Morehouse School of Medicine Atlanta, GA, United States
Ryan Alevy, BS1, Afolarin Ajose, MBBS2, Krystal Mills, MD1 1Morehouse School of Medicine, Atlanta, GA; 2Babcock University College of Medicine, Atlanta, GA
Introduction: Massive hepatomegaly may be caused by inflammation, infiltration, vascular congestion, biliary obstruction, or inappropriate storage disorders. We present a case of a 44-year-old woman with worsening abdominal distention, discovered to be from an atypical cause of massive hepatomegaly after extensive work-up.
Case Description/Methods: A 44-year-old woman with a history of Hypertension and Substance Abuse Disorder was referred to the emergency department from primary care clinic for worsening abdominal distension. She endorsed shortness of breath and back pain associated with her increased abdominal girth. She reported intermittent lower abdominal pain. Review of systems with otherwise negative. She admitted to use of alcohol.
Vitals were within normal limits except for tachycardia. Physical examination revealed scleral icterus, decreased bowel sounds, and a grossly distended abdomen with dullness to percussion in the right midclavicular line extending below the right costal margin to the right inguinal region. Pregnancy test was negative. Initial labs revealed WBC 11.2, Hb 9.4, Hct 29, Plt 315, PT 21.3, INR 1.8, Total bilirubin 7.4, Direct bilirubin 5.1, ALT 41, AST 97, ALP 175. Viral hepatitis panel was negative. CT Abdomen and Pelvis with contrast showed massive hepatomegaly with liver measuring at least 30 cm in craniocaudal extent.
Work up revealed negative ANA, Anti-smooth muscle antibody and Anti-mitochondrial antibody. Slit lamp examination was negative for Kayser–Fleischer rings. Serum ceruloplasmin was normal. MRCP showed steatohepatitis, no biliary beading/obstruction and mild splenomegaly suggestive of early portal hypertension. Liver biopsy showed advanced fibrosis with extensive pericellular fibrosis and focal features of bridging. She was diagnosed with massive hepatomegaly secondary to alcoholic hepatitis and counseled on cessation of alcohol use, treated with prednisolone and scheduled for outpatient follow up.
Discussion: The advanced fibrosis seen on histopathology for this case typically correlates with a cirrhotic, shrunken liver on clinical examination. This index case represents an unusual clinical feature of an established disease as, while alcoholic liver disease may cause minimal to moderate hepatomegaly, the massive hepatomegaly and the absence of gross ascites, is atypical. A liver >20 cm is more commonly associated with infiltrative, autoimmune, or infectious causes, which were ruled out in this case.
Figure: Abdominal computed tomography performed showing the coronal, sagittal, and axial planes, respectively. The images visualize the massive hepatomegaly which led to abdominal distention on admission.
Ryan Alevy indicated no relevant financial relationships.
Afolarin Ajose indicated no relevant financial relationships.
Krystal Mills indicated no relevant financial relationships.
Ryan Alevy, BS1, Afolarin Ajose, MBBS2, Krystal Mills, MD1. P1895 - Pregnant with Suspense: An Atypical Case of Massive Hepatomegaly, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.