Obliterative Portal Venopathy Masquerading Large Bile Duct Obstruction in a Patient on Oral Contraceptive Pills

Abstract

Introduction: Oral contraceptives pills (OCP) are generally safe but can cause wide range of side effects. We report a case of obliterative portal venopathy (OPV) causing large bile duct obstruction picture from OCP use and slow resolution after discontinuation of the medication. Case: A 19-year-old woman with medical history of Down's syndrome and hypothyroidism presented with acute jaundice, pruritus and RUQ abdominal pain. She denied any fever, alcohol use, recent travel, sick contacts, new medications or herbal supplements. Her medications included levothyroxine, fexofenadine and OCP. Physical exam was remarkable for icterus and RUQ tenderness with positive Murphy's sign. Labs showed a total bilirubin of 8.0 with direct bilirubin of 5.1, alk phos of 245, AST of 50, ALT of 100 and lipase of 23. Acute and chronic hepatitis work up was negative for acetaminophen toxicity, viral hepatitis, EBV, CMV and HSV serologies, autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, Wilson disease, hemochromatosis, α1 antitrypsin deficiency, and HIV. Urine toxicology was negative. Ultrasound showed no evidence of cholecystitis, cholelithiasis or choledocholithiasis. There was no intra or extra hepatic biliary obstruction on EUS and MRCP. CT scan was unremarkable. Alk phos progressively increased to 500 and the bilirubin slowly improved. The liver biopsy showed histologic features of large bile duct obstruction, and features suggestive of OPV and nodular regenerative hyperplasia. This was most likely thought to be due to OCP use in the absence of other etiologies. OCP was discontinued and LFT's slowly improved with normalization in 5 months. Discussion: OCPs are currently prescribed to 62 million women of reproductive age in the US. While deemed mostly safe, they can cause hepatic and biliary dysfunction, and a small subset of women develop intrahepatic cholestasis. Liver biopsy shows bland cholestasis without significant inflammation. Obstructive picture with OPV has not been described. A prothrombotic state caused by OCP probably resulted in OPV-induced large duct injury and obstruction picture in the biopsy. This report highlights that OCP can present with OPV and secondary changes such as large duct injury due to their prothrombotic effects. OPV should be considered as a differential diagnosis if the labs and biopsy show findings suggestive of large bile duct obstruction before proceeding with invasive procedures like ERCP.