GRANULOMATOUS LIVER DISEASE



Hepatic granulomas are common, being found in 2 to 10 per cent of all liver biopsies, often in association with an elevated serum alkaline phos­phatase level. However, they are rarely a specific finding and have been reported in association with a wide variety of infections, systemic ill­nesses, hepatobiliary disorders, drugs, and toxins, some of which are listed in. Although granulomas are a nonspecific finding, occasion­ally specific features are seen, such as acidfast bacilli in tuberculosis, ova in schistosomiasis, lar­vae in toxocariasis, and birefringent granules in starch, talc, or silicone granulomas. The differ­ential diagnosis of hepatic granulomas is one of the most extensive in medicine, and the workup requires meticulous attention to details of the his­tory, physical examination, and laboratory tests. Indeed, in 20 per cent or more of patients, no cause for granulomas is found despite extensive investigation. A subset of these patients, who have a syndrome consisting of fever, hepatome­galy, and hepatic granulomas which responds to administration of corticosteroids, has been de­scribed as having granulomatous hepatitis, al­though some feel that these individuals have a variant of sarcoidosis.

Conversely, liver biopsy (and culture, particu­larly of acidfast bacteria) is of considerable value in the diagnosis of sarcoidosis, miliary tuberculosis, and histoplasmosis, as virtually all patients with these disorders will have hepatic granu­lomas. Similarly, characteristic granulomas are seen in many patients with primary biliary cir­rhosis, and granulomas may be the first clue to Hodgkin’s disease.





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