1
|
Huang J, Ali T, Feldman DM, Theise ND. Androgen-Induced, β-Catenin-Activated Hepatocellular Adenomatosis with Spontaneous External Rupture. Diagnostics (Basel) 2024; 14:1473. [PMID: 39061609 PMCID: PMC11276095 DOI: 10.3390/diagnostics14141473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 05/29/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
Androgens have long been recognized as oncogenic agents. They can induce both benign and malignant hepatocellular neoplasms, including hepatocellular adenoma (HCA) and hepatocellular carcinoma, though the underlying mechanisms remain unclear. Androgen-induced liver tumors are most often solitary and clinically silent. Herein, we reported an androgen-induced HCA complicated by spontaneous rupture. The patient was a 24-year-old male presenting with fatigue, diminished libido, radiology-diagnosed hepatocellular adenomatosis for 3 years, and sudden-onset, severe, sharp, constant abdominal pain for one day. He used Aveed (testosterone undecanoate injection) from age 17 and completely stopped one year before his presentation. A physical exam showed touch pain and voluntary guarding in the right upper quadrant of the abdomen. An abdominal CT angiogram demonstrated multiple probable HCAs, with active hemorrhage of the largest one (6.6 × 6.2 × 5.1 cm) accompanied by large-volume hemoperitoneum. After being stabilized by a massive transfusion protocol and interventional embolization, he underwent a percutaneous liver core biopsy. The biopsy specimen displayed atypical hepatocytes forming dense cords and pseudoglands. The lesional cells diffusely stained β-catenin in nuclei and glutamine synthetase in cytoplasm. Compared to normal hepatocytes from control tissue, the tumor cells were positive for nuclear AR (androgen receptor) expression but had no increased EZH2 (Enhancer of Zeste 2 Polycomb Repressive Complex 2 Subunit) protein expression. The case indicated that androgen-induced hepatocellular neoplasms should be included in the differential diagnosis of acute abdomen.
Collapse
Affiliation(s)
- Jialing Huang
- Department of Pathology, Geisinger Medical Center, Geisinger Commonwealth School of Medicine, 100 N. Academy Ave, Danville, PA 17822, USA
| | - Towhid Ali
- Department of Radiology, Geisinger Medical Center, Geisinger Commonwealth School of Medicine, 100 N. Academy Ave, Danville, PA 17822, USA
| | - David M. Feldman
- Department of Gastroenterology and Hepatology, New York University Grossman School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| | - Neil D. Theise
- Department of Pathology, NYU Langone Medical Center, New York University Grossman School of Medicine, 550 1st Avenue, New York, NY 10016, USA
| |
Collapse
|
2
|
Frenette C, Mendiratta-Lala M, Salgia R, Wong RJ, Sauer BG, Pillai A. ACG Clinical Guideline: Focal Liver Lesions. Am J Gastroenterol 2024; 119:1235-1271. [PMID: 38958301 DOI: 10.14309/ajg.0000000000002857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 04/25/2024] [Indexed: 07/04/2024]
Abstract
Focal liver lesions (FLLs) have become an increasingly common finding on abdominal imaging, especially asymptomatic and incidental liver lesions. Gastroenterologists and hepatologists often see these patients in consultation and make recommendations for management of multiple types of liver lesions, including hepatocellular adenoma, focal nodular hyperplasia, hemangioma, and hepatic cystic lesions including polycystic liver disease. Malignancy is important to consider in the differential diagnosis of FLLs, and healthcare providers must be familiar with the diagnosis and management of FLLs. This American College of Gastroenterology practice guideline uses the best evidence available to make diagnosis and management recommendations for the most common FLLs.
Collapse
Affiliation(s)
| | | | - Reena Salgia
- Department of Gastroenterology/Hepatology, Henry Ford Health, Detroit, Michigan, USA
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Veterans Affairs Palo Alto Health Care System and Stanford University School of Medicine, Palo Alto, California, USA
| | - Bryan G Sauer
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, University of Chicago Medical Center, University of Chicago, Chicago, Illinois, USA
| |
Collapse
|
3
|
Skrzypiec-Spring M, Pokrywka A, Bombała W, Berezovska D, Rozmus J, Brawańska K, Nowicki K, Abu Faraj G, Rynkowski M, Szeląg A. Illegal Use of Testosterone and Other Anabolic-Androgenic Steroids in the Population of Amateur Athletes in Wrocław, Poland-An Unfavorable Lifestyle Trend in the Population of Men of Reproductive Age. J Clin Med 2024; 13:3719. [PMID: 38999285 PMCID: PMC11242149 DOI: 10.3390/jcm13133719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Revised: 06/17/2024] [Accepted: 06/22/2024] [Indexed: 07/14/2024] Open
Abstract
Background: One factor that may negatively impact male reproductive health is the illegal use of testosterone and anabolic-androgenic steroids. This study aimed to evaluate the prevalence of testosterone use in recreational athletes, as well as factors associated with its use, and to determine the profile of a person using testosterone. Methods: A cross-sectional analysis of data from an anonymous, online questionnaire of men recruited from gyms, randomly selected in Wrocław, Poland, has been performed. The minimal sample size was evaluated with the univariate logistic regression model. The association between testosterone use and other factors was also evaluated with the univariate logistic regression model. Results: A total of 35% of respondents used testosterone. The main purposes of testosterone use were the improvement of training effects and the improvement of body shape. The respondents most likely to use testosterone and other anabolic-androgenic steroids were men aged 26-35, whose earnings were at the level of the middle class or higher, who were married, had children, had training experience of at least 6 months, exercised at least once a week, took part in weightlifting competitions, were managers in a corporation or enterprise, or were self-employed. Most of the people using testosterone had self-treated side effects. Conclusions: The profile of the person most likely to use testosterone corresponds to the characteristics of men in optimal socio-demographic conditions for reproduction. These results indicate that this is a significant social problem that may impact male reproductive health.
Collapse
Affiliation(s)
- Monika Skrzypiec-Spring
- Department of Pharmacology, Wroclaw Medical University, Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland
| | - Andrzej Pokrywka
- Chair and Department of Biochemistry and Pharmacogenomics, Medical University of Warsaw, Banacha 1, 02-097 Warsaw, Poland
- Polish Anti-Doping Agency, Fabryczna 5A, 00-446 Warsaw, Poland
| | - Wojciech Bombała
- Statistical Analysis Centre, Wroclaw Medical University, K. Marcinkowskiego 2-6, 50-368 Wroclaw, Poland
| | - Daria Berezovska
- Chair and Department of Biochemistry and Pharmacogenomics, Medical University of Warsaw, Banacha 1, 02-097 Warsaw, Poland
| | - Julia Rozmus
- Department of Pharmacology, Wroclaw Medical University, Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland
| | - Kinga Brawańska
- Department of Pharmacology, Wroclaw Medical University, Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland
| | - Konrad Nowicki
- Department of Pharmacology, Wroclaw Medical University, Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland
| | - Gina Abu Faraj
- Department of Pharmacology, Wroclaw Medical University, Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland
| | | | - Adam Szeląg
- Department of Pharmacology, Wroclaw Medical University, Mikulicza-Radeckiego 2, 50-345 Wroclaw, Poland
| |
Collapse
|
4
|
Pothuri VS, Anzelmo M, Gallaher E, Ogunlana Y, Aliabadi-Wahle S, Tan B, Crippin JS, Hammill CW. Transgender Males on Gender-Affirming Hormone Therapy and Hepatobiliary Neoplasms: A Systematic Review. Endocr Pract 2023; 29:822-829. [PMID: 37286102 DOI: 10.1016/j.eprac.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/21/2023] [Accepted: 05/29/2023] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Behavioral therapy, gender-affirming hormone therapy (GAHT), and surgery are all components of a successful gender transition, but due to a historical lack of access, there is paucity of long-term data in this population. We sought to better characterize the risk of hepatobiliary neoplasms in transgender males undergoing GAHT with testosterone. METHODS In addition to the 2 case reports, a systematic literature review of hepatobiliary neoplasms in the setting of testosterone administration or endogenous overproduction across indications was conducted. The medical librarian created search strategies using keywords and controlled vocabulary in Ovid Medline, Embase.com, Scopus, Cochrane Database of Systematic Reviews, and clinicaltrials.gov. A total of 1273 unique citations were included in the project library. All unique abstracts were reviewed, and abstracts were selected for complete review. Inclusion criteria were articles reporting cases of hepatobiliary neoplasm development in patients with exogenous testosterone administration or endogenous overproduction. Non-English language articles were excluded. Cases were collated into tables based on indication. RESULTS Forty-nine papers had cases of hepatocellular adenoma, hepatocellular carcinoma, cholangiocarcinoma, or other biliary neoplasm in the setting of testosterone administration or endogenous overproduction. These 49 papers yielded 62 unique cases. CONCLUSION Results of this review are not sufficient to conclude that there is an association between GAHT and hepatobiliary neoplasms. This supports current evaluation and screening guidelines for initiation and continuation of GAHT in transgender men. The heterogeneity of testosterone formulations limits the translation of risks of hepatobiliary neoplasms in other indications to GAHT.
Collapse
Affiliation(s)
| | | | - Emily Gallaher
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Benjamin Tan
- Washington University School of Medicine, St. Louis, Missouri; Department of Medicine, Washington University in St Louis, St Louis, Missouri; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey S Crippin
- Washington University School of Medicine, St. Louis, Missouri; Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Chet W Hammill
- Washington University School of Medicine, St. Louis, Missouri; Alvin J. Siteman Cancer Center, Washington University School of Medicine, St Louis, Missouri; Department of Surgery, Washington University in St Louis, St Louis, Missouri.
| |
Collapse
|
5
|
Singh A, Kaur A, Stephens C, Fekete I, Nelson J, Kodwani N. Pulmonary haemorrhage and extensive arterial thrombosis with anabolic steroid abuse. BMJ Case Rep 2023; 16:e254817. [PMID: 37640416 PMCID: PMC10462977 DOI: 10.1136/bcr-2023-254817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
Anabolic-androgenic steroids (AASs) are commonly implicated in thromboembolic events but rarely cause diffuse alveolar haemorrhage. We report the case of a Caucasian man in his late 40s who was consuming supratherapeutic doses of AAS and presented with shortness of breath and haemoptysis. Chest imaging showed bilateral patchy infiltrates in the lungs with diffuse blood throughout the airways on bronchoscopy. Extensive infectious and autoimmune workup were unremarkable. The patient then developed right foot ischaemia and was found to have extensive aortic and bilateral lower extremity arterial thrombosis. Anticoagulation was attempted despite haemoptysis. Thrombectomy procedures were unsuccessful and the patient eventually developed worsening rhabdomyolysis requiring intubation and bilateral amputation. His clinical condition continued to worsen and he passed away 10 days after admission. This case highlights the rare synchronous occurrence of two life-threatening complications secondary to anabolic steroid abuse which can pose a significant diagnostic and therapeutic challenge for clinicians.
Collapse
Affiliation(s)
- Angad Singh
- Internal Medicine, HCA MidAmerica DIvision, Kansas City, Kansas, USA
| | - Anahat Kaur
- Hematology and Medical Oncology, Albert Einstein College of Medicine D Samuel Gottesman Library, Bronx, New York, USA
| | - Corbin Stephens
- Internal Medicine, HCA MidAmerica DIvision, Kansas City, Kansas, USA
| | - Ian Fekete
- Internal Medicine, HCA MidAmerica DIvision, Kansas City, Kansas, USA
| | - John Nelson
- Internal Medicine, HCA MidAmerica DIvision, Kansas City, Kansas, USA
| | - Naresh Kodwani
- Internal Medicine, HCA MidAmerica DIvision, Kansas City, Kansas, USA
| |
Collapse
|
6
|
Pinazo-Bandera JM, García-Cortés M, Segovia-Zafra A, Lucena MI, Andrade RJ. Recreational Drugs and the Risk of Hepatocellular Carcinoma. Cancers (Basel) 2022; 14:5395. [PMID: 36358813 PMCID: PMC9657889 DOI: 10.3390/cancers14215395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/03/2023] Open
Abstract
Recreational or aesthetic drug use is a distinctive behavior of humans, principally attested in the last century. It is known that recreational and illegal drugs are major contributors to the universal morbidity rate worldwide. Many of these substances have a well-established hepatotoxic potential, causing acute or chronic liver injury, liver fibrosis and cirrhosis, but their implications for hepatocellular carcinoma or other varieties of liver tumors are little known. In this article, we perform an extensive literature review, aiming to provide updated information about recreational drug use and the risk of developing liver tumors. Khat use and pyrrolizidine alkaloid consumption (present in some natural plants) have been linked to liver cirrhosis. Kava intake is associated with different liver tumors in animal models but not in humans. Cannabis' potential to accelerate liver fibrosis in chronic hepatitis is controversial according to the existing data. Cigarette smoking is an important contributor to hepatocellular carcinoma, and anabolic androgen steroids are well-defined causes of a variety of liver cancers and other hepatic tumors. Long-term follow-up studies of subjects who have developed injuries in association with the use of recreational drugs are warranted so as to better define the risk of developing hepatocellular carcinoma in association with these substances and, thus, to implement health care policies to combat this preventable cause of cancer.
Collapse
Affiliation(s)
- José M. Pinazo-Bandera
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
| | - Miren García-Cortés
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 29010 Madrid, Spain
| | - Antonio Segovia-Zafra
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 29010 Madrid, Spain
- Service of Clinical Pharmacology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
| | - María Isabel Lucena
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 29010 Madrid, Spain
- Service of Clinical Pharmacology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
| | - Raúl J. Andrade
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Universidad de Málaga, 29010 Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, 29010 Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), 29010 Madrid, Spain
| |
Collapse
|
7
|
Large Hepatic Adenomas and Hepatic Adenomatosis: A Multicenter Study of Risk Factors, Interventions, and Complications. Am J Gastroenterol 2022; 117:1089-1096. [PMID: 35333776 DOI: 10.14309/ajg.0000000000001743] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 03/14/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Beyond oral contraceptives (OCs), metabolic factors have been suggested to increase the risk of hepatocellular adenoma (HCA). The impact of risks remains poorly defined, particularly among men and those with adenomatosis. Thus, we aimed to examine HCA clinical and outcome characteristics through a large multicenter cohort. METHODS HCA diagnosis was made based on a combination of clinical, radiologic, and histologic criteria. Patient and clinical data including follow-up imaging, complications, and interventions were collected between 2004 and 2018 from 3 large academic centers. RESULTS Among 187 patients (163 female and 24 male) with HCA, 75 had solitary HCA, 58 had multiple HCAs, and 54 had adenomatosis. Over a median follow-up of 3.3 years (quartile 1: 1.2, quartile 3: 8.8), 34 patients (18%) had radiologic interventions, 41 (21%) had surgical resections, 10 (5%) developed tumoral hemorrhage, and 1 had malignant transformation. OC and corticosteroid use were present in 70% and 16%, respectively. Obesity (51%), type 2 diabetes (24%), hypertension (42%), and hypertriglyceridemia (21%) were also common. Metabolic comorbidities were more common in patients with large HCAs and adenomatosis. Compared with women, men had less hepatic steatosis (4% vs 27%), smaller HCAs (2.3 cm vs 4.4 cm), and more corticosteroid use (38% vs 11%) ( P < 0.05 for all). With OC cessation, 69% had a decrease in size of HCA, but 25% eventually required advanced interventions. DISCUSSION In this large HCA cohort, obesity and metabolic comorbidities were important risk factors associated with large HCAs and adenomatosis. Long-term adverse outcomes were infrequent, 5% had tumor hemorrhage, and 1 patient exhibited malignant transformation.
Collapse
|
8
|
Does Argininosuccinate Synthase 1 (ASS1) Immunohistochemistry Predict an Increased Risk of Hemorrhage for Hepatocellular Adenomas? Appl Immunohistochem Mol Morphol 2021; 28:464-470. [PMID: 31135443 DOI: 10.1097/pai.0000000000000774] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatocellular adenomas (HCAs) often pursue an innocuous clinical course. Recent work has elucidated important subtypes of HCA and biomarkers to identify them, including HCA at an increased risk for malignant transformation. Another key complication of HCAs is the risk of spontaneous tumoral hemorrhage, which may be life-threatening. Identification of a predictive biomarker for this clinical complication would therefore be of clinical value. It has been suggested that Argininosuccinate Synthase 1 (ASS1) immunohistochemistry (IHC) identifies HCA with a high propensity for hemorrhage. The aim of our study was to validate ASS1 IHC as a predictive marker of hemorrhage. Eighty-nine HCAs were collected for ASS1 IHC and subtyped according to published criteria. Clinical records were examined for evidence of tumoral hemorrhage. Twenty-one (23.6%) HCAs were complicated by clinically detected hemorrhage and were more likely to be resected (P=0.0002). Hemorrhage complicated all WHO subtypes of HCA. There was no association between hemorrhage and HCA subtype (P=0.92). Neither the distribution of ASS1 expression nor the intensity of ASS1 expression compared to normal liver showed a significant association with hemorrhage (P=0.051 and 0.34). Interlaboratory comparison of 8 cases showed good agreement regarding the intensity (6/8 and 7/8) and distribution of staining (7/8 and 7/8) across 3 laboratories performing ASS1 IHC. In conclusion, all subtypes of HCA may be complicated by hemorrhage. ASS1 IHC expression did not correlate with hemorrhagic complications. Caution is prudent before routine implementation of ASS1 IHC in clinical practice.
Collapse
|
9
|
McCullough D, Webb R, Enright KJ, Lane KE, McVeigh J, Stewart CE, Davies IG. How the love of muscle can break a heart: Impact of anabolic androgenic steroids on skeletal muscle hypertrophy, metabolic and cardiovascular health. Rev Endocr Metab Disord 2021; 22:389-405. [PMID: 33269425 PMCID: PMC8087567 DOI: 10.1007/s11154-020-09616-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 12/13/2022]
Abstract
It is estimated 6.4% of males and 1.6% of females globally use anabolic-androgenic steroids (AAS), mostly for appearance and performance enhancing reasons. In combination with resistance exercise, AAS use increases muscle protein synthesis resulting in skeletal muscle hypertrophy and increased performance. Primarily through binding to the androgen receptor, AAS exert their hypertrophic effects via genomic, non-genomic and anti-catabolic mechanisms. However, chronic AAS use also has a detrimental effect on metabolism ultimately increasing the risk of cardiovascular disease (CVD). Much research has focused on AAS effects on blood lipids and lipoproteins, with abnormal concentrations of these associated with insulin resistance, hypertension and increased visceral adipose tissue (VAT). This clustering of interconnected abnormalities is often referred as metabolic syndrome (MetS). Therefore, the aim of this review is to explore the impact of AAS use on mechanisms of muscle hypertrophy and markers of MetS. AAS use markedly decreases high-density lipoprotein cholesterol (HDL-C) and increases low-density lipoprotein cholesterol (LDL-C). Chronic AAS use also appears to cause higher fasting insulin levels and impaired glucose tolerance and possibly higher levels of VAT; however, research is currently lacking on the effects of AAS use on glucose metabolism. While cessation of AAS use can restore normal lipid levels, it may lead to withdrawal symptoms such as depression and hypogonadism that can increase CVD risk. Research is currently lacking on effective treatments for withdrawal symptoms and further long-term research is warranted on the effects of AAS use on metabolic health in males and females.
Collapse
Affiliation(s)
- Deaglan McCullough
- Research Institute of Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK.
| | - Richard Webb
- Faculty of Science, Liverpool Hope University, Liverpool, UK
| | - Kevin J Enright
- Research Institute of Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Katie E Lane
- Research Institute of Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Jim McVeigh
- Substance Use and Associated Behaviours Group, Manchester Metropolitan University, Manchester, UK
| | - Claire E Stewart
- Research Institute of Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK
| | - Ian G Davies
- Research Institute of Sport and Exercise Science, Liverpool John Moores University, Liverpool, UK.
| |
Collapse
|
10
|
Oldhafer KJ, Habbel V, Horling K, Makridis G, Wagner KC. Benign Liver Tumors. Visc Med 2020; 36:292-303. [PMID: 33005655 DOI: 10.1159/000509145] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/03/2020] [Indexed: 12/12/2022] Open
Abstract
Background Due to the frequent use of medical imaging including ultrasonography, the incidence of benign liver tumors has increased. There is a large variety of different solid benign liver tumors, of which hemangioma, focal nodular hyperplasia (FNH), and hepatocellular adenoma (HCA) are the most frequent. Advanced imaging techniques allow precise diagnosis in most of the patients, which reduces the need for biopsies only to limited cases. Patients with benign liver tumors are mostly asymptomatic and do not need any kind of treatment. Symptoms can be abdominal pain and pressure effects on adjacent structures. The 2 most serious complications are bleeding and malignant transformation. Summary This review focuses on hepatic hemangioma (HH), FNH, and HCA, and provides an overview on clinical presentations, surgical and interventional treatment, as well as conservative management. Treatment options for HHs, if indicated, include liver resection, radiofrequency ablation, and transarterial catheter embolization, and should be carefully weighed against possible complications. FNH is the most frequent benign liver tumor without any risk of malignant transformation, and treatment should only be restricted to symptomatic patients. HCA is associated with the use of oral contraceptives or other steroid medications. Unlike other benign liver tumors, HCA may be complicated by malignant transformation. HCAs have been divided into 6 subtypes based on molecular and pathological features with different risk of complication. Key Message The vast majority of benign liver tumors remain asymptomatic, do not increase in size, and rarely need treatment. Biopsies are usually not needed as accurate diagnosis can be obtained using modern imaging techniques.
Collapse
Affiliation(s)
- Karl J Oldhafer
- Department für Chirurgie, Klinik für Leber-, Gallenwegs- und Pankreaschirurgie, Asklepios Klinik Barmbek, Hamburg, Germany.,Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Victoria Habbel
- Department für Chirurgie, Klinik für Leber-, Gallenwegs- und Pankreaschirurgie, Asklepios Klinik Barmbek, Hamburg, Germany.,Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | | | - Georgios Makridis
- Department für Chirurgie, Klinik für Leber-, Gallenwegs- und Pankreaschirurgie, Asklepios Klinik Barmbek, Hamburg, Germany.,Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| | - Kim Caroline Wagner
- Department für Chirurgie, Klinik für Leber-, Gallenwegs- und Pankreaschirurgie, Asklepios Klinik Barmbek, Hamburg, Germany.,Semmelweis University Budapest, Asklepios Campus Hamburg, Hamburg, Germany
| |
Collapse
|
11
|
Abstract
Focal nodular hyperplasia and hepatocellular adenoma are benign liver lesions that occur most frequently in women and may be found as incidental findings on imaging. hepatocellular adenomas may be infrequently associated with malignant progression or risk of rupture and as such, require surveillance or definitive treatments based on their size threshold. It is important clinically to differentiate these lesions, and utilizing imaging modalities such as contrast enhanced ultrasound or magnetic resonance imaging can be helpful in diagnosis. Further molecular subtyping of hepatocellular adenoma lesions may be beneficial to describe risk factors and potential future clinical complications.
Collapse
Affiliation(s)
- Lauren Myers
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, MNP 4112, Portland, OR 97239, USA.
| | - Joseph Ahn
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, MNP 4112, Portland, OR 97239, USA
| |
Collapse
|
12
|
Wang L, Wang C, Li W, Meng F, Li Y, Fan H, Zhou Y, Bharathi G, Gao S, Yang Y. Multiple hepatocellular adenomas associated with long-term administration of androgenic steroids for aplastic anemia: A case report and literature review. Medicine (Baltimore) 2020; 99:e20829. [PMID: 32664077 PMCID: PMC7360229 DOI: 10.1097/md.0000000000020829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Anabolic steroids are widely administered to patients with aplastic anemia (AA) and are associated with numerous medical complications. To assist with future diagnoses, we report about a young boy with multiple hepatocellular adenomas (HAs) induced by long-term use of anabolic androgenic steroids (AAS) for AA and present a related literature review. PATIENT CONCERN A 15-year-old boy who was diagnosed with AA in 2011 had been treated with stanozolol (6 mg per day) and ciclosporin A (120-150 mg per day) for almost 4 years. He presented with epigastric pain and fever, and abdominal computed tomography showed a lesion of heterogenous density measuring 13.5 × 13.0 × 8.0 cm in the left hepatic lobe, which was initially misdiagnosed as a liver abscess. DIAGNOSIS The patient went into hemorrhagic shock twice after invasive manipulation that aimed at diagnosis and was finally diagnosed with HA using fine needle aspiration. INTERVENTIONS The patient discontinued AAS and only reserved ciclosporin A for AA treatment. OUTCOMES Follow-up abdominal computed tomography performed 4 years after AAS discontinuation showed obvious regression of the hepatic lesions. CONCLUSION It is of great importance for hematologists to completely understand that the long-term use of AAS may cause HA, which carries a great risk of hemorrhage and malignant transformation.
Collapse
Affiliation(s)
| | - Cong Wang
- Department of Radiology, The First Hospital of Jilin University
| | | | - Fanyang Meng
- Department of Radiology, The First Hospital of Jilin University
| | | | | | - Yanhua Zhou
- Department of Hematology, the Qianwei Hospital of Jilin Province, Changchun, Jilin, China
| | | | | | | |
Collapse
|
13
|
Bates G, Van Hout MC, Teck JTW, McVeigh J. Treatments for people who use anabolic androgenic steroids: a scoping review. Harm Reduct J 2019; 16:75. [PMID: 31888665 PMCID: PMC6937954 DOI: 10.1186/s12954-019-0343-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 11/21/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND A growing body of evidence suggests that anabolic androgenic steroids (AAS) are used globally by a diverse population with varying motivations. Evidence has increased greatly in recent years to support understanding of this form of substance use and the associated health harms, but there remains little evidence regarding interventions to support cessation and treat the consequences of use. In this scoping review, we identify and describe what is known about interventions that aim to support and achieve cessation of AAS, and treat and prevent associated health problems. METHODS A comprehensive search strategy was developed in four bibliographic databases, supported by an iterative citation searching process to identify eligible studies. Studies of any psychological or medical treatment interventions delivered in response to non-prescribed use of AAS or an associated harm in any setting were eligible. RESULTS In total, 109 eligible studies were identified, which included case reports representing a diverse range of disciplines and sources. Studies predominantly focussed on treatments for harms associated with AAS use, with scant evidence on interventions to support cessation of AAS use or responding to dependence. The types of conditions requiring treatment included psychiatric, neuroendocrine, hepatic, kidney, cardiovascular, musculoskeletal and infectious. There was limited evidence of engagement with users or delivery of psychosocial interventions as part of treatment for any condition, and of harm reduction interventions initiated alongside, or following, treatment. Findings were limited throughout by the case report study designs and limited information was provided. CONCLUSION This scoping review indicates that while a range of case reports describe treatments provided to AAS users, there is scarce evidence on treating dependence, managing withdrawal, or initiating behaviour change in users in any settings. Evidence is urgently required to support the development of effective services for users and of evidence-based guidance and interventions to respond to users in a range of healthcare settings. More consistent reporting in articles of whether engagement or assessment relating to AAS was initiated, and publication within broader health- or drug-related journals, will support development of the evidence base.
Collapse
Affiliation(s)
- Geoff Bates
- Public Health Institute, Liverpool John Moores University, Liverpool, England
| | | | | | - Jim McVeigh
- Department of Sociology, Manchester Metropolitan University, Manchester, England
| |
Collapse
|
14
|
|
15
|
van Rosmalen BV, Coelen RJS, Bieze M, van Delden OM, Verheij J, Dejong CHC, van Gulik TM. Systematic review of transarterial embolization for hepatocellular adenomas. Br J Surg 2017; 104:823-835. [DOI: 10.1002/bjs.10547] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/02/2016] [Accepted: 02/22/2017] [Indexed: 02/06/2023]
Abstract
Abstract
Background
Hepatocellular adenoma (HCA) larger than 5 cm in diameter is considered an indication for elective surgery, because of the risk of haemorrhage and malignant transformation. Transarterial embolization (TAE) is used to manage bleeding HCA and occasionally to reduce tumour size. TAE might have potential as an elective therapy, but its current role in this context is uncertain. This systematic review provides an overview of clinical outcomes after TAE, in bleeding and non-bleeding HCA.
Methods
Two independent reviewers performed a systematic search of literature in PubMed and Embase. Outcomes were change in tumour size, avoidance of surgery, complications and malignant transformation after TAE in bleeding and non-bleeding HCA. The Critical Appraisal Skills Programme tool for cohort studies was used for quality assessment of included studies.
Results
From 320 potential articles, 20 cohort studies and 20 case reports including 851 patients met the inclusion criteria. TAE was performed in 151 of 851 patients (17·7 per cent), involving 196 tumours, of which 95 (48·5 per cent) were non-bleeding. Surgical treatment was avoided in 68 of 151 patients (45·0 per cent). Elective TAE was performed in 49 patients involving 66 HCAs, with 41 of these patients (84 per cent) not requiring surgery. Major complications occurred in eight of 151 patients (5·3 per cent); no death was reported. Among cohort studies, complete tumour disappearance was observed in 10 per cent of patients, and regression in 75 per cent.
Conclusion
Acute or elective TAE in the management of HCA is safe. In the elective setting, TAE provides a potential alternative to surgery.
Collapse
Affiliation(s)
- B V van Rosmalen
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - R J S Coelen
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - M Bieze
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - O M van Delden
- Department of Interventional Radiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - J Verheij
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
| | - C H C Dejong
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - T M van Gulik
- Department of Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| |
Collapse
|
16
|
Seitz J, Lyall AE, Kanayama G, Makris N, Hudson JI, Kubicki M, Pope HG, Kaufman MJ. White matter abnormalities in long-term anabolic-androgenic steroid users: A pilot study. Psychiatry Res 2017; 260:1-5. [PMID: 27988413 PMCID: PMC5272808 DOI: 10.1016/j.pscychresns.2016.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Revised: 10/14/2016] [Accepted: 12/01/2016] [Indexed: 12/21/2022]
Abstract
Recent studies of long-term anabolic-androgenic steroid (AAS) users reported amygdala structural and functional connectivity abnormalities. We assessed white matter microstructure in the inferior-fronto-occipital fasciculus (IFOF), a major associative bundle of the amygdala network. Diffusion weighted images acquired from 9 male long-term AAS users and 8 matched controls aged 36-51 years old were processed using a standardized pipeline (Tract-Based Spatial Statistics). Group differences were examined using linear regression with adjustment for age and current testosterone level. Compared to nonusers, AAS users exhibited significantly higher fractional anisotropy (FA) in the IFOF. Users showed markedly greater FA than nonusers on the left IFOF but only a modest, nonsignificant difference on the right IFOF. Moreover, FA was positively associated with lifetime cumulative AAS dose. Our results suggest that long-term AAS use alters IFOF white matter organization and integrity, which in turn might affect amygdala-related processes such as reward system function. Accordingly, further studies are needed to replicate findings in larger subject groups to determine the functional significance of the FA abnormality.
Collapse
Affiliation(s)
- Johanna Seitz
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amanda E Lyall
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gen Kanayama
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, Massachusetts, USA, and Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nikos Makris
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Departments of Psychiatry, Neurology and Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - James I Hudson
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, Massachusetts, USA, and Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marek Kubicki
- Psychiatry Neuroimaging Laboratory, Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Departments of Psychiatry, Neurology and Radiology, Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Harrison G Pope
- Biological Psychiatry Laboratory, McLean Hospital, Belmont, Massachusetts, USA, and Department of Psychiatry, Harvard Medical School, Boston, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marc J Kaufman
- McLean Imaging Center, McLean Hospital, Department of Psychiatry, Harvard Medical School, 115 Mill St., Belmont 02478, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
17
|
Abstract
Correlation between androgen use and hepatocellular neoplasia is well established. However, there are no detailed studies of the histopathology and immunohistochemical/molecular profile of these tumors. We studied 9 patients with androgen-associated hepatocellular neoplasms. In addition to histology, immunostains for liver fatty acid-binding protein, β-catenin, glutamine synthetase, C-reactive protein, and serum amyloid A were utilized for tumor subtyping. Molecular testing using Solid Tumor Targeted Cancer Panel was performed on 3 cases. The neoplasms were predominantly seen in male individuals (7/9). Two patients (22%) had multifocal lesions. All lesions had architectural and 4/9 had cytologic atypia. Cholestasis was present in 6/9 cases. Reticulin was focally disrupted in 5/9 cases. Given the clinical setting, all lesions were classified as well-differentiated hepatocellular neoplasms of uncertain malignant potential. In cases with follow-up (6/9 cases, 67%), there were no recurrences or metastases. On the basis of the immunoprofile, 7 (78%) cases were β-catenin activated (including 1 hepatic adenoma with concurrent hepatocyte nuclear factor 1α inactivation) and 2 (22%) had inflammatory phenotype. Somatic mutations in CTNNB1 were detected in all 3 tested cases (all β-catenin activated by immunostain), all involving exon-3. Our data indicate that androgen-associated hepatocellular neoplasms most often develop in male individuals and always show some degree of atypia and/or focal reticulin disruption. Most are β-catenin activated, often harboring CTNNB1 exon-3 mutations, and a minority is inflammatory type. Although β-catenin and inflammatory pathways likely play a role in pathogenesis, the heterogenous molecular profile suggests there are other (yet to be characterized) primary oncogenic mechanisms in this unique tumor type.
Collapse
|
18
|
Zhang C, Shi X, Zhao L. Synchronous giant hepatic adenoma in siblings-A case report and brief literature review. Cancer Biol Ther 2016; 17:727-31. [PMID: 27096392 DOI: 10.1080/15384047.2016.1177682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
A 47-year-old woman was referred to our department for a hepatic mass. She denied history of hepatitis or alcohol consumption and regular oral contraceptive use, except for the emergency contraceptive pill taken once a decade ago. Hepatitis B surface antigen and anti-hepatitis C antibody were negative, α-fetoprotein was within normal limit. CT scan revealed an enormous mass measuring 26.0×16 5×13 0 cm that almost totally replaced the right hepatic lobe. The neoplasm was completely resected and pathologically diagnosed as hepatic adenoma. Literature review indicates this is the largest hepatic adenoma reported so far. At the same time, clinical examination also revealed a hepatic mass in the patient's 42-year-old brother, which was pathologically confirmed as hepatic adenoma, too. He denied history of anabolic steroid use. Immunohistochemical analysis revealed the subtypes of both tumors as the inflammatory hepatic adenoma. Literature review indicates this is the first report of synchronous hepatic adenomas in siblings.
Collapse
Affiliation(s)
- Chengsheng Zhang
- a Shandong Provincial Cancer Hospital and Institute, Shandong Academy of Medical Science , Jinan , China.,b School of Medicine and Life Sciences, University of Jinan-Shandong Academy of Medical Sciences , Jinan , China
| | - Xuetao Shi
- a Shandong Provincial Cancer Hospital and Institute, Shandong Academy of Medical Science , Jinan , China
| | - Lei Zhao
- a Shandong Provincial Cancer Hospital and Institute, Shandong Academy of Medical Science , Jinan , China
| |
Collapse
|
19
|
Pulmonary hemorrhage following anabolic agent abuse: Two cases. Respir Med Case Rep 2016; 18:45-7. [PMID: 27330949 PMCID: PMC4901164 DOI: 10.1016/j.rmcr.2016.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/06/2016] [Accepted: 04/11/2016] [Indexed: 12/01/2022] Open
Abstract
Numerous adverse effects follow anabolic agent abuse. Pulmonary hemorrhage is not considered one of them. We present two cases of young male bodybuilders who developed diffuse alveolar bleeding as a result of anabolic steroid abuse. Diffuse alveolar hemorrhage associated with anabolic agent abuse has not been described previously in the literature. Both patients developed acute dyspnea and hemoptysis with consistent radiological findings. In both cases symptoms promptly resolved with cessation of exposure and no medical intervention was required and no signs of persistent lung damage were seen. It is crucial to be aware of pulmonary hemorrhage as an acute complication of anabolic agent abuse. It should be considered an important differential diagnosis in the athletic patient presenting with respiratory symptoms.
Collapse
|
20
|
Liu HP, Zhao Q, Jin GZ, Qian YW, Gu YJ, Dong H, Lu XY, Cong WM, Wu MC. Unique genetic alterations and clinicopathological features of hepatocellular adenoma in Chinese population. Pathol Res Pract 2015; 211:918-24. [DOI: 10.1016/j.prp.2015.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 09/02/2015] [Indexed: 01/09/2023]
|
21
|
Donner DG, Beck BR, Bulmer AC, Lam AK, Du Toit EF. Improvements in body composition, cardiometabolic risk factors and insulin sensitivity with trenbolone in normogonadic rats. Steroids 2015; 94:60-9. [PMID: 25554582 DOI: 10.1016/j.steroids.2014.12.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Revised: 08/11/2014] [Accepted: 12/17/2014] [Indexed: 11/24/2022]
Abstract
Trenbolone (TREN) is used for anabolic growth-promotion in over 20 million cattle annually and continues to be misused for aesthetic purposes in humans. The current study investigated TREN's effects on body composition and cardiometabolic risk factors; and its tissue-selective effects on the cardiovascular system, liver and prostate. Male rats (n=12) were implanted with osmotic infusion pumps delivering either cyclodextrin vehicle (CTRL) or 2mg/kg/day TREN for 6 weeks. Dual-energy X-ray Absorptiometry assessment of body composition; organ wet weights and serum lipid profiles; and insulin sensitivity were assessed. Cardiac ultrasound examinations were performed before in vivo studies assessed myocardial susceptibility to ischemia-reperfusion (I/R) injury. Circulating sex hormones and liver enzyme activities; and prostate and liver histology were examined. In 6 weeks, fat mass increased by 34±7% in CTRLs (p<0.01). Fat mass decreased by 37±6% and lean mass increased by 11±4% with TREN (p<0.05). Serum triglycerides, HDL and LDL were reduced by 62%, 57% and 78% (p<0.05) respectively in TREN rats. Histological examination of the prostates from TREN-treated rats indicated benign hyperplasia associated with an increased prostate mass (149% compared to CTRLs, p<0.01). No evidence of adverse cardiac or hepatic effects was observed. In conclusion, improvements in body composition, lipid profile and insulin sensitivity (key risk factors for cardiometabolic disease) were achieved with six-week TREN treatment without evidence of adverse cardiovascular or hepatic effects that are commonly associated with traditional anabolic steroid misuse. Sex hormone suppression and benign prostate hyperplasia were confirmed as adverse effects of the treatment.
Collapse
Affiliation(s)
- Daniel G Donner
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia.
| | - Belinda R Beck
- School of Allied Health Sciences, Griffith University, Gold Coast, Queensland, Australia
| | - Andrew C Bulmer
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia
| | - Alfred K Lam
- Cancer Molecular Pathology, School of Medicine, Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia
| | - Eugene F Du Toit
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Gold Coast, Queensland, Australia
| |
Collapse
|
22
|
ACG clinical guideline: the diagnosis and management of focal liver lesions. Am J Gastroenterol 2014; 109:1328-47; quiz 1348. [PMID: 25135008 DOI: 10.1038/ajg.2014.213] [Citation(s) in RCA: 244] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Accepted: 05/22/2014] [Indexed: 12/11/2022]
Abstract
Focal liver lesions (FLL) have been a common reason for consultation faced by gastroenterologists and hepatologists. The increasing and widespread use of imaging studies has led to an increase in detection of incidental FLL. It is important to consider not only malignant liver lesions, but also benign solid and cystic liver lesions such as hemangioma, focal nodular hyperplasia, hepatocellular adenoma, and hepatic cysts, in the differential diagnosis. In this ACG practice guideline, the authors provide an evidence-based approach to the diagnosis and management of FLL.
Collapse
|
23
|
Herbs and liver injury: a clinical perspective. Clin Gastroenterol Hepatol 2014; 12:1069-76. [PMID: 23924877 DOI: 10.1016/j.cgh.2013.07.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 07/22/2013] [Accepted: 07/23/2013] [Indexed: 02/07/2023]
Abstract
Despite a perception that herbal and dietary supplements are safe, devastating liver injury has been reported to result from their use. The difficulty in characterizing liver injury attributable to herbal and dietary supplements stems from the permissive regulatory environment, the complexity of marketed products, and underreporting by the patients who use them. Despite these limitations, researchers, clinicians, and regulators have increasing awareness of the need for study in this area.
Collapse
|
24
|
Perera NJ, Steinbeck KS, Shackel N. The adverse health consequences of the use of multiple performance-enhancing substances--a deadly cocktail. J Clin Endocrinol Metab 2013; 98:4613-8. [PMID: 24217902 DOI: 10.1210/jc.2013-2310] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT The harmful consequences of abuse of performance-enhancing substances (PESs), stimulants, and masking agents among athletes, recreational weight lifters, and physical trainers are common. However, the adverse health outcomes with severe unexpected and dramatic consequences are unrecognized or under-reported at the expense of short-term glory or body-image effects, especially in elite sports. OBJECTIVE We report the case of a recreational weight lifter/physical trainer to help summarize the adverse health consequences and outcomes of polypharmacy among athletes and growing subsets in our population engaged in physical/fitness training. We show that in addition to the risk inherent to "stacking" of PESs, the users are predisposed to harmful consequences, including risk of exposure to toxic contaminants. DESIGN AND SETTING A previously healthy man with chronic use of multiple PESs, stimulants, and masking agents presented to a tertiary-care hospital with jaundice and mild hepatitis with rapid progression into liver and multisystem organ failure. This is followed by a brief overview of the specific toxicity (arsenic) and PESs that contributed to the poor outcome in this case. CONCLUSION Surreptitiously or self-administered cocktails of potential PESs including anabolic agents, emerging classes of GH-releasing peptides, androgen precursors, stimulants, and masking agents could lead to adverse consequences including early mortality, multisystem pathology, unmask/accelerate malignancy, and expose or predispose users to extreme danger from contaminants. This cautionary case reinforces the need to increase awareness and highlights the challenges that testing agencies, regulators, and clinicians face in the fast-developing licit/illicit trade of these products.
Collapse
Affiliation(s)
- Nimalie J Perera
- Department of Endocrinology, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW 2050, Australia.
| | | | | |
Collapse
|
25
|
Abstract
Drug-induced hepatotoxicity is underrecognized but increasingly identified as causing acute and chronic liver disease. Several prescription drugs, over-the-counter medications, dietary and/or supplementary agents, and herbal products are hepatotoxic. Drug-induced liver injury mimics other primary acute and chronic liver diseases and it should be considered in patients with hepatobiliary disease. Certain drugs result in specific histopathologic patterns of liver injury, which may help in sorting out the responsible drug. The diagnosis of drug-induced hepatotoxicity is challenging. It involves excluding other possible causes, careful medication history, the latent period between drug exposure and symptom onset and/or abnormal liver tests, and histopathologic findings.
Collapse
Affiliation(s)
- Xuchen Zhang
- Department of Pathology, VA Connecticut Health System and Yale University School of Medicine, 310 Cedar Street, LH 108, New Haven, CT 06516, USA.
| | | | | |
Collapse
|
26
|
|
27
|
Focal nodular hyperplasia and hepatic adenoma: current diagnosis and management. Updates Surg 2013; 66:9-21. [DOI: 10.1007/s13304-013-0222-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 06/16/2013] [Indexed: 12/25/2022]
|
28
|
Marcacuzco Quinto AA, Manrique Municio A, Loinaz Segurola C, Jiménez Romero LC. Spontaneous hepatic rupture associated with the use of anabolic steroids. Cir Esp 2013; 92:570-2. [PMID: 23466314 DOI: 10.1016/j.ciresp.2012.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 10/15/2012] [Accepted: 11/22/2012] [Indexed: 11/27/2022]
Affiliation(s)
- Alberto A Marcacuzco Quinto
- Servicio de Cirugía General C y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, España.
| | - Alejandro Manrique Municio
- Servicio de Cirugía General C y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, España
| | - Carmelo Loinaz Segurola
- Servicio de Cirugía General C y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, España
| | - Luis C Jiménez Romero
- Servicio de Cirugía General C y Trasplante de Órganos Abdominales, Hospital Universitario 12 de Octubre, Madrid, España
| |
Collapse
|
29
|
Pais-Costa SR, Lima OAT, Soares AF. Adenoma hepático gigante associado com uso abusivo de esteróide androgênico anabolizante: relato de caso. ABCD-ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA 2012; 25:180-2. [DOI: 10.1590/s0102-67202012000300010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
30
|
Ao J, Meng J, Zhu L, Nie H, Yang C, Li J, Gu J, Lin Q, Long W, Dong X, Li C. Activation of androgen receptor induces ID1 and promotes hepatocellular carcinoma cell migration and invasion. Mol Oncol 2012; 6:507-15. [PMID: 22819717 DOI: 10.1016/j.molonc.2012.06.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 06/25/2012] [Accepted: 06/28/2012] [Indexed: 02/07/2023] Open
Abstract
Androgen receptor (AR) activity is associated with cancer development and progression. In hepatocellular carcinoma (HCC), AR contributes to HCC incidence, but the role of AR in HCC cell migration and invasion remains largely unknown. In this study, we found that AR was expressed at high levels in a subgroup of HCC cell lines with high metastatic potential. Experiments using lentiviral overexpression or small hairpin RNA knockdown of AR as well as activation of AR by its ligand indicated that AR activation promoted HCC cell migration and invasion. We also found that AR activation enhanced the expression of a metastasis-promoting gene, ID1, which led to increased HCC cell migration and invasion. An AR antagonist was able to block this process, suggesting that AR activation in AR-positive HCC may be therapeutically inhibited as a potential intervention strategy.
Collapse
Affiliation(s)
- Junping Ao
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai 200032, China
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
What can allostasis tell us about anabolic-androgenic steroid addiction? Dev Psychopathol 2011; 23:907-19. [PMID: 21756441 DOI: 10.1017/s0954579411000393] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Anabolic-androgenic steroids (AASs) are synthetic hormones used by individuals who want to look better or perform better in athletics and at the gym. Their use raises an interesting paradox in which drug use is associated with a number of health benefits, but also the possibility of negative health consequences. Existing models of AAS addiction follow the traditional framework of drug abuse and dependence, which suggest that harmful use occurs as a result of the drug's ability to hijack the motivation-reward system. However, AASs, unlike typical drugs of abuse, are not used for acute intoxication effects or euphoria. Rather, AASs are used to affect the body through changes to the musculoskeletal system and the hypothalamic-pituitary-gonadal axis as opposed to stimulating the reward system. We offer an allostatic model of AAS addiction to resolve this inconsistency between traditional drug addiction and AAS addiction. This allostatic framework provides a way to (a) incorporate exercise into AAS misuse, (b) identify where AAS use transitions from recreational use into a drug problem, and (c) describe individual differences in vulnerability or resilience to AASs. Implications for this model of AAS addiction are discussed.
Collapse
|
32
|
Kim TY, Kim BS, Hyun CL, Song BC. [Hepatocellular adenoma treated with radiofrequency ablation in young male]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 57:384-7. [PMID: 21694493 DOI: 10.4166/kjg.2011.57.6.384] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Tae Yun Kim
- Department of Internal Medicine, Jeju National University School of Medicine, Jeju, Korea
| | | | | | | |
Collapse
|
33
|
Biologic and clinical features of benign solid and cystic lesions of the liver. Clin Gastroenterol Hepatol 2011; 9:547-62.e1-4. [PMID: 21397723 DOI: 10.1016/j.cgh.2011.03.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 02/24/2011] [Accepted: 03/02/2011] [Indexed: 02/07/2023]
Abstract
The widespread use of imaging analyses, either routinely or to evaluate symptomatic patients, has increased the detection of liver lesions (tumors and cysts) in otherwise healthy individuals. Although some of these incidentally discovered masses are malignant, most are benign and must be included in the differential diagnosis. The management of benign hepatic tumors ranges from conservative to aggressive, depending on the nature of the lesions. New imaging modalities, increased experience of radiologists, improved definition of radiologic characteristics, and a better understanding of the clinical features of these lesions have increased the accuracy of diagnoses and reduced the need for invasive diagnostic tests. These advances have led to constant adjustments in management approaches to benign hepatic lesions. We review the biologic and clinical features of some common hepatic lesions, to guide diagnosis and management strategies.
Collapse
|
34
|
Lin H, van den Esschert J, Liu C, van Gulik TM. Systematic review of hepatocellular adenoma in China and other regions. J Gastroenterol Hepatol 2011; 26:28-35. [PMID: 21175790 DOI: 10.1111/j.1440-1746.2010.06502.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hepatocellular adenoma (HCA) is a benign liver neoplasm with a risk of spontaneous bleeding and malignant transformation. The aim of this review article is to review all the case reports and case series of patients with HCA from 1998 to 2008 in China and other parts of the world in order to compare clinical presentation, surgical management and outcomes. A search for all reports of HCA in the world literature from 1998 to 2008 was performed. A total of 356 patients were identified, including 191 patients from China, 104 from Europe, 46 from North America, and 15 from South-East Asia. A female predominance was not observed in Chinese patients in contrast to the other regions. Acute/chronic abdominal pain was the main clinical presentation in all regions. Twenty patients were diagnosed with coexistent hepatocellular carcinoma (HCC), and hepatitis B virus infection (HBV) was found among six of them. The management of HCA consisted of resection in most cases. The clinical presentation of HCA in China differed from other parts of the world regarding male predominance and a higher incidence of coexistent HCC in China. This might be the result of the birth control policy in China, limited oral contraceptive use, and the higher incidence of HBV.
Collapse
Affiliation(s)
- Haoming Lin
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | | |
Collapse
|
35
|
Martins RA, Gomes GAS, Aguiar O, Medalha CC, Ribeiro DA. Chromosome damage and cytotoxicity in oral mucosa cells after 2 months of exposure to anabolic steroids (decadurabolin and winstrol) in weight lifting. Steroids 2010; 75:952-5. [PMID: 20566358 DOI: 10.1016/j.steroids.2010.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2009] [Revised: 05/20/2010] [Accepted: 05/21/2010] [Indexed: 11/24/2022]
Abstract
The aim of the present study was to evaluate DNA damage (micronucleus) and cellular death (pyknosis, karyolysis and karyorrhexis) in exfoliated buccal mucosa cells from anabolic steroid users after 2 months of exposure. Two experimental groups consisting of 15 adult males who practise weight lifting and are anabolic steroid users or 15 adult males who practise weight lifting, but are non-anabolic steroid users, were recruited. In addition, 20 sedentary males, who do not practise any physical activity regularly, were matched by age with experimental groups. No significant statistical differences (p>0.05) were noticed in individuals who practise physical activity only. On the other hand, an increase of micronucleated cells (MNCs) in anabolic steroid (decadurabulin and Winstrol) users was observed. Regarding cytotoxic parameters, the same observation has occurred, that is, significant statistical differences (p<0.05) were noticed in the group exposed to anabolic steroids when compared with other controls, as depicted by high frequencies of pyknosis, karyolysis and karyorrhexis. Taken together, our results suggest that genomic instability and cytotoxicity are induced by anabolic steroid administration in oral mucosa cells as assessed by the micronucleus test.
Collapse
Affiliation(s)
- Renato A Martins
- Departamento de Biociências, Universidade Federal de São Paulo - UNIFESP, Av. Ana Costa 95, 11060-001 Santos, SP, Brazil
| | | | | | | | | |
Collapse
|
36
|
Herlitz LC, Markowitz GS, Farris AB, Schwimmer JA, Stokes MB, Kunis C, Colvin RB, D'Agati VD. Development of focal segmental glomerulosclerosis after anabolic steroid abuse. J Am Soc Nephrol 2010; 21:163-72. [PMID: 19917783 PMCID: PMC2799287 DOI: 10.1681/asn.2009040450] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2009] [Accepted: 09/17/2009] [Indexed: 11/03/2022] Open
Abstract
Anabolic steroid abuse adversely affects the endocrine system, blood lipids, and the liver, but renal injury has not been described. We identified an association of focal segmental glomerulosclerosis (FSGS) and proteinuria in a cohort of 10 bodybuilders (six white and four Hispanic; mean body mass index 34.7) after long-term abuse of anabolic steroids. The clinical presentation included proteinuria (mean 10.1 g/d; range 1.3 to 26.3 g/d) and renal insufficiency (mean serum creatinine 3.0 mg/dl; range 1.3 to 7.8 mg/dl); three (30%) patients presented with nephrotic syndrome. Renal biopsy revealed FSGS in nine patients, four of whom also had glomerulomegaly, and glomerulomegaly alone in one patient. Three biopsies revealed collapsing lesions of FSGS, four had perihilar lesions, and seven showed > or =40% tubular atrophy and interstitial fibrosis. Among eight patients with mean follow-up of 2.2 yr, one progressed to ESRD, the other seven received renin-angiotensin system blockade, and one also received corticosteroids. All seven patients discontinued anabolic steroids, leading to weight loss, stabilization or improvement in serum creatinine, and a reduction in proteinuria. One patient resumed anabolic steroid abuse and suffered relapse of proteinuria and renal insufficiency. We hypothesize that secondary FSGS results from a combination of postadaptive glomerular changes driven by increased lean body mass and potential direct nephrotoxic effects of anabolic steroids. Because of the expected rise in serum creatinine as a result of increased muscle mass in bodybuilders, this complication is likely underrecognized.
Collapse
Affiliation(s)
| | | | - Alton B. Farris
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joshua A. Schwimmer
- Medicine, Columbia University, College of Physicians and Surgeons, New York, New York
- Department of Medicine, Lenox Hill Hospital, New York, New York; and
| | | | - Cheryl Kunis
- Medicine, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Robert B. Colvin
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
37
|
Dokmak S, Paradis V, Vilgrain V, Sauvanet A, Farges O, Valla D, Bedossa P, Belghiti J. A single-center surgical experience of 122 patients with single and multiple hepatocellular adenomas. Gastroenterology 2009; 137:1698-705. [PMID: 19664629 DOI: 10.1053/j.gastro.2009.07.061] [Citation(s) in RCA: 247] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2008] [Revised: 07/24/2009] [Accepted: 07/29/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Hepatocellular adenoma (HA) is associated with risk of bleeding and malignancy, justifying resection. Patients with multiple forms of HA are difficult to manage. We evaluated the characteristics and outcome of 122 patients with single and multiple HAs after surgery. METHODS From 1990 to 2004, 122 patients (14 male) underwent surgical resection. Complications (hemorrhage and malignancy) were assessed according to size, number, and histologic subtype (steatotic, telangiectatic, and unclassified), with a mean follow-up period of 70 months. RESULTS Hemorrhagic HA occurred in 21% of cases and malignant HA occurred in 8%. Risk of complications was not related to the number of HAs but was associated with size (>5 cm), especially of telangiectatic and unclassified subtypes. Patients with steatotic HA had a low risk of complications. Malignant HA was more frequent in men (43%); all patients treated by partial resection survived, without recurrent malignancy, after a mean follow-up period of 78 months. After 109 patients with benign HA revealed recurrence or progression of HA in 8% and regression in 9% of cases. No complications were observed in 11 women who became pregnant during the follow-up period. CONCLUSIONS Patients with HAs greater than 5 cm, telangiectatic or unclassified subtypes, and men have an increased risk of complicated disease; resection should be restricted to these patients. The risk of complications was not related to the number of HAs, so patients with multiple HAs do not need liver transplantation.
Collapse
Affiliation(s)
- Safi Dokmak
- Department of HepatoBilioPancreatic Surgery, University of Paris 7 and Beaujon Hospital, Clichy, France
| | | | | | | | | | | | | | | |
Collapse
|
38
|
Bispo M, Valente A, Maldonado R, Palma R, Glória H, Nóbrega J, Alexandrino P. Anabolic steroid-induced cardiomyopathy underlying acute liver failure in a young bodybuilder. World J Gastroenterol 2009; 15:2920-2. [PMID: 19533818 PMCID: PMC2699014 DOI: 10.3748/wjg.15.2920] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Heart failure may lead to subclinical circulatory disturbances and remain an unrecognized cause of ischemic liver injury. We present the case of a previously healthy 40-year-old bodybuilder, referred to our Intensive-Care Unit of Hepatology for treatment of severe acute liver failure, with the suspicion of toxic hepatitis associated with anabolic steroid abuse. Despite the absence of symptoms and signs of congestive heart failure at admission, an anabolic steroid-induced dilated cardiomyopathy with a large thrombus in both ventricles was found to be the underlying cause of the liver injury. Treatment for the initially unrecognized heart failure rapidly restored liver function to normal. To our knowledge, this is the first reported case of severe acute liver failure due to an unrecognized anabolic steroid-induced cardiomyopathy. Awareness of this unique presentation will allow for prompt treatment of this potentially fatal cause of liver failure.
Collapse
|
39
|
Bispo M, Valente A, Maldonado R, Palma R, Glória H, Nóbrega J, Alexandrino P. Anabolic steroid-induced cardiomyopathy underlying acute liver failure in a young bodybuilder. World J Gastroenterol 2009. [PMID: 19533818 DOI: pmid/19533818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023] Open
Abstract
Heart failure may lead to subclinical circulatory disturbances and remain an unrecognized cause of ischemic liver injury. We present the case of a previously healthy 40-year-old bodybuilder, referred to our Intensive-Care Unit of Hepatology for treatment of severe acute liver failure, with the suspicion of toxic hepatitis associated with anabolic steroid abuse. Despite the absence of symptoms and signs of congestive heart failure at admission, an anabolic steroid-induced dilated cardiomyopathy with a large thrombus in both ventricles was found to be the underlying cause of the liver injury. Treatment for the initially unrecognized heart failure rapidly restored liver function to normal. To our knowledge, this is the first reported case of severe acute liver failure due to an unrecognized anabolic steroid-induced cardiomyopathy. Awareness of this unique presentation will allow for prompt treatment of this potentially fatal cause of liver failure.
Collapse
Affiliation(s)
- Miguel Bispo
- Department of Gastroenterology, Egas Moniz Hospital, Lisbon, Portugal.
| | | | | | | | | | | | | |
Collapse
|