。③脐静脉：胎儿期胎盘结核病灶中的结核杆菌通过脐静脉进入胎儿体内引起先天性肝结核。④淋巴系统：肝内淋巴管直接与腹腔淋巴丛、腹膜后淋巴结相通，故腹腔内结核可经淋巴入肝形成感染灶。⑤直接蔓延：肝脏邻近器官组织的结核病灶可直接侵及肝脏。

　　The basic pathological change of hepatic tuberculosis is granuloma. It can develop into different pathological types due to differences in the number, location of the invading tubercle bacilli, and the body's immune function status. Generally, it can be divided into: ① Millet grain type: most common. It is part of the systemic hematogenous disseminated millet grain type tuberculosis. The lesion is of millet grain size to 2cm, hard, and presents as multiple white or grayish white small nodules, widely scattered throughout the liver. This type is severe, difficult to diagnose clinically, and is often found during post-mortem examination or laparotomy. ② Nodular type: less common. Lesions are more localized, forming single or multiple nodules more than 2-3cm in size, hard, and grayish white, even融合 into lumps, resembling tumors, and also known as tuberculosis nodules. ③ Empyema type: The center of the tuberculous lesion forms white or yellowish white caseous pus, which can be single or multiple, with the cavity being mostly unilocular, and bilocular being rare. ④ Biliary type: Hepatic tuberculosis lesions involve the bile duct or abscesses break into the bile duct, forming biliary tuberculosis lesions, manifested as thickening of the bile duct wall, ulcers, or stenosis. This type is rare. ⑤ Peritoneal type: It is manifested as millet grain type tuberculosis foci in the liver capsule or the capsule hyperplasia and hypertrophy forming the so-called 'candy-coated liver'. It is relatively rare.

　　Jaundice is generally mild or moderate, mostly persistent, with a few cases showing fluctuations. It often occurs in conjunction with acute fulminant type. The causes include:

　　1, Tuberculous lymph nodes compressing extrahepatic bile ducts.

　　2, Destruction of liver parenchyma or ulceration into the bile duct by intrapulmonary tuberculous granuloma.

　　3, Obstruction of the intrahepatic bile ducts.

　　4, Toxic liver cell damage, fatty liver, and others. For a specific patient, it may be caused by several factors.

　　5, Chronic disseminated tuberculosis and the terminal stage of tuberculosis accompanied by hepatic tuberculosis, with 80% of cases presenting with jaundice, indicating that jaundice is a sign of severe illness.

　　6, Hepatomegaly is present in the vast majority of patients (76% to 95%), with those having an enlargement between 2 to 6cm below the ribs being more common (42%). The liver surface is usually of moderate hardness and generally smooth, with a few having明显 nodules. The liver may be tender, and sometimes the tuberculous lesion involves the liver capsule, resulting in a friction sound. If there is the formation of an intrapulmonary tuberculous abscess, the pain and tenderness of the liver become more pronounced; when the abscess ruptures, there may be severe abdominal pain, shock, and signs of peritonitis. The causes of hepatomegaly include tuberculous liver abscess, tuberculosis nodule, tuberculous granuloma, nonspecific reactive hepatitis, fatty liver, amyloidosis, and others.

　　7, Splenomegaly is observed in about half of the cases, with significant enlargement, usually between 0.5 to 9cm below the ribs, and may extend beyond the navel. Splenomegaly associated with hepatic tuberculosis generally indicates splenic tuberculosis. It is mainly due to the infiltration of tuberculous granulomas and the proliferation of splenic reticular cells. Splenomegaly is often accompanied by hypersplenism, with varying degrees of reduction in all three blood formed elements.

　　8. Ascites and abdominal mass are mainly due to tuberculous peritonitis and lymph node tuberculosis.

　　The main symptoms of this disease include fever, loss of appetite, fatigue, pain in the liver area or upper right quadrant, liver enlargement, fever often in the afternoon, sometimes accompanied by chills and night sweats; there are also patients with low fever and remitting fever, fever can reach 39～41℃, 91.3% of patients have fever symptoms, and those with tuberculosis or a clear history of tuberculosis, long-term repeated fever, and excluding other causes, often have liver tuberculosis.

　　Liver enlargement is the main sign, more than half have tenderness, liver texture is hard, nodular mass; about 15% of patients may have mild jaundice due to nodular compression of the hepatic bile duct, and 10% of cases have ascites.

　　Preventing and treating primary extrahepatic tuberculosis is the key to preventing liver tuberculosis:

　　1. First, it should be to actively, as soon as possible, and completely cure active pulmonary tuberculosis, so that sputum bacteria turn negative.

　　4. Develop good hygiene habits, do not swallow sputum containing Mycobacterium tuberculosis.

　　3. Use the utensils of patients with active pulmonary tuberculosis separately, and disinfect them regularly by boiling to prevent cross-infection.

　　2. Milk must be pasteurized (56℃×30min) or boiled before drinking, do not drink raw milk.

　　5. Strengthen personal hygiene, often expose clothes, bedding and other household items to the sun, kill the contaminated Mycobacterium tuberculosis.

　　5. Strengthen physical exercise, improve the body's resistance to disease.

　　First, suitable foods:

　　1, Starch and bean selection: soybeans and soy products, brown rice, buckwheat, rice, millet,芡实, mung bean, red bean, corn, wheat, etc.

　　2, Meat, egg, and milk selection: fish, eggs, dairy products, lean meat, pork liver, lung, old hen, beef, mutton, eel, turtle, tortoise, black fish, duck egg, duck, abalone, jellyfish skin, etc.

　　3, Vegetable selection: lily, green vegetables, winter melon, lotus root, tomato, potato, carrot, radish, water chestnut, lotus seed, water caltrop, silver ear, yam, black fungus, and white fungus, etc.

　　4, Fruit selection: pear, persimmon, orange, sugarcane, water chestnut, banana, jujube, apple, lotus seed, papaya, pear, watermelon, etc.

　　5, Other honey, peanuts, sesame seeds, goji berries, chestnuts, etc.

　　Dietary taboos: fatty meat, alcohol, bamboo shoots, spinach, pepper, chili, mustard, ginger, chive, onion, shallot, star anise, and fried and dry braised dishes.

　　Second, food therapy recipes:

　　1, Sheep marrow and raw earth soup: 50 grams each of sheep spinal cord and honey, 10 grams of raw earth, 15 grams of cooked sheep lard oil, 25 grams of yellow wine, a few strands of ginger, and a little refined salt. Place the sheep spinal cord and raw earth in a pot, boil the soup until cooked, remove the medicine residue, then add cooked sheep lard oil, refined salt, ginger strands, yellow wine, and honey, and heat until boiling.

　　2, Silver ear pigeon egg custard: 2 grams of silver ear, 20 grams of rock sugar, and 1 pigeon egg. Soak the silver ear in water for 20 minutes, knead it into pieces, add 400 grams of water, boil with high heat, then add rock sugar, and simmer with low heat until soft; then crack the pigeon egg, steam with low heat for 3 minutes, and put it into the cooked silver ear custard, and boil it.

　　3, Carrot honey soup: 1000 grams of carrots, 100 grams of honey, and 3 grams of alum. Clean the carrots, slice them, add 350 grams of water, boil for 20 minutes, remove the residue and take the juice, add honey and alum, stir well, and boil for a moment more.

　　4, Turtle nourishing yin soup: 250 grams of turtle meat, 9 grams each of bai bu, di gu pi, and zhi mu, 24 grams of raw earth, and an appropriate amount of refined salt. Place the turtle in a pot of boiling water to kill it, cut off the head and claws; peel off the hard shell, remove the internal organs, clean and cut into 1 cm square pieces, and place them with the cleaned bai bu, di gu pi, zhi mu, and raw earth in a pot. Add an appropriate amount of water, boil with high heat, then simmer with low heat for 2 hours, season with refined salt, and it is ready.

　　5, Chicken liver and oyster conch shell soup: 1-2 chicken livers, 15-24 grams of fresh oysters, 12-15 grams of conch shell. Clean and cut the chicken liver, crush the fresh oysters and conch shell; first decoct the oysters and conch shell, add the chicken liver after 60 minutes, and drink the soup after the chicken liver is cooked.

　　6. Snow Pear and Spinach Root Soup: One snow pear, 30 grams of spinach root and lily, 12 grams of Bai Bu. Wash the snow pear clean and cut into pieces, wash the spinach root clean and cut into segments, and cook with lily and Bai Bu in a pot, add an appropriate amount of water, boil the soup, and it is ready after boiling for 40 minutes.

　　First, traditional Chinese medicine treatment methods for liver tuberculosis

　　Liver tuberculosis is also known as liver consumption in traditional Chinese medicine. Traditional Chinese medicine explains liver consumption as the invasion of consumptive worms into the liver, blocking the discharge, consuming nutrients, and eroding the liver Yin. Therefore, according to the syndrome differentiation and treatment of traditional Chinese medicine, the following treatment methods can be adopted.

　　1. Heat-toxin and liver stasis syndrome:Right side pain, mass under the right ribs, local tenderness, aversion to cold and fever or alternating fever and chills, bitter taste in the mouth and dry throat, dizziness and blurred vision, red tongue with thin yellow coating, wiry and rapid pulse. Clear the liver and泻火, remove blood stasis and detoxify. Huaihu Qinggan Decoction added with Di Bi, Xuanfu Hua, etc.

　　2. Liver stasis and phlegm mass syndrome:Right side piercing pain, there is a mass under the ribs, which is not moved when pushed, local tenderness, muscle atrophy, decreased appetite, occasional fever and chills, purple tongue with ecchymosis,涩脉. Remove blood stasis, phlegm, soften hard mass, and disperse nodules. Biejia Fuming Pill with modifications.

　　3. Liver and kidney Yin deficiency syndrome:Right side pain, liver enlargement, soreness in the loins and knees, dizziness and blurred vision, tinnitus and deafness, irritability and night sweats, hot palms and soles, dry mouth and throat, red tongue with little coating, fine and rapid pulse. Tonify the liver and kidney, clear heat and resist tuberculosis. Zhizi Dihuang Decoction added with Bai Bu, Bai He, Bai Wei, etc.

　　Second, Western medical treatment methods for liver tuberculosis

　　The treatment of liver tuberculosis is the same as that of miliary tuberculosis, including the use of anti-tuberculosis drugs and nutritional support therapy.

　　1. Drug Treatment:Rifampin, isoniazid, ethambutol, and streptomycin are the first-line drugs for tuberculosis, and kanamycin, ethionamide, and crotamiton, and other drugs can also be selected. In clinical practice, rifampin is often used in combination with isoniazid, or pyrazinamide is used in combination with rifampin and isoniazid to reduce the production of drug resistance in Mycobacterium tuberculosis. For tuberculous liver abscess, surgical drainage or lobectomy of the liver should be considered; for biliary obstruction and obstructive jaundice, surgical drainage can also be considered.

　　2. Nutritional Support:For patients, high-protein, high-calorie, high-carbohydrate foods rich in vitamins B and C should be provided, and the intake of fat should be moderate to avoid increasing the digestive burden on the liver. In addition, foods rich in calcium and iron, such as milk, dairy products, and seafood, bone soup, animal liver or blood, and egg yolks, can also be provided for patients.