Miliary tuberculosis of the spleen. Changes in the spleen in metabolic disorders, inflammatory processes, circulatory disorders. Folk remedies

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Spleen infarction

The disease is clinically manifested by the sudden appearance of sharp pains in the left hypochondrium. Fever, severe tachycardia, vomiting, intestinal paresis, muscle tension in the left hypochondrium, a positive symptom of Blumberg-Shchetkin are noted.

In some cases, infection, tissue melting and abscess formation occur in the infarction area.

When a heart attack is infected, there is a higher body temperature, leukocytosis with a shift of the leukoformula to the left. Small heart attacks can occur without much symptomatology. Almost self-healing occurs, followed by the formation of scar tissue on the surface of the spleen.
In the zone of infarction, a false cyst of the spleen sometimes develops.

The differential diagnosis of spleen infarction should be carried out with its spontaneous rupture.

Tuberculosis of the spleen

Clinic and diagnostics. The disease has no specific characteristic clinical symptoms. Fever may occur periodically. The first sign of the disease is often hepatosplenomegaly. The spleen reaches a considerable size. In the blood, the phenomena of hypersplenism are revealed: anemia, leukopenia, thrombocytopenia. A decrease in the number of platelets leads to the development of hemorrhagic syndrome. Tuberculosis tests are usually positive. Mycobacterium tuberculosis is found in the punctate of the spleen. RI allows you to identify calcified foci of tuberculosis in the spleen.

Treatment. Conduct conservative treatment with anti-tuberculosis drugs. Rational anti-tuberculosis treatment leads to a decrease in the size of the spleen, an improvement in the general condition and hemogram parameters.

The indication for splenectomy is isolated tuberculosis of the spleen, which is not amenable to specific therapy. The latter is carried out in the pre- and postoperative period.

Tuberculosis of the liver is a pathological process that occurs as a result of hematogenous dissemination or the spread of Koch's bacillus by the lymphogenous route. The disease is dangerous, often diagnosed in people who abuse alcohol, smoke, are subject to frequent stress, with poor living conditions and personal hygiene.

Sometimes the disease becomes secondary (with the existing pathological process in the body). Left untreated, mycobacteria can spread through the bloodstream to other organs.

Causes and types of the disease

The most common form of the disease is pulmonary TB. However, the weakening of the immune system, which is caused by various factors, leads to the emergence of extrapulmonary forms of the disease.

From the lungs, Koch's wand, getting into the blood, spreads throughout the body. Any tissues and organs are affected, the following varieties are more often noted:

• tuberculosis of the spleen;
• TB of the genitourinary organs;
• TB of bones;
• tuberculous pericarditis;
• TB of the central nervous system;
• tuberculosis of the heart.

The causes of the disease are different, the main one is the penetration of mycobacteria into tissues and organs along with the blood flow. As a result, the following forms of liver damage develop:

• focal TB;
• miliary TB;
• tuberculous granulomatosis.

Miliary tuberculosis of the liver develops as a result of the penetration of bacilli into the liver. More common and easier flows another form - tuberculous granulomatosis.

The examination reveals multiple granulomas, in the center of which is necrosis. Over time, fibrous zones form around them, which causes fibrotic changes in the liver.

When caseous particles enter the lumen of the bile ducts, tuberculous cholangitis and tuberculous pylephlebitis develop. A severe lesion is a combination of tuberculosis of the liver, spleen and bone marrow.

Tuberculosis of the internal organs has various manifestations, which depend on the type of development, the individual characteristics of the patient, the form of the pathology, etc.

The presence of a large number of signs creates difficulties in diagnosis.

Symptoms depending on the type

At the initial stage of hepatitis TB, the manifestations are similar to those of pulmonary TB. More often, miliary lesions develop as a result of a long course of chronic pulmonary or intestinal tuberculosis. It happens that the pathology is detected after the death of the patient.

Characteristic manifestations for miliary tuberculosis:

• hepatomegaly;
• sometimes - splenomegaly;
• yellowness of the sclera, skin;
• symptoms of intoxication: chills, excessive sweating, fever.

Such symptoms occur as a result of the formation of granulomas in the lobules of the liver and the walls of the ducts. The yellowness of the skin is due to compression of the hepatic duct.

Tuberculous granulomatosis is more common (in patients with pulmonary and extrapulmonary forms). Clinical manifestations are minimal, and an increase in the size of the liver is not always noted.

It is characterized by the formation of tubercles surrounded by a fibrous capsule with areas of necrosis in the center of the focus.

In the process of palpation, it is possible to determine hepatomegaly, in some cases - protrusions of a tumor-like form on the surface of the liver. Over time, patients begin to worry about:

• severe weakness;
• loss of appetite;
• weight loss;
• fever.

Once in the lumen of the bile ducts, caseous particles cause intrahepatic cholestasis and destruction of duct tissues. This is accompanied by:

• fever;
• loss of appetite;
• weight loss;
• jaundice.

In case of damage to the portal lymph nodes, if infected masses enter the lumen of the portal vein, tuberculous pylephlebitis develops. Often this pathology ends in death.

When breast tuberculosis occurs, symptoms include:

• loss of appetite;
• temperature rise;
• weight loss;
• increased sweating;
• redness of the skin over the seal.

Diagnosis and treatment

Diagnosis of liver tuberculosis on the basis of patient complaints is difficult: the general condition may be disturbed by tuberculous lesions of other organs.

Of the laboratory research methods used:

• general blood test;
• biochemical blood test;
• tuberculin test.

To confirm the diagnosis is carried out:

• chest x-ray;
• Ultrasound of the liver and bile ducts;
• fine needle puncture biopsy;
• echography;
• diagnostic laparoscopy.

Often there is an accelerated ESR, an increased level of gamma-glutamyl transpeptidase, alkaline phosphatase, alpha-2-globulin fractions. Sometimes patients develop symptoms of anemia.

Differential diagnosis of liver tuberculosis is carried out with the following pathologies:

• hepatosis;
• chronic hepatitis;
• chronic cholangitis;
• cirrhosis of the liver;
• intestinal tuberculosis.

If liver tuberculosis is diagnosed, treatment continues for about a year. Its purpose is to eliminate the source of infection. Of the anti-tuberculosis drugs, Rifampicin, Isoniazid, Streptomycin, Pyrazinamide, Ethambutol are used.

The dosage of drugs and the regimen of administration depend on the location of the pathological focus. Given the high toxicity of anti-tuberculosis drugs, during treatment, the patient may need to consult a nephrologist, cardiologist, ophthalmologist, etc.

To normalize the activity of the body, hepatoprotectors, protease inhibitors, glucocorticosteroids are prescribed. Patients are recommended diet No. 5 or No. 5a with a restriction:

• spicy, canned, salty, fried foods;
• extractive substances;
• refractory fats (cream, fatty meat, butter).

Treatment options for liver tuberculosis include:

• vitamin therapy (to accelerate the recovery of liver tissue);
• infusion therapy (for detoxification of the body).

Which doctor to contact

If you experience a cough at night, persistent fever, excessive sweating, hemoptysis, pain, you should contact a phthisiatrician.

Depending on the age of the patient, the doctors to whom you should contact: a general practitioner or a pediatrician.

A TB doctor is a doctor who diagnoses and treats TB.

Other doctors to contact:

• hepatologist;
• gastroenterologist.

Damage to the liver with Koch's bacillus is a dangerous disease, the outcome of treatment depends on the form of the pathology and the timeliness of detection.

Tuberculosis of the spleen is a process of tissue destruction or modification caused by bacterial overgrowth. The spleen is covered with nodes of various sizes. The spread of infection adversely affects the functioning of the organ.

Tuberculosis of the spleen is not a very well-known disease. Most often, a person learns about the existence of a pathology when the doctor makes this diagnosis. And this means that the disease is already progressing. If you know in advance about a possible lesion, you can avoid all the difficulties associated with treatment and recovery. Tuberculosis is a dangerous disease that threatens to be fatal if measures are not taken in time to identify and eliminate the focus.

Causes of pathology

1. Most often, tuberculosis of the spleen is a consequence of tuberculosis of the lungs. This happens when the disease is in an acute form. This pathology is called miliary tuberculosis, which is characterized by infection of the entire body, including the spleen. Pathogenic bacteria spread through the blood or lymph throughout the body. There are cases when the disease arose independently, and did not become secondary against the background of a mass defeat of the body.
2. A negative environmental situation can cause a primary disease, since pathogenic bacteria enter the body through physical contact with the source of infection, as well as through inhalation of a pathogen diffused in the air.
3. Decreased immunity can also be the cause of the development of the disease. Nature has a natural resistance to aggressive bacteria that cause tuberculosis. However, with a decrease in the protective barrier, the risk of injury increases.

Symptoms of tuberculosis of the spleen

Sometimes the disease progresses rapidly, but most often the symptoms are not pronounced, and the development of the disease is long-term.

Main symptoms:

1. Pain in the left side.
2. Body temperature stays at 37˚-37.5˚ for a long period of time.
3. Chronic loss of strength.
4. Lack of appetite.
5. Splenomegaly of the spleen, in which its value significantly exceeds the norm and can reach 3.5 kg.

With the rapid development of the disease, the patient experiences physical exhaustion, a critical temperature rise to 40˚, and a change in blood composition.

Diagnosis of the disease

Diagnosis of the disease can be difficult due to extensive infection of the body. Local diagnostics includes:

• test samples that help assess the level of anti-tuberculosis immunity;
• blood analysis;
• x-ray and ultrasound of the abdominal cavity;
• examination of biological material for the presence of pathogenic bacteria;
• examination using a camera that is inserted surgically.

The last two methods give the greatest objectivity in diagnosing. However, accurate confirmation of the disease can only be obtained after surgery based on laboratory tests of the removed organ.

How to treat tuberculosis of the spleen

The development of medicine has reached a high level, so it is possible to cope with tuberculosis of the spleen only by conservative methods.

In very rare cases, resort to surgery. This is due to the fact that the spleen is located in the place of a large number of adhesions and this causes a number of complications during the operation. The indication for splenectomy is the rapid course of the disease. In this case, the essence of the operation is reduced to the partial or complete removal of the affected areas of the organ. Postoperative recovery is carried out with the help of drugs.

Medical treatment

1. Main purpose - Streptomycin. It is one of the most effective anti-tuberculosis antibiotics. After its use, blood counts improve, the spleen returns to normal, the patient's condition stabilizes. The use of this drug or its analogues lasts from six to twenty-four months. The first two months of treatment takes place in a hospital.
2. Restoration of vitamin and mineral balance. The doctor prescribes the main groups of vitamins, since tuberculosis greatly weakens the body, causing decomposition and inflammation.
3. Health food. To speed up the recovery processes, much attention is paid to the nutrition of the patient. Tuberculosis leads to the decomposition of proteins in the body, so the patient is prescribed a diet in which proteins predominate. Compliance with the norms of nutrients, vitamins, micro and macro elements stimulate a speedy recovery.
4. Immunostimulation. Decreased immunity is one of the main causes of tuberculosis damage to the spleen, so much attention is paid to immunotropic drugs. They have a beneficial effect on the restoration of protective functions and increase the body's resistance.

Treatment of tuberculosis of the spleen with folk methods

As additional methods of treatment, you can use folk recipes. Herbs and foods also have powerful anti-inflammatory effects and are natural antibiotics. It is not worth focusing on the treatment of folk remedies, but even doctors recommend taking decoctions as a supportive remedy.

1. A decoction of aloe and honey. A glass of honey, half a glass of water, 3 tablespoons of aloe leaves simmer for about two hours. Take 1 tablespoon 1 time per day.
2. Birch bud tincture. For half a liter of vodka, take 1 tablespoon of kidneys and insist until dark brown. Take 1 tablespoon before meals.
3. Knotweed decoction. 1 tablespoon of knotweed leaves is poured into 250 ml of boiling water and infused for about 10 minutes. Take 20 minutes before meals, 1 tablespoon.

Features of the treatment of tuberculosis of the spleen during pregnancy

There is no need to be afraid of spleen tuberculosis if it is discovered during pregnancy. With proper treatment, the disease is not transmitted to the fetus. The only difficulty is that the symptoms of tuberculosis coincide with the manifestations of toxicosis, so diagnosing the disease can be difficult.

After establishing an accurate diagnosis, the doctor exercises individual control over the patient. Treatment occurs both during pregnancy and after childbirth. The doctor examines the mother's condition, assesses the possible risks and prescribes an acceptable dosage of medicines. Basically it is antibacterial drugs.

Mothers prescribe the diet. It also plays an important role in maintaining a healthy lifestyle. After the birth of a child, a woman is examined for the presence of pathogenic bacteria. Breastfeeding is allowed only with a positive test result. If microorganisms are found, then the child is transferred to artificial feeding. The child must be vaccinated against tuberculosis in order to protect him from infection. For safety reasons, all family members are also tested for tuberculosis.

To protect yourself from the appearance of such diseases, you need to take preventive measures, undergo regular examinations, and take care of your immune system.

UDK 616.36-002.5

O. S. Talanova, O. A. Kuzmina, A. O. Holeva, L. N. Savonenkova, O. L. Aryamkina

TB OF THE LIVER AND SPLEEN

Annotation. The liver and spleen in abdominal tuberculosis are affected in every third case (32.3%). Tuberculosis of the liver and spleen in 69.4% of cases is combined with pulmonary tuberculosis, predominantly miliary, in 58.1% with tuberculosis of extrapulmonary localizations, which testifies in favor of lymphohematogenous spread of the infection. Tuberculous hepatitis and splenitis currently occurs mainly in the form of miliary forms, against the background of tuberculous intoxication - febrile fever, increased ESR, lymphopenia, moderate anemia. For tuberculous hepatitis, hepatomegaly, moderate cytolysis, slight parenchymal jaundice, thickening of the capsules of the liver and spleen, diaphragmatic adhesions, the presence of "millet" rashes, epithelioid cell granulomas with caseous necrosis are pathognomonic.

Keywords: liver tuberculosis, spleen tuberculosis, clinic, diagnostics.

abstract. In cases of abdominal tuberculosis liver and spleen are affected in 32.3% of patients. Liver tuberculosis and splenic tuberculosis are accompanied in 69% of cases by pulmonary tuberculosis, mostly by its miliary form, and in 58.1% of cases -by extrapulmonary tuberculosis, which tests to lymphohematogenic dissemination of infection. Tubercular hepatitis and splenitis most frequently occur in military forms against the background of tubercular intoxication - febrile fever, increased erythrocyte sedimentation rates, lymphopenia, mild anemia. Pathognomonic for tubercular hepatitis are as following: hepatomegaly, moderate degree of cytolysis, mild hepatocellular jaundice, enlarged liver and splenic capsules, diaphragmatic adhesions, military eruptions, epithelioid cell granulomas with caseation necrosis.

Key words: liver tuberculosis, splenic tuberculosis, clinical picture, diagnostics.

Introduction

The number of patients with pathology of the digestive organs and, first of all, with chronic hepatitis is progressively increasing all over the world. Differential diagnosis of clinical and laboratory syndromes of hepatitis is very difficult due to the fact that, on the one hand, they are nonspecific, and on the other hand, they can be manifestations of diseases of various etiologies. In recent years, ideas about the etiology, clinic, course and outcomes of chronic hepatitis have been expanded, and its extrahepatic manifestations have been described. Against the background of an increase in the number of patients with severe viral and alcoholic liver diseases, the number of patients with autoimmune, drug-induced, non-alcoholic steatohepatitis, as well as with liver lesions of a different etiology, is also increasing. In the gastroenterological clinic, cases with newly diagnosed abdominal tuberculosis, including those of the liver, are increasingly being detected.

Tuberculosis is one of the most important medical and social problems of modern Russia. In Russia, the incidence of tuberculosis and its prevalence from 1990 to 2004 increased by 2.4 and 1.2 times, reaching the

respectively 83.1 and 218.3 per 100,000 population. Over the past four or five years, these figures have stabilized. However, the high drug resistance of the pathogen, severe concomitant pathology, including HIV infection, late detection of the disease with a predominance of common generalized processes in newly diagnosed patients maintain the intensity of the epidemic situation for tuberculosis. The level of detection of extrapulmonary tuberculosis is also unsatisfactory. Half of patients with extrapulmonary tuberculosis are diagnosed with advanced forms of the disease, which leads to disability in 25-50% of them.

Abdominal tuberculosis, which occupies a special position among extrapulmonary forms due to the significant difficulties in its diagnosis, accounts for 4.4–8.3 to 17–21% of all extrapulmonary localizations, which does not allow us to consider it a rare disease. In 2/3 of cases, abdominal tuberculosis is diagnosed in medical institutions of the general network: therapeutic and infectious services - in 13.4%, surgical - in 40.1%, oncological or hematological - in 16.2% of cases, and in 1/3 of cases - postmortally. At the same time, the number of its cases with generalized and advanced forms is increasing, and the time from the initial contact of a patient with abdominal tuberculosis to the medical network to determining the correct diagnosis is unreasonably high.

Abdominal forms, in addition to those included in the clinical classification of tuberculosis of the intestine, peritoneum and mesenteric lymph nodes, should also include tuberculosis of the parenchymal organs of the abdominal cavity - the liver and spleen. In the 70-90s. of the last century, specific damage to the liver and spleen was diagnosed in 22% of those who died from pulmonary tuberculosis, as well as in 5.8-10.7% of patients with abdominal localizations of tuberculosis. However, until now tuberculosis of the liver and spleen are considered rare localizations. Since they are not officially registered as independent forms, it should be assumed that the data on their prevalence are not true. The clinical picture of a specific lesion of the liver and spleen is described on the example of single observations of abdominal tuberculosis.

Purpose - to study the clinical picture and diagnostic criteria for tuberculosis of the liver and spleen.

Materials and methods

We examined 192 patients with abdominal tuberculosis aged 41.2 ± 0.94 years (95% CI 35.4-47), 2/3 of which were men, with an equal ratio of urban and rural residents, identified for the first time by a continuous sampling method over the period from 1990 to 2010. The diagnosis of tuberculosis of abdominal localizations was established on the basis of an assessment of a complex of clinical, laboratory and instrumental data and in 86.5% of cases it was verified morphologically by analyzing biopsy specimens obtained during laparoscopy or laparotomy (n = 78), endoscopy (n = 13) , sections (n ​​= 75). The study included only cases of tuberculosis of the liver and spleen,

established in 62 patients, confirmed histologically and diagnosed in medical institutions of the general network in 80.6% of cases. Tuberculous hepatitis was differentiated from hepatitis of viral, alcoholic and other etiologies. Statistical data processing was carried out using licensed statistical packages 8TLT18T1SL 6.0, 8R88 13.0, using parametric and nonparametric methods.

Results and its discussion

It was found that among the organs of the abdominal cavity, intra-abdominal lymph nodes and organs of the gastrointestinal tract were most often involved in a specific process in abdominal tuberculosis, less often parenchymal organs and serous membranes (Fig. 1).

Rice. 1. The frequency of involvement of various abdominal organs in abdominal tuberculosis

Abdominal tuberculosis can occur in isolation, spreading only to the abdominal organs, or combined with pulmonary tuberculosis or other extrathoracic localizations.

Specific inflammation of the parenchymal organs - the liver and (or) spleen - occurred in every third patient with abdominal tuberculosis (n = 62, 32.3%), and in 3/4 of them (n = 49.79%), the liver and spleen were affected simultaneously. Liver tuberculosis (n = 60, 31.3%) and spleen tuberculosis (n = 51, 26.6%) occurred in patients with abdominal tuberculosis with the same frequency (p > 0.05).

Tuberculous hepatitis and splenitis in 21% of cases proceeds in isolation, and in 79% of patients - in the form of combined forms. Combined tuberculosis of parenchymal organs occurred simultaneously with pulmonary tuberculosis (n = 43), tuberculosis of extrapulmonary localizations (n ​​= 36), including pulmonary tuberculosis and extrapulmonary tuberculosis, simultaneously (n = 25). In addition, tuberculosis of the parenchymal organs of the abdominal cavity in 38 (61.3%) patients proceeded with specific lesions of the intra-abdominal lymph nodes and peritoneum, less often of the intestines. The multiplicity of lesions makes it difficult to timely diagnose abdominal tuberculosis, including the liver and spleen.

In 49 out of 62 patients (79%) with tuberculosis of the liver and spleen, both respiratory organs and organs of other organs were involved in a specific process.

systems, including 25 (40.3%) of both at the same time. Pulmonary tuberculosis occurred in 43 patients; in 69.4% of cases. In 12 of them, destructive forms of pulmonary tuberculosis with bacterial excretion were diagnosed - infiltrative in the decay phase and fibrous-cavernous. In 31 patients, pulmonary tuberculosis was without decay and without bacterial excretion: in 29 people in the form of miliary, in 2 - disseminated form. It should be noted that abdominal tuberculosis is combined mainly with miliary pulmonary tuberculosis (X = 4.51; p< 0 ,05). Это свидетельствует о генерализации в организме туберкулезной инфекции, об ее лимфогематогенном, но не спутогенном распространении и, собственно, о тяжести заболевания.

Specific damage to organs of other systems, often two or more, including the kidneys, bones and joints, meninges, peripheral lymph nodes, genitals, occurs in more than half of cases (58.1%) of tuberculous hepatitis and splenitis. Tuberculosis of the liver and spleen is combined with pulmonary tuberculosis and other extrapulmonary tuberculosis with the same frequency (p > 0.05). In a third of cases (30.6%), tuberculosis of the abdominal parenchymal organs is combined with multiple specific extrapulmonary lesions in the form of miliary forms, which indicates a generalization of the infection. In every fourth case (27.4%), tuberculous hepatitis and splenitis are diagnosed simultaneously with destructive forms of nephrotuberculosis, osteoarticular tuberculosis and caseous salpingo-oophoritis, which are sources of infection spread to the abdominal parenchymal organs, and indicates a long-term widespread specific process.

Dynamic monitoring of the majority of patients in the process of diagnostic search, as well as the ability to assess pathomorphological changes in the abdominal organs in all, and in some cases in the lungs and other organs, made it possible to determine the morphological changes and pathogenetic mechanisms of tuberculosis of the parenchymal organs of the abdominal cavity, which is important for their timely diagnosis.

Tuberculosis of the liver and spleen can occur in the form of a miliary or diffuse form, focal form or tuberculoma. In the patients examined by us, tuberculosis of the abdominal parenchymal organs proceeded in the vast majority of cases (85.5%) in the form of miliary hepatitis and splenitis, developing as a result of hematogenous or lymphohematogenic dissemination of mycobacteria from other organs. The source of the spread of Mycobacterium tuberculosis in the abdominal parenchymal organs was most often extrapulmonary foci of caseous necrosis (66.1%) located in other organs of the abdominal cavity (38.7%), in the kidneys or bones (27.4%). In 19.4% of cases, the liver and spleen were affected by a specific process hematogenously during the dissemination of infection from the decay cavities in the lungs.

Much less often (14.5%), tuberculosis of the parenchymal organs of the abdominal cavity occurs in the form of single tuberculomas. Since there are no other foci of tuberculosis infection in the body, and tuberculomas contain calcifications, it can be assumed that their formation occurred in the primary period of infection. It is most likely that contamination with mycobacterium tuberculosis occurred at the stage of bacterial infection.

mii with primary aerogenic, and possibly with alimentary infection.

Tuberculosis of the liver and spleen always occurs against the background of tuberculosis intoxication. Intoxication and tuberculous lesions of organs prevail in the clinical picture of tuberculosis of the abdominal parenchymal organs. In addition to intoxication, there are also symptoms from the organs affected by the tuberculous process - abdominal and extra-abdominal. In 3/4 of patients with tuberculosis of the liver and spleen (79.0%), in addition to abdominal symptoms, clinical signs were detected from the organs of other systems (lungs, meninges, kidneys, etc.).

Objective signs of intoxication are manifested by febrile fever with an increase in body temperature up to 38.6 ± 0.2° (95% CI 38.2-38.9°) and changes in the hemogram: an increase in ESR (36.6 ± 3.1; 95% CI 30.342.9 mm/hour); slight leukocytosis (8.5 ± 0.7; 95% CI 7.1-9.8 x 109/l) and lymphopenia (16.3 ± 1.7; 95% CI 12.8-19.8%). A moderate decrease in hemoglobin level is also detected (105.7 ± 4.1; 95% CI 97.7-113.9 g/l). Clinical manifestations of intoxication are more pronounced in patients with tuberculous hepatitis and splenitis, combined with tuberculosis of the lungs and other organs. So, in the combined course of tuberculous hepatitis and splenitis, compared with its isolated variant, fever and an increase in ESR are higher (p< 0,001 , р < 0 ,05) в 1,1-1,4-1,6 раза, а анемия и лимфоцитопения в 1,2-1,8 раза более выражены (р < 0,05).

Since in 2/3 of cases (61.3%) with tuberculosis of the liver and spleen, the peritoneum, intra-abdominal lymph nodes, and sometimes the intestines are involved in a specific process, abdomialgia, stool disorders, and ascites occur.

Against the background of the symptoms listed above, hepatitis was diagnosed. Differences in the clinical manifestations of miliary tuberculous hepatitis and liver tuberculomas were revealed. The miliary form of liver tuberculosis is characterized by hepatomegaly - in 85.4% of cases the liver enlarges significantly, palpable 4-5 cm below the edge of the costal arch, and patients note heaviness and discomfort in the right hypochondrium. In these cases, most often right ventricular heart failure, septic lesions, carcinomatosis, hepatitis of various etiologies (acute viral, toxic, drug) were excluded. A quarter of patients (26.8%) had jaundice and pruritus, in 14.6% of cases - hemorrhagic rash.

Laboratory signs of tuberculous hepatitis are changes in biochemical samples. Cytolysis, hepatocellular insufficiency, parenchymal jaundice, and rarely cholestasis are detected. Hyperbilirubinemia reaches an increase in the level of the indicator by no more than two or three norms, averaging 33.1 ± 4.5 µmol / l (95% CI 23.5-42.6) with a ratio of its direct and indirect fractions of 54.6 / 45.4. The decrease in the level of prothrombin varies from 88 to 49%, the decrease in the activity of cholineserase reaches 4560 I / 1, and the laboratory activity of hepatitis corresponds to a moderate (II) degree - the activity of ALT and AST reaches an increase of 2.5-3.5 of the norm. Under the conditions of an infectious process - against the background of intoxication and fever - it is difficult to judge the markers of mesenchymal inflammation. However, the increase in the thymol test level reached a threefold value of normal values. From the laboratory

markers of cholestasis in tuberculous hepatitis, only a non-permanent increase in GGTP activity (maximum - up to 153 I / 1, on average up to 79.2 ± 13.6 I / 1 (95% CI 47.9-110.6)) or an excess the norm of the indicator is not more than 3-4.6 norms.

An increase in the activity of alkaline phosphatase up to 1.2-1.5 norms was detected only in cases of tuberculous lesions of the bones with a combined course of tuberculous hepatitis.

Liver tuberculomas are asymptomatic. There are no changes in biochemical samples with them, however, they require differential diagnosis with volumetric formations in the liver of various origins, since according to sonographic and macroscopic signs, either formations or calcifications are detected in the liver.

Clinical signs of a specific lesion of the spleen were manifested only by splenomegaly, which was physically detected only in half of the patients with its involvement and only in miliary form. With tuberculomas of the spleen, calcifications are most often detected in it.

Diagnostic difficulties are caused not only by cases of isolated, i.e. without involvement of the lungs and other organs, tuberculosis of the abdominal parenchymal organs. Tuberculous hepatitis and splenitis, combined with miliary pulmonary tuberculosis, the clinical and radiological picture of which, as is known, most often does not have pathognomonic signs, and the causative agent of the disease is absent in sputum, also causes difficulties in diagnosis. Miliary pulmonary tuberculosis in such cases is diagnosed only after the diagnosis of tuberculosis of the abdominal parenchymal organs is established.

According to the results of anamnesis, physical and laboratory examination, a specific etiology of lesions of parenchymal abdominal organs could be suspected in 12 of 62 patients (19.4%), namely, with destructive bacillary forms of pulmonary tuberculosis with multidrug resistance of the pathogen. However, tuberculosis of the abdominal parenchymal organs in these patients was diagnosed only after death, the cause of which was infectious-toxic shock.

Diagnosis of tuberculous hepatitis and splenitis, as shown by the results of the study, presents significant difficulties. Clinical manifestations of tuberculosis of the abdominal parenchymal organs were taken as symptoms of congestive heart failure, systemic connective tissue diseases, sepsis, alcoholic, viral and drug-induced hepatitis, and after the exclusion of the above pathology, for neoplastic processes.

Radiation research methods - ultrasound diagnostics, computed tomography, nuclear magnetic resonance imaging - only confirm the presence of hepato- and splenomegaly and make it possible to detect "diffuse changes" in the liver and spleen in miliary form, focal or small-focus formations in the parenchyma of organs and calcifications in case of Berkulemah. In most cases, the nature of the identified changes has not been established. Tuberculosis of the liver and spleen on the basis of radiological research methods could be diagnosed with a sufficient degree of certainty only in cases of simultaneous detection of calcifications in patients.

renchymatous abdominal organs and mesenteric lymph nodes, which occur in every fifth patient.

In most cases, diagnosis of tuberculosis of the parenchymal abdominal organs required diagnostic laparoscopy or laparotomy followed by histological examination.

Hepatomegaly is visualized macroscopically, in 39% of patients - thickening of the liver capsule, adhesions with the diaphragm, and in 19.5% of patients paraportal lymph nodes enlarged to 1-1.5 cm are found. With miliary tuberculous hepatitis and splenitis, multiple small, 2-3-4 mm in size, whitish-yellow tubercles are found, located under the organ capsule, having the same color on the cut, in some cases with "curdled" caseous contents. Tuberculomas of the liver and spleen are mostly single, defined as dense or soft elastic formations of a rounded shape, 0.6-0.8-1.5 cm in size, yellowish-gray in color, on a cut with caseous contents in the form of "crushed" or "pasty" masses, sometimes with inclusions of lime salts in the form of calcifications.

Histologically, epithelioid cell granulomas with the presence of Pirogov-Langhans cells, lymphoid elements and caseous necrosis in the center are determined. At the same time, some of the granulomas are characterized by a predominance of the cellular component, and some - by caseous detritus. Tuberculous hepatitis is morphologically characterized as minimal or mild according to the nomenclature according to Ya. O. Knode11 and a1. (1981) and is not accompanied by the development of fibrosis (Fig. 2).

In 69.6% of patients with tuberculosis of parenchymal organs, the outcome of the disease is unfavorable. The causes of death in them in equal proportions (X2 = 0.56; p > 0.05) are tuberculous intoxication due to the multiplicity and prevalence of the tuberculous process. Fatal complications in tuberculosis of the abdominal parenchymal organs are infectious-toxic shock as a result of severe tuberculosis intoxication, swelling and dislocation of the brain and renal failure in the combined course of abdominal tuberculosis with tuberculosis of the meninges and kidneys. However, hepatocellular insufficiency can complicate the course of the disease. From hepatocellular insufficiency, which complicated the course of tuberculous hepatitis, 1.61% of patients die. Despite the fact that fatal complications associated directly with liver damage develop extremely rarely, early diagnosis of tuberculosis of the abdominal parenchymal organs allows you to gain valuable time for prescribing specific chemotherapy and improve the outcome of the disease.

Thus, tuberculosis of the abdominal parenchymal organs should be suspected in patients with clinical and moderate laboratory signs of hepatitis in the presence of hypoechoic foci of diffuse changes in the parenchyma of the liver and spleen, calcifications in the mesenteric lymph nodes, miliary processes in the lungs, and also in the presence of a destructive specific process in the lungs, kidneys, genitals, bones.

1 Clinical syndromes: hepatomegaly / hepatospleiomegaly)

Intoxication-inflammatory syndrome

Syndromes of cytolysis, mesenchymal inflammation

Cytolysis +, mesenchymal inflammation +++ Cytolysis ++, mesenchymal inflammation +++

Syndrome of hepatocellular insufficiency

1 + -H- / 1 - 1 + 1 + / ++

Syndromes of jaundice, cholestasis

Intermittent at the stage of chronic hepatitis, progressing with cirrhosis Jaundice +++„ PT cholestasis (GGTP), Skin pruritus ±, cholestasis (GTTP) - Jaundice + / cholestasis - Jaundice -H-, cholestasis ±

Edema-ascitic syndrome

Portal hypertension in cirrhosis Hepatitis ++, cirrhosis ^++ ± - ± MVT in ascitic fluid ±

ETIOLOGY

"й-"-pu.. -ісу, cm\o + (Alcohol) Not established Hemoculture + Hemoculture -

HISTOLOGIES OF KSCI AND RESEARCH

Hepatitis with NHA 4_i8 points, Pm_sht% Hepatitis with IHA 4_ge points, p1_sh or U?, Mallory bodies Changes in the bone marrow Small foci of purulent necrosis of the parenchyma of the liver, spleen Eithelial cell granulomas, caseous necrosis, hepatitis with IHA 3_5, G0? lime salts (calcifications) in the liver and spleen

KLIYICHESYUSH DIAGNOSIS

Chronic hepatitis, liver cirrhosis Non-alcoholic (alcoholic) steatoheatitis, liver cirrhosis Hemoblastosis Sepsis Tuberculous hepatitis. Tuberculosis

Rice. 1. Strong points for the diagnosis of tuberculosis of the abdominal parenchymal organs

For timely diagnosis of tuberculosis of the liver and spleen, diagnostic laparoscopy with histological examination is necessary.

1. Tuberculosis of the liver and spleen occurs with the same frequency in a third of patients with abdominal tuberculosis, and in 3/4 of cases both organs are affected simultaneously, in 2/3 of cases with simultaneous involvement of intra-abdominal lymph nodes, peritoneum, intestines.

2. Tuberculous hepatitis and splenitis in 3/4 of cases (79%) develops in generalized specific processes in combination with pulmonary tuberculosis, most often miliary and disseminated, as well as other extrapulmonary localizations.

3. Morphologically, tuberculous hepatitis and splenitis in 85.5% of cases proceeds in the form of a miliary form with hematogenous spread from extrapulmonary foci.

4. Tuberculosis of the liver always occurs against the background of tuberculous intoxication, is characterized by clinical and laboratory signs of hepatitis of moderate laboratory activity, and in case of spleen tuberculosis, splenomegaly and calcifications are detected, in every fifth case combined with calcifications of the abdominal lymphatic apparatus.

Bibliography

1. Shulutko, B. I. Standards for the diagnosis and treatment of internal diseases / B. I. Shulutko, S. V. Makarenko. - 4th ed. - St. Petersburg. : ELBI-SPb, 2007. - 704 p.

2. Gastroenterology: national guide / ed. V. T. Ivashkina, T. L. Lapina. - M. : GEOTAR-Media, 2008. - 704 p. - (National guides).

3. Kalinin, A. V. Gastroenterology and hepatology. Diagnosis and treatment / A. V. Kalinin; ed. A. V. Kalinina, A. I. Khazanova. - M. : Miklosh, 2007. -602 p.

4. Phthisiology: national guidelines / ed. M. I. Perelman. - M. : GEOTAR-Media, 2007. - 512 p. - (National guides).

5. Federal target program "Prevention and control of socially significant diseases for 2007-2011". - IYL: http://www.cnikvi.ru/

content.php?id=2.99

6. Shilova, M. V. Results of providing anti-tuberculosis care to the population of Russia in 2003 / M. V. Shilova // Problems of tuberculosis and lung diseases. -

2005. - No. 6. - S. 3-10.

7. Russkikh, O. E. Tuberculosis, combined with HIV infection, in correctional institutions of the Udmurt Republic / O. E. Russkikh, V. A. Stakhanov // Russian Medical Journal. - 2009. - No. 1. - S. 9-10.

8. Levashov, Yu. N. Extrapulmonary tuberculosis in Russia: official statistics and reality / Yu. N. Levashev et al. // Problems of tuberculosis and lung diseases. -

2006. - No. 11. - S. 3-6.

9. Savonenkova, L. N. Abdominal tuberculosis / L. N. Savonenkova, O. L. Aryamkina. - Ulyanovsk: Publishing house Ulyan. state un-ta, 2007. - 163 p.

10. Aryamkina, O. L. Abdominal tuberculosis / O. L. Aryamkina, L. N. Savonenkova // Gastroenterology of St. Petersburg. - 2008. - No. 1. - S. 41-43.

11. Savonenkova, L. N. Specific and non-specific abdominal lesions in tuberculosis: clinic, diagnosis, course, prognosis: Abstract of the thesis. ... Dr. med. Sciences / Savonenkova L. N. - Novosibirsk, 2008.- 42 p.

12. Skopin, M. S. Tuberculosis of the abdominal organs and features of its detection / M. S. Skopin et al. // Problems of tuberculosis and lung diseases. -

2007. - No. 1. - S. 22-26.

13. Skopin, M. S., Kornilova Z. Kh., Batyrov F. A., Matrosov M. V. Features of the clinical picture and diagnosis of complicated forms of tuberculosis of the abdominal cavity // Problems of tuberculosis and lung diseases. . -

2008. - No. 9. - S. 32-40.

14. Parpieva, N. N. Clinic of abdominal tuberculosis in modern conditions / N. N. Parpieva, M. A. Khakimov, K. S. Mukhammedov, Sh. Sh. Massavirov // Tuberculosis in Russia, 2007: materials of the VIII Russian Congress phthisiatricians. -M. : Idea LLC, 2007. - S. 350-351.

15. Batyrov, F. A. A difficult case of diagnosis and treatment of abdominal tuberculosis / F. A. Batyrov, M. V. Matrosov, M. S. Skopin // Russian Medical Journal. - 2009. - No. 1. - S. 56.

16. Matrosov, M. V. The value of a comprehensive endoscopic examination in the detection of tuberculosis of the abdominal organs / M. V. Matrosov et al. // Russian Medical Journal. - 2009. - No. 1. - S. 40-42.

Talanova Olga Stanislavovna post-graduate student, Ulyanovsk State University

Email: [email protected]

Kuzmina Olga Anatolyevna post-graduate student, Ulyanovsk State University

Email: [email protected]

Holeva Anna Olegovna Resident Physician, City Polyclinic No. 4 (Ulyanovsk); postgraduate student, Ulyanovsk State University

Email: [email protected]

Savonenkova Lyudmila Nikolaevna Doctor of Medical Sciences, Professor, Department of Faculty Therapy, Ulyanovsk State University

Email: [email protected]

Aryamkina Olga Leonidovna Doctor of Medical Sciences, Professor, Department of Faculty Therapy, Ulyanovsk State University

Email: [email protected]

Talanova Olga Stanislavovna Postgraduate student, Ulyanovsk State University

Kuzmina Olga Anatolyevna Postgraduate student, Ulyanovsk State University

Kholeva Anna Olegovna Resident, outpatients’ Municipal clinic No. 4 (Ulyanovsk); postgraduate student, Ulyanovsk State University

Savonenkova Lyudmila Nikolaevna Doctor of medical sciences, professor, sub-department of faculty therapy, Ulyanovsk State University

Aryamkina Olga Leonidovna Doctor of medical sciences, professor, sub-department of faculty therapy, Ulyanovsk State University

UDC 616.36-002.5 Talanova, O. S.

Tuberculosis of the liver and spleen / O. S. Talanova, O. A. Kuzmina, A. O. Holeva, L. N. Savonenkova, O. L. Aryamkina // News of higher educational institutions. Volga region. Medical Sciences. - 2012. - No. 4 (24). -FROM. 112-122.

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If a patient has been diagnosed with tuberculosis of the spleen, then most often this indicates the presence of a pathological process in other organs. This disease is not very common, but it is desirable to know its symptoms for timely treatment to a doctor. How does such a lesion of the spleen proceed, how does it manifest itself and what clinical picture does it form? This will be discussed in this article.

What is tuberculosis of the spleen?

Tuberculosis of the spleen is a pathological process that develops in the tissues of an organ when a pathogen enters it, and is accompanied by degeneration and destruction of tissues, which has a negative effect on the functioning of the organ and causes severe symptoms. The condition develops mainly secondary, that is, as a complication of another tuberculous process in the body (most often, pulmonary tuberculosis). The primary occurrence, that is, infection of the organ directly by the pathogen directly, is extremely rare.

The condition is quite unpleasant and dangerous, but due to the fact that it forms specific symptoms, it is diagnosed quite well and in a timely manner. In the presence of adequate treatment, both conservative and, if necessary, surgical, complete recovery and recovery is possible.

Causes of the disease

As mentioned above, in the vast majority of cases, the disease is of a secondary nature. Thus, when the tuberculosis process develops in the lungs, pathogens spread throughout the body. This happens with the movement of blood and lymph. Some of the pathogens can settle in certain organs. With the accumulation of a sufficient number of pathogens in the spleen in this way, a tuberculous process may begin. Although this requires some additional conditions, such as a drop in immunity, for example, for this reason, such a complication does not develop in absolutely all patients with tuberculosis.

The primary development of the pathological process in the spleen is almost never diagnosed, since when a pathogen enters the body, it usually begins its active activity in the lungs. In general, the pathogen can enter the body by airborne droplets, airborne dust and contact-household methods.

Risk factors

Which patients are most likely to develop this pathology? From what has been written above, it is clear that, given the very nature of the onset of the disease, people who already suffer from a primary tuberculous process, especially in the lungs, are considered the most vulnerable to pathology. However, for the development of pathology, some more factors must be present;

• Reduced general immunity, for example, as a result of inflammatory processes;
• Reduced local immunity, for example, during surgery on the spleen;
• Immunodeficiency states, including HIV;
• General weakening of the body as a result of poor, insufficient or unbalanced nutrition in terms of vitamin and mineral composition, excessive physical, emotional and intellectual stress;
• Poor living conditions;
• Pathological processes in the spleen.

In the presence of such features, the likelihood of developing pathology becomes several times higher.

People who have not been vaccinated with the BCG tuberculosis vaccine are most susceptible to primary infection with the disease.

Clinical manifestations

At the very initial stages of the development of pathology, it may not manifest itself in any way. But as the pathology develops, a certain clinical picture is still formed. The following symptoms appear:

1. Slight and poorly localized pains in the upper part of the left side;
2. Enlargement of the spleen, noticeable on palpation;
3. Periodic increase in body temperature to subfebrile figures.

In general, the presence of such symptoms in a patient with tuberculosis already gives reason to suspect damage to the spleen. However, it is somewhat more difficult to make a differential diagnosis based on symptoms during a primary infection, since in this case the doctor has nothing to rely on initially, and such symptoms can be associated with many pathologies.

Diagnostics

Diagnosis is not too difficult. Typically, the following methods are used:

1. Tuberculin tests (not informative enough, since with a secondary occurrence they are naturally positive, and with a primary one they can often be false negative);
2. General and biochemical blood test;
3. X-ray examination of the abdominal organs;
4. Ultrasound examination of the abdominal organs;
5. Biopsy of spleen tissue;
6. Diagnostic laparoscopy.

The most informative are the last two methods. But they are also the most traumatic, therefore they are prescribed only when the results of other analyzes and studies contradict each other or are absolutely not informative.

Treatment

Therapy is carried out by a hepatologist together with a phthisiatrician. Preferably medical conservative treatment with anti-tuberculosis drugs, but in some cases, surgery may be performed if indicated.

conservative methods

Treatment is with anti-tuberculosis drugs. With a secondary occurrence, when treatment for tuberculosis is already underway, additional therapy is usually not prescribed. Usually, doctors prescribe a combination of 3-4 anti-tuberculosis drugs (Ftivazid, Tubazid, Saluzid, Rifampicin, Streptomycin) for admission in an individual dosage and according to an individual scheme. Therapy lasts from six months to two years, and its first months should take place while the patient is in the hospital. In addition, it is important to prescribe immunostimulating drugs and vitamins for admission, as they increase the body's own resistance to pathology.

Diet therapy also plays an important role. Food should be rich in vitamins and minerals, have an increased calorie content.

Operational containment

Surgical treatment is usually not indicated. It can be indicated when the infection is insensitive to conservative treatment or with the rapid development of the process. In this case, part of the affected tissues of the organ is removed. Also, the surgical method is indicated for isolated forms of spleen tuberculosis during primary infection. In this case, it is quite effective and allows the body to recover faster. After the surgical intervention, drug treatment is also prescribed according to schemes similar to those described in the previous section.

Forecast

The prognosis of the disease is quite favorable with a responsible approach to treatment. With careful implementation of adequate therapy, recovery occurs simultaneously with recovery from pulmonary tuberculosis and the body is fully restored. In the absence of treatment, the prognosis for the disease is unfavorable - without therapy, it leads to death in the vast majority of cases, while death occurs from impaired liver function most often.

Effects

Is this disease so dangerous, and what consequences can it lead to? Provided that continuous treatment is available, complications and consequences usually do not develop. However, without treatment, anemia and cachexia may develop. The functioning of the liver will gradually be inhibited until complete failure. Also, the inflammatory process can spread to adjacent tissues, causing peritonitis.

Conclusion

This disease can lead to quite serious consequences for the body, therefore its development cannot be ignored. If you find similar symptoms, you should immediately contact a phthisiatrician and a hepatologist.