Peliosis hepatis

A 52-years-old woman was admitted to our emergency department with 4 hours history of right-upper-quadrant abdominal pain radiating to the back. No other symptoms were revealed. There was a history of oral contraceptive administration.

Laboratory test showed leukocytosis with blood white cell of 16.6 /mmc, C- reactive protein of 59.7 mg/dl and lactate dehydrogenase of 1136 IU/L.
An abdominal computed tomography (CT) was performed after injection of an iodine contrast medium.
CT demonstrated a complex mass occupying almost the entire left liver lobe, about 10 cm in diameter, with hypo- and isodense areas and presence of vessels with contrast and areas of bleeding. It identified another complex mass in the subcapsular region of the left liver lobe of similar characteristics to that previously described, suggesting subcapsular haematoma. Abundant intraabdominal free fluid, predominately perihepatic, with densities of liquid and blood was seen. All these findings suggest ruptured subcapsular liver haematoma and haemoperitoneum.
After partial left hepatic lobectomy and splenectomy (the latter due to a splenic laceration found intraoperatively), the diagnosis of peliosis hepatis was made with histology.

Peliosis hepatis is a rare condition characterized by multiple small blood-filled spaces in the liver parenchyma [1].
The cause of peliosis can be related to drugs (anabolic steroids, oral contraceptives [2], corticosteroids, tamoxifen, diethylstilbestrol, 6-mercaptopurine, azathioprine and methotrexate); chronic wasting diseases (tuberculosis, leprosy and hepatocellular carcinoma); and infection in AIDS [3]. Other conditions are described as associated with peliosis hepatis, including sprue, diabetes mellitus, necrotizing vasculitis, and haematologic disorders.
The pathogenesis of peliosis is unknown, with many investigators proposing that the primary event could be obstruction of hepatic outflow at the sinusoidal level.
Most cases are discovered incidentally in asymptomatic people and others present hepatomegaly, ascites, portal hypertension [4] and adenopathy (the last in patients with Bartonella henselae). In some circumstances, patients suffered complications like hepatic rupture [5].
Peliosis hepatis regresses after drug withdrawal, cessation of steroid therapy, or resolution of an associated infectious disease [6].
At unenhanced Computer Tomography (CT), lesions are predominately hypoattenuating.
At contrast enhanced CT:
- Arterial phase: early globular enhancement.
- Portal phase: centripetal or centrifugal enhancement without mass effect.
- Delayed phase: Diffuse increased attenuation. [7]
CT findings vary with the presence of thrombosed cavities and presence of haemorrhage.
In cases of intralesional haemorrhage, peliotic lesions are hyperattenuating to liver parenchyma.

Hepatocellular adenoma is included in the differential diagnosis.
Hepatocellular adenomas are uncommon benign liver masses most commonly seen in women. Aetiologic factors for hepatic adenomas include oral contraceptive use, anabolic steroids in men, the metabolic syndrome and excessive alcohol use.
Adenomas can have variable amounts of fat and may show intralesional haemorrhage and necrosis.
Multiphasic helical CT can demonstrate findings that appear to be quite characteristic of hepatocellular adenoma. These include the presence of single or multiple masses that may contain areas of fat or haemorrhage, but are otherwise nearly isoattenuating relative to normal liver on unenhanced, portal venous-phase, and delayed-phase images. The lesions are moderately hyperattenuating relative to liver at hepatic arterial-phase imaging and enhance nearly homogeneously.

In this case we only obtained a portal venous phase CT that demonstrated ruptured subcapsular liver haematoma and haemoperitoneum.

Finally the diagnosis was made with histology.
Histological pictures of left hepatectomy revealed blood-filled irregular cavities that were neither lined by endothelium nor by fibrous tissue, characteristics of peliosis hepatis. No tumour proliferation was observed.

The clinical context of the patient helps to make a correct diagnosis, for example HIV, chronic diseases, medications. Consider peliosis hepatis in the differential diagnosis of enhanced lesions that do not fit the criteria of other more common aetiologies [8, 9, 10]