Peliosis Hepatis in an Adult Patient with a History of Childhood Ulcerative Colitis

Abstract

Purpose: JB was diagnosed with ulcerative colitis (UC) as a child when she presented with failure to thrive. She was started on sulfasalazine for UC. She was also treated with growth hormones for her short stature, although neither the patient nor her mother acknowledged this fact until a later date. At her adult presentation, the patient appeared well, except her height was 4'10”. Baseline lab results revealed an alkaline phosphatase of 344 IU/L (nl 25-150) and an ALT of 56 IU/L (nl 0-40). The remainder of labs, including autoimmune work-up, was unremarkable. Magnetic resonance imaging with MRCP revealed no evidence of biliary or parenchymal abnormality. Suspecting primary sclerosing cholangitis, endoscopic retrograde cholangiopancreatography was attempted but was unsuccessful; the patient refused another attempt. Therefore, a large core (18g) liver biopsy was obtained, without immediate complication. One week later, the patient presented complaining of right upper quadrant pain. Computed tomography confirmed a large heterogenous mass in the right lobe of the liver, consistent with a hepatic hematoma. Due to continuing transfusion requirements, the patient underwent embolization, which showed “innumerable foci of punctuate extravasation from the branches of the right hepatic artery,” and “several foci of extravasation from the peripheral branches of the left hepatic artery” (see image below). Gelfoam infusion was used to stop the bleeding. The patient was discharged several days later. Post hoc review of the images led to a radiographic diagnosis of peliosis hepatis. Peliosis is characterized by the gross appearance of multiple cyst-like, blood-filled cavaties within parenchymal organs. Peliosis has been associated with the use of anabolic and androgenic steroids. Prior to her biopsy, both the patient and her mother failed to disclose that she had taken growth hormones. Direct questioning of patients about past use of growth hormones, especially those with obvious short stature and/or a history of chronic childhood illness, should be regular practice, especially before proceeding with invasive procedures.Figure: [978]