Hepatic peliosis is a rare benign vascular condition characterized by dilatation of sinusoidal blood-filled spaces within the liver. There may be involvement of other organs, most commonly the spleen and bone marrow. It can be seen in a variety of settings and is important as appearances may mimic malignancy.
As the causes of peliosis are varied, the demographics will reflect the underlying cause.
Patients are usually asymptomatic 6 and thus the condition is discovered incidentally on imaging or autopsy. In some instances, lesions may be complicated by hemorrhage presenting acutely or result in hepatomegaly or liver impairment.
The pathogenesis remains uncertain, with possible etiologies including the breakdown of the sinusoidal borders, hepatic outflow obstruction and dilatation of the central vein of the hepatic lobule.
Histologically, hepatic peliosis is characterized by multiple mottled blood-filled cyst-like spaces within the liver with associated sinusoidal dilatation 1,2. These vary in size from <1 mm to several centimeters in diameter.
Macroscopically, the liver appears dark or even purple, and usually, the entire liver is involved to a greater or lesser degree. Focal lesions may demonstrate central areas of hemorrhage.
- idiopathic: 20-50%
- polyvinyl chloride (PVC)
- thorium oxide
- anabolic steroids
- diethylstilbestrol (DES)
- immunoglobulin therapy
- oral contraceptives
- 6-thioguanine (6-TG)
- 6-mercaptopurine (6-MP)
- chronic illness
- infection in AIDS
- bacillary peliosis caused by Bartonella henselae, Bartonella quintana and Rochalimaea henselae
- renal or cardiac transplantation
Unfortunately, appearances are non-specific with variable enhancement patterns. Typically, there are multiple lesions, ranging from a few large lesions to innumerable small lesions.
Sonographic appearances are non-specific, usually demonstrating an irregular hypoechoic region/mass 2.
Appearance on pre-contrast CT is variable, depending on liver density, but is usually of multiple hypoattenuating lesions of variable size. Central hemorrhage may lead to areas of hyperattenuation and even dystrophic calcification 1.
Following contrast administration, there is usually globular centrifugal (more common) or centripetal arterial enhancement with no washout, the lesion remaining slightly hyperattenuating compared to surrounding liver on portal venous phase 1. Enhancement may be uniform or peripheral or irregular, but in contrast to cavernous hemangioma, it is usually continuous. There is no mass effect on neighboring hepatic vessels 6.
Signal characteristics may be altered due to the presence of hemorrhage; however, in general:
- T1: typically hypointense (unless complicated by recent hemorrhage)
- T2: hyperintense
- C+ (Gd): enhancement is typical, and is usually centrifugal (from center outward)
- hypervascular with multiple vascular nodules
Treatment and prognosis
It is important not to drain peliosis, having mistaken it for a hepatic abscess, as hemorrhage can be life threatening 7.
Treatment depends on the cause. When a causative drug/toxin is suspected, withdrawal of that agent may result in resolution. If seen in the setting of HIV/AIDS, antibiotic treatment may be effective in eradicating B. henselae. If focal and hemorrhagic, resection may also be beneficial 1.
History and etymology
From the Greek word pelios, meaning "dusky" or "purple" 1.
General imaging differential considerations include:
- globular discontinuous contrast enhancement tends to be centripetal (periphery first) rather than centrifugal (center first)
hepatocellular carcinoma (HCC)
- usually bright arterial enhancement with early washout
- fluid component does not enhance
focal nodular hyperplasia (FNH)
- when typical, are easy to distinguish: central scar; homogeneous arterial enhancement (except for scar); delayed enhancement of the scar; isoattenuating on portal venous phase; strong enhancement on hepatobiliary phase
- may contain fat
- hypervascular metastases
- hepatic sinusoidal dilation: usually the enhancement pattern is different on CT/MRI 5
- 1. Iannaccone R, Federle MP, Brancatelli G et-al. Peliosis hepatis: spectrum of imaging findings. AJR Am J Roentgenol. 2006;187 (1): W43-52. doi:10.2214/AJR.05.0167 - Pubmed citation
- 2. Savastano S, San bortolo O, Velo E et-al. Pseudotumoral appearance of peliosis hepatis. AJR Am J Roentgenol. 2005;185 (2): 558-9. AJR Am J Roentgenol (full text) - Pubmed citation
- 3. Elsayes KM, Narra VR, Yin Y et-al. Focal hepatic lesions: diagnostic value of enhancement pattern approach with contrast-enhanced 3D gradient-echo MR imaging. Radiographics. 25 (5): 1299-320. doi:10.1148/rg.255045180 - Pubmed citation
- 4. Maves CK, Caron KH, Bisset GS et-al. Splenic and hepatic peliosis: MR findings. AJR Am J Roentgenol. 1992;158 (1): 75-6. AJR Am J Roentgenol (citation) - Pubmed citation
- 5. Yang DM, Jung DH, Park CH et-al. Imaging findings of hepatic sinusoidal dilatation. AJR Am J Roentgenol. 2004;183 (4): 1075-7. AJR Am J Roentgenol (full text) - Pubmed citation
- 6. Torabi M, Hosseinzadeh K, Federle MP. CT of nonneoplastic hepatic vascular and perfusion disorders. Radiographics. 28 (7): 1967-82. doi:10.1148/rg.287085067 - Pubmed citation
- 7.Cohen GS, Ball DS, Boyd-kranis R et-al. Peliosis hepatis mimicking hepatic abscess: fatal outcome following percutaneous drainage. J Vasc Interv Radiol. 5 (4): 643-5. - Pubmed citation
Related Radiopaedia articles
- depositional disorders
- infection and inflammation
- liver abscess
- hepatic hydatid infection
- liver and intrahepatic bile duct tumors
- benign epithelial tumors
- hepatocellular hyperplasia
- hepatocellular adenoma
- hepatic/biliary cysts
- benign nonepithelial tumors
- primary malignant epithelial tumors
- hepatocellular carcinoma
- hepatocellular carcinoma variants
- biliary cystadenocarcinoma
- combined hepatocellular and cholangiocarcinoma
- undifferentiated carcinoma
- primary malignant nonepithelial tumors
- hematopoietic and lymphoid tumors
- secondary tumors
- adrenal rest tumors
- hepatic carcinosarcoma
- hepatic fibroma
- hepatic Kaposi sarcoma
- hepatic lipoma
- hepatic mesenchymal hamartoma
- hepatic myxoma
- hepatic rhabdoid tumor
- hepatic solitary fibrous tumor
- hepatic teratoma
- hepatic yolk sac tumor
- inflammatory myofibroblastic tumor (inflammatory pseudotumor)
- nodular regenerative hyperplasia
- pancreatic rest tumors
- primary hepatic carcinoid
- benign epithelial tumors
- liver and intrahepatic bile duct tumors
vascular and perfusion disorders
portal vein related
- portal vein thrombosis (acute and chronic)
- extra-hepatic portal vein obstruction
- portal hypertension
- portal venous aneurysm
- portal venous gas
- congenital portosystemic shunts
- transjugular intrahepatic portosystemic shunt (TIPS)
- porto-portal shunt
- hepatic artery related
- hepatic veins related
- inferior vena cava related
- third inflow
- liver thrombotic angiitis
- infra diaphragmatic total anomalous pulmonary venous return (TAPVR)
- hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease)
- portal vein related