Hepatic granulomas: review of 73 patients from one hospital and survey of the literature
Irani, S.K.; Dobbins, W.O.
Journal of Clinical Gastroenterology 1(2): 131-143
1979
ISSN/ISBN: 0192-0790 PMID: 400661 Document Number: 4202
Sarcoidosis accounted for more than half (55%) the hepatic granulomas on biopsy at George Washington University Hospital from 1952 through 1975, rather more than the 39% deemed the result of sarcoidosis in 10,008 liver biopsies reported in the literature. The higher incidence in our series probably reflects patient selection and reliance on biopsy of the liver rather than of other tissues at our hospital to prove granulomas in patients thought to have sarcoidosis. Fever was present in less than one-third of patients. Liver enlargement by itself was not diagnostically helpful, as patients with sarcoidosis had the lowest incidence of hepatic involvement. Bilateral hilar adenopathy was present only in patients with sarcoidosis, but in only 66% of such patients. Of the 40 patients with sarcoid of the liver and hilar adenopathy, eight showed no clinical or laboratory evidence of liver involvement. Liver function studies were not a helpful index of hepatic involvement by granulomas. Although the serum alkaline phosphatase is considered to be a sensitive indicator of intrahepatic lesions, it was elevated in only 65% of patients tested. SGOT was elevated in all five patients with primary liver disease, and in three of four with drug-associated granulomatous liver disease, suggesting that elevated SGOT indicates that hepatocellular injury accompanies the granulomas. Bilirubin elevations occurred in the majority of patients with granulomatous hepatitis, with primary liver disease, and with drug reactions. Only one-third of patients with extrahepatic biliary tract disease and hepatic granuloma had an elevated serum bilirubin. The lowest incidence of bilirubin elevation was in patients with sarcoidosis (3/32) and tuberculosis (1/8). Increased serum globulin levels were of no diagnostic value. The finding of peripheral eosinophilia was rarely helpful, even though three of the four patients with drug-associated granulomas had eosinophilia. Serum calcium was elevated only in sarcoidosis, in about 10% of patients. This study emphasizes nonspecific nature of granulomas in the liver. In only one specimen did special stains establish a clear diagnosis by showing acid-fast bacteria. Characteristic granulomas from a retained suture and from schistosomiasis were also diagnostic. The nuclear inclusions in the biopsy of a patient with cytomegalic inclusion disease required serologic confirmation for diagnosis. The presence of granulomas within the liver should be termed "hepatic granuloma," not "granulomatous hepatitis." The term "granulomatous hepatitis" is best reserved for designation of a specific disorder presenting as fever of undetermined origin.
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