abdominal tb , a common clinical entity in indian sub - continent can infect the gastrointestinal tract , peritoneum , mesentery , lymph nodes , liver , spleen and pancreas .
hepatic tb is usually associated with miliary tb or active pulmonary tb . however , isolated liver tb in the absence of miliary tb is very rare restricted to case reports and case series in english literature .
the diagnosis is often delayed due to lack of specific symptoms and laboratory findings . here
we report a case of synchronous hepatic tb and adenocarcinoma of the colon which is a very rare finding with only a few reports in the literature and none from the indian subcontinent .
this case illustrates the diagnostic difficulties of hepatic tb and the need to consider it in the differential diagnosis of hepatic nodular lesions in carcinoma colon patients . increased awareness of this rare association
a 50-year - old female presented to the emergency department with pain in the abdomen since 5 days , vomiting and constipation since 3 days .
she had no other co - morbidities , and her family history was not significant . on examination she was conscious , oriented with a regular low volume pulse of 98/min , blood pressure 98/66 mmhg , respiratory rate 22/min , and temperature of 98.8 f. abdominal examination revealed mild distension with visible peristalsis .
rectum was empty on per rectal examination , and there was no evidence of any growth .
clinical impression of acute intestinal obstruction was made , and the patient was subjected to blood and radiological investigations .
her blood investigations were - hemoglobin : 9.1 g / dl , total leucocyte count : 7000 cells / mm , serum bilirubin 0.9 mg% , serum glutamic - oxaloacetic transaminase : 55 iu , serum glutamic pyruvic transaminase : 48 iu , blood urea : 29 mg% , serum creatinine : 1.4 mg% , potassium : 3.2 meq / l , sodium : 139 meq / l , random blood sugar : 98 mg% patient was subjected to x - ray abdomen and chest .
x - ray abdomen showed multiple air fluid levels while chest x - ray was normal .
based on history , clinical examination and x - ray findings , an impression of acute intestinal obstruction secondary to postoperative adhesions was made .
exploration revealed distended small bowel and caecum with a circumferential growth at the hepatic flexure of size around 5 cm  5 cm .
the mesenteric lymph nodes were enlarged , and there were three liver lesions , two on the right lobe and one on the left ranging in size from 2 cm to 5 cm .
an extended right - sided hemicolectomy with ileocolic , end - to - end anastomosis was done .
patient recovered well though she developed superficial surgical wound infection which was treated with irrigation and antibiotics as per the culture and sensitivity .
post - operative contrast enhanced computerized tomography of the abdomen showed multiple hypodense lesions in both lobes of the liver suggestive of metastases [ figure 1a and b ] .
histopathological examination of the resected bowel revealed well - differentiated mucin secreting adenocarcinoma invading the muscular layer [ figure 2c and d ] .
biopsy from the liver nodules showed multiple confluent epithelioid granulomas with caseation necrosis suggestive of tb [ figure 2a and b ] .
hypodense lesion in segment 3 of the liver suggestive of metastasis ( b ) microphotograph showing numerous confluent epithelioid granulomas effacing the normal liver architecture ( h and e , 100 ) ( a ) .
high power view of caseating granuloma with adjacent normal hepatocytes ( h and e , 400 ) ( b ) .
adenocarcinomatous glands with extracellular mucin infiltrating the muscle layer ( h and e , 100 ) ( c ) .
high power view showing glands lined by malignant cells having enlarged hyperchromatic nuclei , coarse chromatin and eosinophilic cytoplasm ( h and e , 400 ) based on the histopathology findings , patient was put on anti - tubercular treatment .
chemotherapy was not started as it was a t2 tumor and patient was put on regular follow - up .
thus , the patient responded well to anti - tubercular treatment and is still continuing with the treatment .
third and much rarer form is focal hepatic tb in the form of local tuberculoma or abscess .
our case was also an example of the third form that is , focal hepatic tb with three nodular lesions seen in liver . incidence of isolated hepatic tb is estimated to be 0.3% .
it is rare due to low tension of hepatic oxygen which is unfavorable for the mycobacterial growth .
hepatomegaly is the most common finding present in 96% of the cases although it was not present in our case .
it is not possible to diagnose hepatic tb on imaging as other focal lesions in the liver such as metastasis , and hepatocellular carcinoma can have a similar appearance .
noninvasive diagnosis is , therefore , difficult , and up to 90% cases require laparotomy for definitive diagnosis as seen in our case too .
the best method of diagnosis remains pathological examination of liver biopsy which will show characteristic caseating granulomas . in a study by landen et al .
major hepatectomy was done in a colon cancer patient diagnosed with focal liver lesions presuming it to be colonic liver metastasis .
our patient also showed numerous confluent epithelioid granulomas with caseation necrosis thus clinching the diagnosis of hepatic tb .
the possible mechanisms include reactivation of the dormant bacilli due to immunosuppression caused by cancer and derangement of host 's intestinal mucosal barrier by underlying malignancy . however , coexistence of colon carcinoma with isolated hepatic tb is very rare and , therefore , no cause - effect relationship could be defined .
isolated hepatic tb although uncommon should be included in the differential diagnosis of liver mass especially in areas endemic for tb .
it can be confused with primary or metastatic carcinoma especially if associated with other malignancies .
coexistence of carcinoma colon and hepatic tb , although rare should be kept in mind especially in countries where tb is rampant .
 tuberculosis ( tb ) presenting as isolated liver mass without clinical evidence of tb is difficult to diagnose preoperatively and is usually mimicked by primary or metastatic carcinoma of the liver . 
 hepatic tb associated with carcinoma colon is a rare association which has very rarely been reported in the literature . 
 this case illustrates the diagnostic difficulties of hepatic tb and the need to consider it in the differential diagnosis of hepatic nodular lesions in carcinoma colon patients . here 
 , we report a case of 48-year - old female who presented in the casualty with features of acute intestinal obstruction . 
 preoperatively a mass was seen at the hepatic flexure along with three lesions in the liver presumed to be metastatic in origin 
 . however , histopathology of the mass revealed adenocarcinoma colon and the liver lesion proved to be hepatic tb . 
 we wish to highlight that on encountering a hepatic lesion in a carcinoma colon patient the possibility of hepatic tb should also be kept in mind apart from the obvious possibility of metastasis especially in an endemic country like india . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION