Hepatic peliosis with acute hemorrhage

Case contributed by Joseph Morrow

Presentation

Acute abdominal pain and anemia. No prior medical history.

Patient Data

Age: 40 years
Gender: Female

4 Phase Liver CT 2014

ct

The entire right lobe of the liver is markedly abnormal.  Multifocal near-confluent non-enhancing oblong lesions occupy the majority of the right lobe of the liver.  There is early filling of the right branch of the portal vein on the arterial phase of imaging consistent with gross arterioportal shunting.  This is most prominent in the anterior sector of the right lobe. No features of liver cirrhosis.  There is a large subcapsular hematoma. There is active extravasation into the subcapsular hematoma on the portal venous and the delayed phases of imaging. There is a large volume of and density fluid within the abdomen. There is layering of fluid in the pelvis consistent with hemorrhage. 

DynaCT embolization 2014

ct

Procedure: Mesenteric and hepatic angiography and right hepatic artery embolization. 

Using real-time ultrasound/fluoroscopic guidance, a 6-French sheath was placed in the right common femoral artery. Sim catheter used to access the Celiac artery. Co-axial microcatheter placed in the common hepatic artery and a Dyna CT was performed, demonstrating active hemorrhage.  Super-selective anterior sectoral embolization followed by further embolization of the right hepatic artery - Gelfoam used. 

MRI Liver with Primovist 2016

mri

About 20 months post embolization, the large vascular lesion has almost completely atrophied.  Reduction in size of the right perihepatic hematoma with fibrous scarring.  The healing process in the region of peliosis has obliterated the right hepatic vein which originally ran through the lesion.

There is some tortuosity of the right posterior sectoral intrahepatic bile ducts, which may represent ischemic change. Compared to the original scans, there is atrophy of the right lobe of the liver. There is compensatory hypertrophy of the left lobe of the liver. There are no areas of abnormal enhancement in the left lobe of the liver. There are two tiny linear foci of high-signal peripherally situated in segment 2/3 that could represent small cysts or dilated peripheral bile ducts. The mild intra and extrahepatic bile duct dilatation is stable. No significant fluid in the abdominal wall or upper abdomen. Splenomegaly. 

Multiphasic Liver CT 2020

ct

Peliosis related changes which now occupies the majority of segments 2, 3, 4, 8 and 7. Hemorrhagic perihepatic, perisplenic and pelvic fluid. No active extravasation identified. Normal appearance of the portal vein and hepatic arteries.

Liver Biopsy Results

pathology

1.  Liver biopsy with no inflammation and very focal sinusoidal dilatation.

2.  Warthin-Starry stain shows rare bacilli suggestive of Bartonnella type sp. in the current clinical context. 

Case Discussion

The patient presented after hemorrhage from the region of peliosis in the right lobe of the liver.  Embolization was performed to manage the bleeding. 

The changes in the hepatic parenchyma resolved over the following years and were near normal on MRI in 2016.  Multiple recurrences of peliosis occured in 2018, 2020 and 2021 in variable parts of the liver often with accompanying hemorrhage. 

Transjugular liver biospy performed in 2021 demonstrated bartonella like organisms, an organism known to predispose to hepatic peliosis.  The patient has been treated for bartonella.  The patient has been under consideration for, but is not currently listed for liver transplant.

Acknowledgements:

Dr Laoise Coady and Prof Aurelie Fabre, St Vincent's University Hospital Histopathology Department.

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