Anabolic androgenic steroids are commonly used at high doses by bodybuilders and athletes to enhance physique and improve performance levels. We report a case of spontaneous hepatic rupture with life-threatening haemorrhage associated with a past history of anabolic steroid use.A nabolic androgenic steroids (AAS) are commonly used in high doses by bodybuilders and athletes to enhance physique and improve performance levels. These agents are known to produce changes in various organ systems and cause adverse effects such as gynaecomastia, hypertension, ischaemic heart disease, psychological disturbances, testicular atrophy and acne.1 They have also been associated with prostate cancer and nephroblastoma.2-4 AAS also have a profound impact on the liver, including peliosis hepatis, cholestasis and hepatocellular adenomas. 5 We report a case of spontaneous hepatic rupture with life-threatening haemorrhage associated with a history of anabolic steroid use. CASE REPORTA 43-year-old man was brought to the accident and emergency department after he collapsed at home. He had the physique of a professional bodybuilder. He reported that he had epigastric pain for 2 days before the collapse. There was no history of trauma. On examination, he was found to be markedly tender over the epigastric and left hypochondrial areas. On arrival, he had a heart rate of 124 beats/min and a blood pressure of 69/ 30 mm Hg. He was conscious and alert with an oxygen saturation of 100%. Investigations revealed a haemoglobin of 10.6 g/dl, an international normalised ratio of 4.2, creatinine of 148 mmol/l and bilirubin of 27 mmol/l. All other parameters were within normal limits. The patient was resuscitated in the accident and emergency department with intravenous fluids and was transferred to the high dependency unit. His medical history included Crohn's disease and a recurrent deep vein thrombosis related to a familial thrombophilia for which he took warfarin and anabolic steroids. He had stopped taking steroids 4 years previously. He had been taking AAS for 25 years, which included nandrolone decanoate, stanozolol, primabolin and most forms of testosterone. By comparison with the doses taken in the bodybuilding fraternity, his consumption was at the low end of the range of steroid usage. Before a computed axial tomography scan was performed, he had a cardiovascular collapse that required aggressive resuscitation with blood products and intravenous fluids, and he underwent an emergency laparotomy. Three litres of blood was evacuated from his abdomen. A ruptured subcapsular haematoma of the liver was identified as the source of the haemorrhage. The abdomen was packed as the haemorrhage was difficult to control, being aggravated by the raised international normalised ratio. His postoperative period was complicated by sepsis, and acute renal and cardiovascular failure requiring renal and inotropic support. Re-exploration of his abdomen at 72 h was uneventful. He subsequently made an uncomplicated but slow recovery, being extubated at 10 days an...
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