1976, British Journal of Radiology, 49, 184-185
Case reports
Hepatic haematoma in polyarteritis nodosa By A. B. Ayers, D.M.R.D., M.D., F.R.C.R.,* and D. H. Fitchett, M.B., M.R.C.P. The Department of Diagnostic Radiology and The Department of Medicine, Hammersmith Hospital, Du Cane Road, London, W.12 {Received December, 1974 and in revised form March, 1975)
Case history
A 21-year-old man presented two years ago with upper abdominal discomfort, anorexia, weight loss and low grade fever. He was hypertensive and had a right foot drop and hepatosplenomegaly. Polyarteritis nodosa was diagnosed on muscle biopsy but a liver biopsy was normal. Regression of symptoms followed treatment with corticosteroids and methyldopa. In 1974, whilst in hospital for treatment of Vincent's angina, he suddenly became shocked with upper abdominal pain. His liver became enlarged and tender. Transfusion produced a rapid recovery. The following day a liver scan was performed (Fig. 1). A week later he suffered a similar episode requiring further transfusion. Abdominal angiography was then performed and demonstrated the changes of polyarteritis nodosa in the liver (Figs. 2-3) without other visceral involvement. DISCUSSION
It is well known that polyarteritis nodosa may affect the parenchymal arteries of many viscera but particularly those in the abdomen. However, it was not FIG. 2. Selective hepatic arteriogram—antero-posterior.
FIG. 1. A " T c m sulphur colloid liver scan—right anterior oblique. There is a large area of decreased activity in the right lobe of the liver.
•Present address: St. Thomas' Hospital, London, S.E.I.
FIG. 3. Selective hepatic arteriogram—right posterior oblique. There is displacement of the right liver edge ( j ) from the abdominal wall ( f) and displacement of the coeliac axis to the left. Many aneurysms and stenoses are demonstrated in the intraparenchymal arteries. Some of the aneurysms are large and multilocular.
184
FEBRUARY 1976
Case reports
until 1965 that the ante-mortem angiographic findings were demonstrated (Fleming and Stern, 1965; Bron, Strott and Shapiro, 1965). Since then abdominal arteriography has been used in both diagnosis and management based on the high frequency of pathological changes found in the abdominal viscera. Muscle biopsy is commonly used in the investigation of these patients but voluntary muscle is affected in only 20-39 per cent of cases whereas renal involvement is described in 80-85 per cent (Cabal and Holtz, 1971). Most reported cases of polyarteritis nodosa, studied by angiography, have demonstrated renal involvement but similar changes are described in hepatic, splenic, mesenteric, lumbar, intercostal, pulmonary and intracerebral arteries (Herschmann, Blumm and Lee, 1970; Leonhardt, Jakobson and Ringqvist, 1972). Haemorrhage from affected arteries is well recognized and many cases of perinephric haematoma are described (Ostrumand Soder, 1960; Peterson et al., 1970). Haemorrhage may also occur from mesenteric arteries (Capps and Klein, 1970). The aneurysms described in polyarteritis nodosa are usually small, but larger aneurysms have been described in the hepatic arteries (Chudacek, 1967; Essinger and Bonard, 1971) even in the presence of a normal liver biopsy (Bron and Gajaraj, 1970). Robins and Bookstein (1972) have reported regression of aneurysms during treatment. The angiographic appearances are distinctive, but not pathognomonic as they have also been described in the necrotizing arteritis associated with drug abuse (Halpern and Citron, 1971). The present case demonstrates widespread hepatic abnormalities, without renal or other abdominal visceral involvement. Some of the aneurysms are large and multilocular. The clinical, liver scan and angiographic evidence also suggests that the patient suffered massive hepatic haemorrhage on at least two occasions—firstly into the central portion right lobe and subsequently into the outer part of the right lobe with displacement of the rest of the liver substance to the left. The haematoma appears to have been contained within the liver capsule and was limited superiorly by the liver's attachment to the
central tendon of the diaphragm. At no time was there clinical or radiological evidence of free intraperitoneal blood. Angiography has been valuable in demonstrating the limitation of visceral involvement and should a further hepatic bleed occur ligation of the common hepatic artery will be seriously considered. This case has also been presented to the Clinical Section of the Royal Society of Medicine (Proceedings of the Royal Society of Medicine, 1976, in press). ACKNOWLEDGMENTS
We are grateful to Dr. C. M. Oakley for permission to publish this case. REFERENCES BRON, K. M., and GAJARAJ, A., 1970. Demonstration of
hepatic aneurysms in polyarteritis nodosa by arteriography. New England Journal of Medicine, 282, 1024-1025 BRON, K. M., STROTT, C. A., and SHAPIRO, A. P., 1965.
The diagnostic value of angiographic observations in polyarteritis nodosa. A case of multiple aneurysms in, the visceral organs. Archives of Internal Medicine, 116 450-454. CABAL E., and HOLTZ, S., 1971. Polyarteritis as a cause of
intestinal haemorrhage. Gastroenterology, 61, 99-105. CAPPS, J. H., and KLEIN, R. M., 1970. Polyarteritis nodosa
as a cause of perirenal and retroperitoneal haemorrhage. Radiology, 94, 143-146. CHUDACEK, Z., 1967. Angiographic diagnosis of polyarteritis nodosa of the liver, kidney and mesentery. British Journal of Radiology, 40, 864-865. ESSINGER, A., and BONARD, M., 1971. Panarteritis nodosa,
an angiographic entity—presentation of two cases. BritishJournal of Radiology, 44, 184-188. FLEMING, R. J., and STERN, L. Z., 1965. Multiple intra-
parenchymal renal aneurysms in polyarteritis nodosa. Radiology, 84, 100-103. HALPERN, M., and CITRON, B. P., 1971. Necrotizing angiitis
associated with drug abuse. American Journal of Roentgenology, 111, 663-671. HERSCHMAN, A., BLUM, R., and LEE, Y. C , 1970. Angio-
graphic findings in polyarteritis nodosa. Radiology, 94, 147-148. LEONHARDT, E. T. G., JAKOBSON, H., and RINGQVIST, O. T.
A., 1972. Angiographic and clinico-physiologic investigation of a case of polyarteritis nodosa. American Journal of Medicine, 53,242-256. OSTRUM, B. J., and SODER, P. D., 1960. Periarteritis nodosa
complicated by spontaneous haematoma; Roentgenographic findings in 3 cases and review of the literature. American Journal of Roentgenology, 84, 849-860. PETERSON, C , WILLERSON, J. T., DOPPMAN, J. L., and
DECKER, J. L., 1970. Polyarteritis nodosa with bilateral renal artery aneurysms and perirenal haematomas; angiographic and nephrotomographic features. British Journal of Radiology, 43, 62-71. ROBINS, J. M., and BOOKSTEIN, J. J., 1972. Regressing
185
aneurysms in periarteritis nodosa. Radiology, 104, 39-42.
Case reports
Hepatic haematoma in polyarteritis nodosa By A. B. Ayers, D.M.R.D., M.D., F.R.C.R.,* and D. H. Fitchett, M.B., M.R.C.P. The Department of Diagnostic Radiology and The Department of Medicine, Hammersmith Hospital, Du Cane Road, London, W.12 {Received December, 1974 and in revised form March, 1975)
Case history
A 21-year-old man presented two years ago with upper abdominal discomfort, anorexia, weight loss and low grade fever. He was hypertensive and had a right foot drop and hepatosplenomegaly. Polyarteritis nodosa was diagnosed on muscle biopsy but a liver biopsy was normal. Regression of symptoms followed treatment with corticosteroids and methyldopa. In 1974, whilst in hospital for treatment of Vincent's angina, he suddenly became shocked with upper abdominal pain. His liver became enlarged and tender. Transfusion produced a rapid recovery. The following day a liver scan was performed (Fig. 1). A week later he suffered a similar episode requiring further transfusion. Abdominal angiography was then performed and demonstrated the changes of polyarteritis nodosa in the liver (Figs. 2-3) without other visceral involvement. DISCUSSION
It is well known that polyarteritis nodosa may affect the parenchymal arteries of many viscera but particularly those in the abdomen. However, it was not FIG. 2. Selective hepatic arteriogram—antero-posterior.
FIG. 1. A " T c m sulphur colloid liver scan—right anterior oblique. There is a large area of decreased activity in the right lobe of the liver.
•Present address: St. Thomas' Hospital, London, S.E.I.
FIG. 3. Selective hepatic arteriogram—right posterior oblique. There is displacement of the right liver edge ( j ) from the abdominal wall ( f) and displacement of the coeliac axis to the left. Many aneurysms and stenoses are demonstrated in the intraparenchymal arteries. Some of the aneurysms are large and multilocular.
184
FEBRUARY 1976
Case reports
until 1965 that the ante-mortem angiographic findings were demonstrated (Fleming and Stern, 1965; Bron, Strott and Shapiro, 1965). Since then abdominal arteriography has been used in both diagnosis and management based on the high frequency of pathological changes found in the abdominal viscera. Muscle biopsy is commonly used in the investigation of these patients but voluntary muscle is affected in only 20-39 per cent of cases whereas renal involvement is described in 80-85 per cent (Cabal and Holtz, 1971). Most reported cases of polyarteritis nodosa, studied by angiography, have demonstrated renal involvement but similar changes are described in hepatic, splenic, mesenteric, lumbar, intercostal, pulmonary and intracerebral arteries (Herschmann, Blumm and Lee, 1970; Leonhardt, Jakobson and Ringqvist, 1972). Haemorrhage from affected arteries is well recognized and many cases of perinephric haematoma are described (Ostrumand Soder, 1960; Peterson et al., 1970). Haemorrhage may also occur from mesenteric arteries (Capps and Klein, 1970). The aneurysms described in polyarteritis nodosa are usually small, but larger aneurysms have been described in the hepatic arteries (Chudacek, 1967; Essinger and Bonard, 1971) even in the presence of a normal liver biopsy (Bron and Gajaraj, 1970). Robins and Bookstein (1972) have reported regression of aneurysms during treatment. The angiographic appearances are distinctive, but not pathognomonic as they have also been described in the necrotizing arteritis associated with drug abuse (Halpern and Citron, 1971). The present case demonstrates widespread hepatic abnormalities, without renal or other abdominal visceral involvement. Some of the aneurysms are large and multilocular. The clinical, liver scan and angiographic evidence also suggests that the patient suffered massive hepatic haemorrhage on at least two occasions—firstly into the central portion right lobe and subsequently into the outer part of the right lobe with displacement of the rest of the liver substance to the left. The haematoma appears to have been contained within the liver capsule and was limited superiorly by the liver's attachment to the
central tendon of the diaphragm. At no time was there clinical or radiological evidence of free intraperitoneal blood. Angiography has been valuable in demonstrating the limitation of visceral involvement and should a further hepatic bleed occur ligation of the common hepatic artery will be seriously considered. This case has also been presented to the Clinical Section of the Royal Society of Medicine (Proceedings of the Royal Society of Medicine, 1976, in press). ACKNOWLEDGMENTS
We are grateful to Dr. C. M. Oakley for permission to publish this case. REFERENCES BRON, K. M., and GAJARAJ, A., 1970. Demonstration of
hepatic aneurysms in polyarteritis nodosa by arteriography. New England Journal of Medicine, 282, 1024-1025 BRON, K. M., STROTT, C. A., and SHAPIRO, A. P., 1965.
The diagnostic value of angiographic observations in polyarteritis nodosa. A case of multiple aneurysms in, the visceral organs. Archives of Internal Medicine, 116 450-454. CABAL E., and HOLTZ, S., 1971. Polyarteritis as a cause of
intestinal haemorrhage. Gastroenterology, 61, 99-105. CAPPS, J. H., and KLEIN, R. M., 1970. Polyarteritis nodosa
as a cause of perirenal and retroperitoneal haemorrhage. Radiology, 94, 143-146. CHUDACEK, Z., 1967. Angiographic diagnosis of polyarteritis nodosa of the liver, kidney and mesentery. British Journal of Radiology, 40, 864-865. ESSINGER, A., and BONARD, M., 1971. Panarteritis nodosa,
an angiographic entity—presentation of two cases. BritishJournal of Radiology, 44, 184-188. FLEMING, R. J., and STERN, L. Z., 1965. Multiple intra-
parenchymal renal aneurysms in polyarteritis nodosa. Radiology, 84, 100-103. HALPERN, M., and CITRON, B. P., 1971. Necrotizing angiitis
associated with drug abuse. American Journal of Roentgenology, 111, 663-671. HERSCHMAN, A., BLUM, R., and LEE, Y. C , 1970. Angio-
graphic findings in polyarteritis nodosa. Radiology, 94, 147-148. LEONHARDT, E. T. G., JAKOBSON, H., and RINGQVIST, O. T.
A., 1972. Angiographic and clinico-physiologic investigation of a case of polyarteritis nodosa. American Journal of Medicine, 53,242-256. OSTRUM, B. J., and SODER, P. D., 1960. Periarteritis nodosa
complicated by spontaneous haematoma; Roentgenographic findings in 3 cases and review of the literature. American Journal of Roentgenology, 84, 849-860. PETERSON, C , WILLERSON, J. T., DOPPMAN, J. L., and
DECKER, J. L., 1970. Polyarteritis nodosa with bilateral renal artery aneurysms and perirenal haematomas; angiographic and nephrotomographic features. British Journal of Radiology, 43, 62-71. ROBINS, J. M., and BOOKSTEIN, J. J., 1972. Regressing
185
aneurysms in periarteritis nodosa. Radiology, 104, 39-42.
